Accepted for/Published in: JMIR Medical Informatics
Date Submitted: Sep 15, 2022
Date Accepted: Dec 1, 2022
Effect of Implementation of Guideline Order Bundles into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Design
ABSTRACT
Background:
Clinical practice guidelines (CPGs) help disseminate evidence-based practices to improve patient outcomes. Clinical decision support through disease-specific order sets can improve adoption of CPGs. However, many patients eligible for CPGs are not managed in concordance with CPG recommendations.
Objective:
To determine how integrating disease-specific order groups into a common general admission order set influences adoption of clinical practice guideline CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service.
Methods:
We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared order bundle usage rates for eligible encounters pre- and post-implementation at both an intervention and non-intervention site for integrated CPGs. We also assessed order bundle adoption for non-integrated CPGs including bronchiolitis, acute gastroenteritis, and croup. In a post-hoc analysis, among encounters without order bundle use, we compared the frequency of diagnostic uncertainty at the time of admission pre- and post-intervention.
Results:
CPG order bundle usage rates for incorporated CPGs increased by +9.8% (from 73.5% to 83.3%) at the intervention site and by +5.1% (66.3% to 71.4%) at the non-intervention site. Order bundle adoption for non-integrated CPGs decreased from 84.0% to 68.5%, driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (12.3% vs. 23.4%).
Conclusions:
The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an under-recognized barrier to guideline adherence that is not addressed by an integrated admission order set.
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