INTRODUCTION
In the evolving landscape of healthcare technology, clinical decision support (CDS) stands out as a crucial tool aimed at supporting clinical decision-making processes. The article, "Using Clinical Decision Support Systems to Decrease Intravenous Acetaminophen Use: Implementation and Lessons Learned," published in Applied Clinical Informatics by authors Tse et al., examines a targeted intervention at an academic pediatric hospital. This research focuses on the implementation of a hard-stop alert designed to minimize the use of intravenous (IV) acetaminophen. The findings underscore the challenges in modifying clinician behavior and the unintended repercussions on patient care and provider workload, providing valuable lessons on the deployment and scalability of CDS in complex healthcare environments.
APPROACH
The hospital embarked on a quality improvement initiative, utilizing the Plan-Do-Study-Act (PDSA) model for implementing a hard-stop alert designed to limit the use of IV acetaminophen to the initial 24 hours of patient care, unless explicitly reauthorized by a clinician. This approach was based on the rationale that IV acetaminophen, while effective, is significantly more costly than its oral counterpart and is often used beyond the period of its greatest benefit. The alert aimed to prompt providers to reassess the necessity of continuing IV acetaminophen, encouraging the switch to oral administration when appropriate. The implementation process involved extensive planning, including the development of the alert logic, integration into the hospital's electronic health record (EHR) system, and communication and training sessions for clinical staff.
RESULTS
Following the implementation of the hard-stop alert, the hospital conducted a comprehensive evaluation to assess its impact on IV acetaminophen use. The data revealed that there was no statistically significant reduction in the hospital-wide administration of IV acetaminophen per 1,000 patient days. Furthermore, feedback collected from clinicians through surveys and interviews indicated substantial challenges. About half of the survey respondents reported experiencing negative consequences, including delays in patient care due to the additional steps required by the CDS and concerns over the system's impact on clinical efficiency and workflow. These findings prompted a critical reevaluation of the alert's design and its integration into the clinical environment.
DISCUSSION
The outcomes of this case study offer important insights into the challenges of implementing CDS in healthcare settings. Firstly, the lack of a significant reduction in IV acetaminophen use suggests that hard-stop interventions alone may not be sufficient to change entrenched clinical behaviors, particularly when they add complexity or burden to the clinical workflow. The feedback from healthcare providers highlighted the importance of designing CDS with a deep understanding of clinical processes and the potential for unintended consequences. These insights underscore the necessity of involving end-users early in the CDS development process and the importance of flexibility and adaptability in its implementation. In response to the feedback, the team decided to remove the hard-stop feature from the CDS, opting instead for a more nuanced approach that includes educational components that respect clinical judgment while still encouraging best practices.
EVALUATING YOUR CDS USING THESE METHODS
Organizations considering the implementation of CDS should take heed of the lessons learned from this case study. It's crucial to engage healthcare providers in the design and testing phases, ensuring that the system supports rather than hinders their workflow. Pilot testing in a controlled environment can offer valuable insights into potential challenges and areas for improvement before a full-scale rollout. Moreover, an iterative approach to CDS development, characterized by ongoing monitoring, evaluation, and adaptation based on real-world use and feedback, can significantly enhance the system's effectiveness and acceptance. By applying these principles, healthcare organizations can leverage CDS to improve patient care outcomes while minimizing disruption to clinical operations.
Journal Club Source
Tse, Gabriel, et al. “Using Clinical Decision Support Systems to
Decrease Intravenous Acetaminophen Use:
Implementation and Lessons Learned.” Applied Clinical Informatics, 2024; 15(01): 64-74. DOI: 10.1055/a-2216-5775