Use of Clinical Decision Support to Improve the Quality of Care Provided to Older Hospitalized Patients

Summary

Background: Frail older inpatients are at risk of unintended adverse events while in hospital, particularly falls, functional decline, delirium and incontinence.

Objective: The aim of this pragmatic trial was to pilot and evaluate a multi-component knowledge translation intervention that incorporated a nurse-initiated computerized clinical decision support tool to reduce harms in the care of older medical inpatients.

Methods: A stepped wedge trial design was conducted on six medical units at two hospitals in Calgary, Alberta, Canada. The primary quantitative outcome was the rate of order set use. Secondary outcomes included the number of falls, the average number of days in hospital, and the total number of consults ordered for each of orthopedics, geriatrics, psychiatry and physiotherapy. Qualitative analysis included interviews with nurses to explore barriers and facilitators around the implementation of the electronic decision support tool.

Results: The estimated mean rate of order set use over a 2 week period was 3.1 (95% CI 1.9–5.3) sets higher after the intervention than before. The estimated odds of a fall happening on a unit over a 2-week period was 9.3 (p = 0.065) times higher before than after the intervention. There was no significant effect of the intervention on length of hospital stay (p = 0.67) or consults to related clinical services (all p <0.2). Interviews with front-line nurses and nurse managers/educators revealed that the order set is not being regularly ordered because its content is perceived as part of good nursing care and due to the high workload on these busy medical units.

Conclusions: Although not statistically significant, a reduction in the number of falls as a result of the intervention was noted. Frontline users’ engagement is crucial for the successful implementation of any decision support tool. New strategies of implementation will be evaluated before broad dissemination of this knowledge translation intervention.

Keywords

Computerized order set - falls - older inpatients - knowledge translation

 

Conflict of Interest

The authors declare that they have no conflicts of interest in the research.

• References

• 1 Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Arch Intern Med 2000; 160 (18) 2717-2728.
• 2 Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D. et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003; 51 (04) 451-458.
• 3 Inouye SK, Bogardus Jr., ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR. et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340 (09) 669-676.
• 4 Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275 (11) 852-857.
• 5 Schmid N. Federal Nursing Service Award Winner. Reducing patient falls: a research-based comprehensive fall prevention program. Mil Med 1990; 155: 202-207.
• 6 Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 2002; 167 (10) S1-S34.
• 7 Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ 2008; 336 7636 130-133.
• 8 Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ. et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328 7441 680.
• 9 Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG. et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009 (02) CD007146.
• 10 Inouye SK. Delirium after hip fracture: to be or not to be?. J Am Geriatr Soc 2001; 49 (05) 678-679.
• 11 Williams-Russo P, Urquhart BL, Sharrock NE, Charlson ME. Post-operative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc 1992; 40 (08) 759-767.
• 12 Francis J, Kapoor WN. Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc 1992; 40 (06) 601-606.
• 13 Gustafson Y, Berggren D, Brannstrom B, Bucht G, Norberg A, Hansson LI. et al. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc 1988; 36 (06) 525-530.
• 14 Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998; 13 (04) 234-242.
• 15 O’Keeffe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc 1997; 45 (02) 174-178.
• 16 Holroyd-Leduc JM, Khandwala F, Sink KM. How can delirium best be prevented and managed in older patients in hospital?. CMAJ 2010; 182 (05) 465-470.
• 17 Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113 (12) 941-948.
• 18 Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc 1998; 46 (04) 473-480.
• 19 Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have?. JAMA 2008; 299 (12) 1446-1456.
• 20 Holroyd-Leduc JM, Straus SE. Management of urinary incontinence in women: scientific review. JAMA 2004; 291 (08) 986-995.
• 21 Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293 (10) 1223-1238.
• 22 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 7494 765.
• 23 Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009 (03) CD001096.
• 24 Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W. et al. Lost in knowledge translation: time for a map?. J Contin Educ Health Prof 2006; 26 (01) 13-24.
• 25 Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F. et al. Designing and evaluating complex interventions to improve health care. BMJ 2007; 334 7591 455-459.
• 26 Forsetlund L, Bjorndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf F. et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009 (02) CD003030.
• 27 Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol 2006; 6: 54.
• 28 Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001; 49 (05) 516-522.
• 29 Lundstrom M, Olofsson B, Stenvall M, Karlsson S, Nyberg L, Englund U. et al. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Aging Clin Exp Res 2007; 19 (03) 178-186.
• 30 Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M. et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331 (13) 821-827.
• 31 Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials 2007; 28 (02) 182-191. Epub 2006 Jul 7.
• 32 Kramer LW. Generational diversity. Dimens Crit Care Nurs 2010; 29 (03) 125-128.
• 33 Richardson A, Storr J. Patient safety: a literature [corrected] review on the impact of nursing empowerment, leadership and collaboration. Int Nurs Rev 2010; 57 (01) 12-21.
• 34 Shojania KG, Jennings A, Mayhew A, Ramsay C, Eccles M, Grimshaw J. Effect of point-of-care computer reminders on physician behaviour: a systematic review. CMAJ 2010; 182 (05) E216-E225.
• 35 Durieux P, Trinquart L, Colombet I, Nies J, Walton R, Rajeswaran A. et al. Computerized advice on drug do-sage to improve prescribing practice. Cochrane Database Syst Rev 2008 (03) CD002894.
• 36 Gurwitz JH, Field TS, Rochon P, Judge J, Harrold LR, Bell CM. et al. Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. J Am Geriatr Soc 2008; 56 (12) 2225-2233.