Improving adherence to asthma clinical guidelines and discharge documentation from emergency departments: Implementation of a dynamic and integrated electronic decision support system†

Objective: The authors previously developed a dynamic and integrated electronic decision support system called ACAFE (Asthma Clinical Assessment Form and Electronic decision support). The objective of this present study was to evaluate the effectiveness of this system on asthma management and documentation in an ED. Method: Observational study using a pre‐ and post‐intervention design, comparing patients managed using ACAFE after its implementation with historical controls. A systematic data abstraction process was used to compare patient records. Results: A total of 50 patients were enrolled in the study group. These were compared with 50 historical controls. Use of ACAFE was associated with significantly higher rates of documentation of asthma severity (98% vs 18%, P < 0.01), as well as other clinically important variables, such as asthma precipitants, intensive care admission history and smoking history. ACAFE was also associated with significantly higher rate of asthma discharge plan documentation (76% vs 16%, P < 0.01), and this remained significant after adjustment for triage category and seniority of treating doctor in a regression model. Conclusion: The use of this decision support system in patients presenting to emergency with asthma was associated with improvements in clinical documentation and discharge management plans. Electronic decision support systems developed collaboratively with clinicians should play an important part of system‐wide efforts to improve guideline adherence and compliance in ED.     

A RCT evaluating the effectiveness and cost-effectiveness of academic detailing versus postal prescribing feedback in changing GP antibiotic prescribing

Purpose The aim of this study is to evaluate the effectiveness of academic detailing (AD) plus postal prescribing feedback versus postal prescribing feedback alone in reducing: (i) the overall rate of antibiotic; and (ii) proportion of second‐line antibiotic prescribing. In addition, the cost‐effectiveness of an outreach prescriber adviser service versus a postal prescribing feedback service was evaluated. Methods Volunteer general practitioner practices (n = 98) were randomized to receive prescribing feedback via postal bulletin (PB) (n = 50) or academic detailing plus postal bulletin (AD) (n = 48). Data analysis was based on the HSE‐primary care reimbursement service (HSE‐PCRS) prescribing database. Regression (β) coefficients, indicating proportion change in prescribing per month, and 95% confidence intervals (CIs) are presented. The cost‐effectiveness ratio was calculated from the total cost of the intervention divided by percentage change in antiobiotic prescribing in AD versus PB group. Results Immediately post intervention PB (β = ?0.02, 95% CI ?0.04, ?0.001) and AD (β = ?0.02, 95% CI ?0.03, ?0.001) practices significantly decreased overall antibiotic prescribing. Second‐line antibiotic prescribing was also significantly decreased by 2–3% in both groups. However, there were no significant differences in antibiotic prescribing between the randomized groups in the immediate or long‐term post‐intervention period. In the cost‐effectiveness analysis a postal prescribing feedback service would cost €88 per percentage change in prescribing practice compared with €778 for a prescriber adviser service. Conclusion Prescribing feedback significantly reduced overall and second‐line antibiotic prescribing, but academic detailing was not significantly more effective than postal bulletin in changing antibiotic prescribing practice.     

A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward

This paper discusses an anonymous incident reporting scheme to reduce drug administration error on the hospital ward, as part of an effective, non-punitive, systems-focused approach to safety. Drug error is costly in terms of increased hospital stay, resources consumed, patient harm, lives lost and careers ruined. Safety initiatives that focus, not on blaming individuals, but on improving the wider system in which personnel work have been adopted in a number of branches of health care. However, in nursing, blame remains the predominant approach for dealing with error, and the ward has seen little application of the systems approach to safety. Safety interventions founded on an effective incident scheme typically pay for themselves in terms of dollar savings arising from averted harm. Recent calls for greater health-care safety require finding new ways to make drug administration safer throughout the hospital, and the scope for such safety gains on the hospital ward remains considerable.     

The effect of laboratory requisition modification,audit and feedback with academic detailing or both on utilization of blood urea testing in family practice in Newfoundland,Canada

ObjectivesMeasuring blood urea at the same time as serum creatinine in stable ambulatory patients in family practice is largely unnecessary. The objective was to assess the relative impact of changing the laboratory requisition versus audit and feedback and academic detailing on the volume of orders for blood urea.Design and methodsA natural experiment was observed over the period April 2015 to March 2018 in the Canadian province of Newfoundland where three health regions had different approaches to trying to reduce such urea testing. The Eastern and Western regions removed urea from the standard laboratory requisition but the test could still be ordered by writing it on the requisition. Central region requisitions continued to list urea. Audit and feedback was undertaken with family doctors in Eastern region after the requisition change and that was followed by academic detailing. A nephrologist gave presentations to groups of family doctors on one occasion in Central region.ResultsThe volume of serum creatinine testing was largely unchanged over time in each region. The volume of urea testing reduced by 73%, 48% and 28% in Eastern, Western and central regions. Interrupted time series analysis showed significant changes in test volume after requisition change in Eastern and Western regions as well as after audit and feedback in Eastern and the presentations in Central region. The incremental impact of academic detailing was not statistically significant.ConclusionWe conclude that removing urea from standard test order menus was the most effective in reducing test volumes, but combination with audit and feedback augmented the impact.     

医疗失效模式与效应分析在静脉用药安全管理中的应用

目的优化静脉用药流程,促进用药安全。方法运用医疗失效模式与效应分析,对静脉用药流程进行危害分析,找出失效模式及潜在原因,针对需优先解决的问题进行改进。结果静脉用药不良事件发生率降低(P<0.01)。结论通过医疗失效模式与效应分析,规范药品转运交接制度并应用屏障技术,优化了静脉用药的流程,可以降低不良事件发生率。     

The potential for intelligent decision support systems to improve the quality and consistency of medication reviews

What is known and Objective: Drug‐related problems (DRPs) are of serious concern worldwide, particularly for the elderly who often take many medications simultaneously. Medication reviews have been demonstrated to improve medication usage, leading to reductions in DRPs and potential savings in healthcare costs. However, medication reviews are not always of a consistently high standard, and there is often room for improvement in the quality of their findings. Our aim was to produce computerized intelligent decision support software that can improve the consistency and quality of medication review reports, by helping to ensure that DRPs relevant to a patient are overlooked less frequently. A system that largely achieved this goal was previously published, but refinements have been made. This paper examines the results of both the earlier and newer systems. Methods: Two prototype multiple‐classification ripple‐down rules medication review systems were built, the second being a refinement of the first. Each of the systems was trained incrementally using a human medication review expert. The resultant knowledge bases were analysed and compared, showing factors such as accuracy, time taken to train, and potential errors avoided. Results and Discussion: The two systems performed well, achieving accuracies of approximately 80% and 90%, after being trained on only a small number of cases (126 and 244 cases, respectively). Through analysis of the available data, it was estimated that without the system intervening, the expert training the first prototype would have missed approximately 36% of potentially relevant DRPs, and the second 43%. However, the system appeared to prevent the majority of these potential expert errors by correctly identifying the DRPs for them, leaving only an estimated 8% error rate for the first expert and 4% for the second. What is new and conclusion: These intelligent decision support systems have shown a clear potential to substantially improve the quality and consistency of medication reviews, which should in turn translate into improved medication usage if they were implemented into routine use.     

Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department

Background

Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP).