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Promoting High-Value Change By Addressing the Structure of Order Sets: Lessons from the Cardiac Catheterization Lab

From the 2018 HVPAA National Conference

Nagendra Pokala (University of Texas Southwestern Medical Center, Dallas, TX;), Arjun Gupta (University of Texas Southwestern Medical Center, Dallas, TX;), Julia Tran (University of Texas Southwestern Medical Center, Dallas, TX;), Ambarish Pandey (University of Texas Southwestern Medical Center, Dallas, TX;), Sandeep Das (University of Texas Southwestern Medical Center, Dallas, TX;)

Background

Order sets in electronic medical records can promote efficiency and reduce variability but can also influence ordering practices. At our institution, one order set was used for right (RHC) and left heart catheterizations (LHC). It included opt-out prescriptions for IV normal saline as well as hydrocodone.

Objectives

Recent data suggest that prophylactic hydration in LHC does not prevent CIN, while prophylactic hydration is always unnecessary and may be harmful in RHC. Additionally, procedure-related pain is usually mild. We hypothesized that the presence of “opt out” saline and opioid orders would lead to overuse. This quality improvement study aimed to minimize unintentional harm and waste – use of unnecessary IV fluids and opioids – for patients undergoing RHC and LHC.

Methods

Medical records of patients undergoing RHC and LHC at our institution were reviewed from October – December 2017. We removed IVF and opioids completely from the order set in January 2018. End users were involved in making changes, and changes were communicated to all staff who used the order set.  We plan to evaluate changes in IVF and opioid prescription rates in the months after this change.

Results

Of 58 and 221 patients undergoing RHC and LHC respectively, 6.9% received IVF with RHC and 35.6% received IVF with LHC. Hydrocodone was prescribed to 1.7% of patients undergoing RHC, and 1.0% of patients undergoing LHC.

Conclusion

Over a 3-month period at our hospital, 1 in 3 patients undergoing LHC and 1 in 14 patients undergoing RHC received unnecessary IVF. Opioid prescription rates were low but still present.

Implications for the Patient

We will evaluate the changes in IVF/ opioid prescription patterns in the next few months post the order set changes.