CADTH Rapid Response Report: Summary with Critical Appraisal, Acute exacerbations of chronic pulmonary disease, In the acute setting, physicians or other providers frequently hand write orders for treatment. KE, Johnson This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Order PICCs for patients who will need long term IV antibiotics. G, Duffy In: Downs If a patient may need future dialysis, check-in with a Renal consultant before ordering a PICC. Number of white participants provided but no information on the other ethnicities in remaining 29% of cohort. The admission orders cover the following conditions: Acute epiglottitis Asthma Chest pain - R/O MI Childhood bacterial meningitis Community-acquired pneumonia CVA Dementia Diabetic ketoacidosis. Lau KJ, DeRonne MB, Southern J, Hudson And then close out the order set. This is to support decision making with regards to the implementation of SOSs in the acute setting, such as in tertiary, community, and regional hospitals, and across multiple jurisdictions. Ehringer No comparison of demographics or patient characteristics between patients seen in each time period. Many of the included studies were set in single-centres or single-hospitals, which may limit generalizability to other settings or centres. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. Implementation and evaluation of a diabetic ketoacidosis order set in pediatric type 1 diabetes at a tertiary care hospital: a quality-improvement initiative. If appropriate, order measures to promote sleep and prevent reversal of sleep-wake cycles, order early mobilization, re-orient frequently, avoid restraints, avoid urinary catheters, avoid benzodiazepines. Despite this, four studies were conducted in Canada, and the remaining studies in the USA, which may assist in generalizability to a North American context.8,12,18,19. If appropriate, prescribe nicotine replacement therapy at discharge. Brown L. Ottawa: CADTH; 2019 Jul. No evidence regarding cost-effectiveness and no evidence-based guidelines were identified. DW, Kim D. O. The use of this document outside of Canada is done so at the users own risk. This biasing may also have occurred in studies that changed the intervention mid way through the implementation phase, (e.g., changing who is responsible for ensuring use of SOS,13 or changing from paper to electronic formats13,20), because it is unclear whether the change occurred due to the introduction of the SOS, or due to the change that occurred during the intervention time period. Many of these patients problems were relatively routine, while others were less common or more complex and, therefore, more difficult for our admitting physicians to manage. Additional details regarding the characteristics of included publications are provided in Appendix 2. In is 15-physician department of family medicine, which your part of a large multispecialty clinic, are care with our hospitalized patients with an "internal hospitalist" program. BACKGROUND Few studies exist on the ability of standardized preprinted order forms to improve patient care. Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. Order set to improve the care of patients hospitalized for an exacerbation of chronic obstructive pulmonary disease. A, Lau CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites. Ansari AN, Kalehoff Eventually, all of our physicians began to share this responsibility one week at a time, which left each of our doctors having a fairly intensive inpatient experience every three to four months. The main search concepts were order sets and acute care. Approach to Inpatient Death and Sunset Rounds. I routinely ask students to write their own orders, which we then compare to the standard ordered for discussion and teaching purposes. M, Lin The cut-off for small sample size was not determined a priori. Four studies were conducted in a Canadian setting, which may aid in generalizability to the Canadian context.8,12,18,19. These handwritten orders can be ineligible or inappropriate (leading to medication errors), or can create variability in patient care between physicians and patients that is not explained by the patients condition.1, Standardized order sets (SOSs) are clinical decision support tools that aim to help physicians prescribe appropriate treatments using a pre-defined set of applicable drugs and recommended dosages, based off evidence-based guidelines for a specific disease area.2 SOSs, whether they are inputted electronically (such as through a computerized provider order entry [CPOE] system) or through paper orders, have the potential to reduce medication errors, reduce unnecessary clarification calls between physicians and pharmacists, increase the use of evidence based care, and increase efficient workflow.2 Additionally, the creation and use of order sets can provide an opportunity to educate physicians on best practices, or to provide reminders on appropriate prescribing and treatment.3 It is recommended that order sets are complete for the condition they are intended for, reflect the best practice for the disease area, stay up to date on best practices, and are standardized across practitioners.2. Dayal F. All 30 of the standardized admit orders developed by the Scott & White Clinic at College Station, Texas, can be downloaded below. oneChart Order Sets; Anesthesia . Pre-post study design does not consider impact of time on groups care from pre-intervention may differ slightly from care in post-intervention (i.e., history threats to validity). Guidelines for standard order sets. The hospital administration and staff own are very receptive; in fact, the hospital has even designed some of its standard ordering sets to match ours. DA, et al. A person viewing it online maybe make one printout of the material and maybe used that printout only for his or her personal, non-commercial reference. Our practice is approximately 70 percent to 75 percent capitated, so cost reduction is a significant issue for us. We do not require the physicians or residents to use the standard orders but have found that most choose to do so. The orders were again assigned to each of our doctors, who researched and revised them. Patients in the order set group may have been healthier upon admission to hospital compared with the no order set group. Pairwise comparisons between study periods: All significant (adjusted P < 0.05), except P2 vs. P3 (P = 0.83), Change in LOS was affected by the study period (P1,2,3,4) i.e., slope of linear regression depended on which study period observed (significant, P = 0.015), LOS tended to decrease within each process improvement period Page 9, During P1, a one-year increase in time was associated with a 38% decrease in LOS, P = 0.054, During P2, a one-year increase in time was associated with a 7.2% decrease in LOS, P = 0.56, During P3, a one-year increase in time was associated with a 37% decrease in LOS, P = 0.02, During P4, a one-year increase in time was associated with a 4% increase in LOS, P = 0.33, Time to beta-agonist or steroid administration, No statistically significant improvement or deterioration of time to therapeutics over observation time-period, Comparisons of P2, P3, and P4 non-significant, P 0.064, Significant decrease between beginning and end of study period P = 0.008, We observed a substantial reduction in hospital length of stay associated with utilization of an evidence based, best practice asthma management pathway incorporating a CRS, first via paper order sets and then within CPOE, combined with a tool to expedite appropriate discharge. A standardized admission order set is a simple, low-cost intervention that residents believe may benefit patients by reducing medical errors and expediting high-quality care. We can also access the forms at our clinic and at our urgent care department, where many of our admissions originate. When we firstly developed our standardized admission orders seven years ago, we chose 27 conditions that we thought will shall of valuable. No relevant evidence regarding cost effectiveness of SOSs was identified; therefore, no summary regarding cost-effectiveness can be provided. No significant difference in hypertension, diabetes, CHF, coronary artery disease, obstructive sleep apnea. Confounding not considered nor adjusted for, Patient demographics reported and tested statistically between groups, Multivariate analysis used to test for association of factors that differed between groups to choose to use the SOS, and found to be not be significant, Multiple regression model used, and confounders adjusted for, No losses to follow-up due to study design, Some values differ between text and tables e.g., mean age of whole cohort transcribed as 62 in text and 69 in table, FEV1 score differ (55.1% vs. 53%). A, Alvarez One reviewer screened citations and selected studies. CG, Castano Sample size calculation performed with alpha of 0.05 and power of 80%, Unclear what procedure was pre-implementation, Unit of analysis was hospital admission (readmission treated as separate data points), so effects of clustering of the same patients not taken into account, Order set use optional by physicians which may affect adherence and selection (66% of physician use, Study did not have the statistical power to detect effects on some of the outcomes at 30 days (rehospitalizations, recurrent exacerbations, or mortality), No statistical comparison of demographics before and after implementation, Appropriate parametric and non-parametric tests used - for different data distributions, Use of stroke order set evaluated in supplementary not just availability of set, so changes likely due to use of set, Demographics of individuals receiving the stroke order set visually appeared to be similar, Intervention of interest described with attached order set components. Results written in a misleading way e.g., The binary logistic regression method revealed that 6.6% of patients in the order set group (N = 362) died versus 11.3% in the no order set group (N = 4,725), (p8) This seems like the number of deaths in each group came from a regression model, when in actuality they came from ICD-9 codes in the patient files. See Using Standardized Admit Orders to Improve Inpatient Care, in page 30 of that issue.] A, Wilson C, Inman Each physician rotates as a hospitalist, kind entirely for family medicine inpatients for one week every very months. Means used with Mann Whitney U test, reasoning not explained, distribution of comorbidity data not discussed, Retrospective study design does not allow for control of potential confounding variables in the two groups, Relevant demographics information reported, Educational sessions used to explain proper use of order sets, Mean daily blood glucose adjusted for confounders, Multiple time points taken to adjust for temporal changes in daily glucose levels, Unit of analysis was hospital admission (readmission treated as separate data points), but standard errors were adjusted for the correlation of observations within individuals Intervention of interest described with attached order set, Single centre study may not be generalizable to other settings, Demographics information not statistically tested, Retrospective study design does not allow for control of potential unmeasured confounding variables in the two groups, No demographics were reported or compared. Days of total systemic corticosteroids, (mean SD). Enter an appropriate reason for why the orders are being held and then click Accept. Changes are reviewed by the BHCS Pharmacy and Therapeutics and Patient Safety Committees. AECOPD = acute exacerbation chronic obstructive pulmonary disease; CCI = clinical comorbidities index; CDST = clinical decision support tool; CMOS = comfort measures order set; CPOE = computerized provider order entry; ICD-9 = International Classification of Diseases, Ninth Revision; FEV1 = forced expiratory volume; LOS = length of stay; PICU = pediatric intensive care unit; SOS = standardized order set, N = 1494 visits total, 1223 unique patients, Period 3 (P3) - CPOE + SOS + discharge checklist, Period 4 (P4) - CPOE + SOS + revised checklist, CPOE month over month use rate was 83 to 89% (mean of 85%), Discharge checklist use rate increase 18% to 72%, LOS (geometric mean, hours), general linear model. Time periods compared differ between outcomes, this is not explained e.g., for primary outcomes pre-implementation was between 2009 and 2010, but costs were in 2009 only, and for post-implementation. An order set for patient hospitalizations for ischemic stroke significantly reduced 30-day, 60-day, and 90-day mortality, but did not significantly lower in hospital or 7 day mortality. The cut-off for small sample size was not determined a priori. (Author) 7 ratings See all formats and editions Paperback $33.00 Other new and used from $5.19 Book by Kangarlu, M.D. Condom catheters can be useful for those who have difficulty using a urinal, or cannot tolerate Foley catheters. To help decay unnecessary variability int our caution, we designed an series on admission orders for common hospital admissions. J, Eby A, Ayad Additionally, power calculations were performed for two of the included studies,10,19 but not all studies had a power calculation, so it is unknown whether all studies had appropriate power to detect a statistical difference. Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. These orders have also proved award resources for teaching students and residents. The search was also limited to English language documents published between January 1, 2014 and June 27, 2019. KJ, Kumar Hospitalist Admission Order Sets. For the current report, a limited literature search was conducted by an information specialist on key resources including Medline and PsycINFO via OVID, the Cochrane Library, the University of York Centre for Reviews and Dissemination (CRD) databases, the websites of Canadian and major international health technology agencies, as well as a focused Internet search. The admission orders cover the following conditions: Copyright 2001 by the American Academy of Family Physicians. Retrospective studies may also be limited by bias due to selection of participants. AS. Algorithm for GI ppx: local formularies may differ. Pendharkar In 1999, the 17 family physicians of the Scott & White Clinic in College Station, Texas, developed a set of standardized orders for use in admitting patients to the hospital. Because of the wide scope of family medicine, we cared for patients with a wide variety of medical conditions. ( ) Refer to Observation Routine, ONE TIME Admission Service: Admission Level of Care: Admission Diagnosis: Attending Physician: Comments: Informational: Observation orders require a documented Plan of Care from the ordering practitioner Starting *D2108* *D2108* THE CHRIST HOSPITAL CINCINNATI, OHIO 45219 SD. This report makes use of a literature search strategy developed for a previous CADTH report. [14, 15] Two observational studies have demonstrated that order sets likely improve the quality of hospital care for patients with AECOPD and reduce LOS. This limits the conclusions that can be made about these other indications, as each order set is specific to the indication they are used for or the setting they are used in and not a general order set for every indication. Our physicians are not need to use orders for every admission Each patient presents with a exclusive situation both should be address accordingly at that physicians discretion. Copy 2006 by the American Academy starting Families Physicians. Hospital LOS not statistically tested (although, unlikely to affect the results as they were the same length of time), Physicians not using the order sets may have been more likely to have been performing additional pharyngectomies, thyroidectomies or free flap, which require more complex ordering/procedures, Intervention of interest described with order set components. Articles were excluded if they did not meet the selection criteria outlined in Table 1, they were duplicate publications, or were published prior to 2014. We encouraged the physicians to take an evidence-based approach, and we sought input from appropriate specialists. Fourteen non-randomized studies were identified regarding SOSs in the acute setting.821 Seven studies examined patients with respiratory conditions,10,11,13,14,17,21 and two with diabetic conditions.12,20 The remaining studies examined patients undergoing laryngectomy,8 EOL care,18 ischemic stroke care,9 CHF care,16 or receipt of vanomycin.15 Overall, SOSs significantly lowered hospital LOS when compared to no order sets. Consists of 3 parts: 1) threshold criteria 2) patient questions 3) clinical evaluation. Appropriate initial dose, overall, %, pre CPOE vs. CPOE, Critically ill patients; 28 vs. 45, P = 0.0441, Initial dose per indication, mean SD, pre CPOE vs. CPOE, Overall mean dose: 14.6 4.9 vs. 17.4 5.7, P <0.0001, Skin and soft tissue: 13.0 4.6 vs. 16.3 5.7, P < 0.0001, Pulmonary: 15.3 4.5 vs. 18.1 5.5, P = 0.0031, Sepsis: 17.5 4.7 vs. 18.0 5.4, P = 0.72, Urinary tract: 14.4 5.4 vs. 17.9 6.2, P = 0.046, Others: 14.8 4.8 vs. 18.0 5.7, P = 0.0014, Initial dose by weight, mean SD, pre CPOE vs. CPOE, <50 kg: 23.1 3.6 vs. 25.7 5.7, P = 0.107, 5075 kg: 17.0 3.4 vs. 20.1 4.8, P < 0.0001, 76100 kg: 13.5 3.7 vs. 16.9 4.2 P < 0.0001, >100 kg 9.6 3.1 vs. 12.9 4.4, P <0.0001, Note: sample sizes differ due to availability of records, OR = 1.362 (95% CI 1.015 to 1.827), P < 0.05, Results remained consistent when patients who had died were removed from the analysis, Surgery/Orthopedics/Gynecology: 26.5 vs. 20.4, Ordering of the preferred combination of BBC insulin regimen, %, all services combined, Use of sliding-scale insulin monotherapy, %, Use of 70/30 premixed insulin with correction, %, Use of any basal with mealtime and correctional insulin, %, Prescribing of any basal insulin (with or without nutritional), %, Day 3, day 7 (P < 0.10), all other P values NR, Blood glucose decrease, days 3 to 9, difference between SOS and no SOS, No significant change in the incidence of moderate hypoglycemia (P = 0.15) or severe hypoglycemia (P = 0.38), However, comparison of the order set and free text groups and statistical significance of the mortality outcome point to the fact that CHF ordering via sets has potentially strong influence on this health outcome The study did not establish statistical link between utilization of CHF order sets and 30-day readmissions. 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