Clinical Decision Support Tool for Parental Tobacco Treatment in Hospitalized Children

Abstract

SummaryObjectives: To create and evaluate the feasibility, acceptability, and usability of a clinical decision support (CDS) tool within the electronic health record (EHR) to help pediatricians provide smoking cessation counseling and treatment to parents of hospitalized children exposed to secondhand smoke (SHS). Methods: Mixed method study of first-year pediatric residents on one inpatient unit. Residents received training in smoking cessation counseling, nicotine replacement therapy (NRT) prescribing, and use of a CDS tool to aid in this process. The tool, which alerted when a patient was identified as exposed to SHS based on the history taken on admission or during a prior encounter, had the following capabilities: adding SHS exposure to the patient's problem list; referral to Free Quitline through discharge instructions; and linking to a printable NRT prescription form. We measured feasibility by EHR utilization data. We measured acceptability and usability of the tool by administering questionnaires to residents. Results: From June-August 2015, the alert triggered for 106 patients, and the tool was used for 52 (49%) patients. 41 (39%) patients had SHS exposure added to the problem list, 34 (32%) parents were referred to the Quitline through discharge instructions, and 15 (14%) parents were prescribed NRT. 10 out of 15 (67%) eligible pediatricians used the tool. All clinicians surveyed (9 out of 10) found the tool acceptable and rated its usability good to excellent (average System Usability Scale score was 85 out of 100, 95% CI,[76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91][92][93]. Conclusions: A non-interruptive CDS tool to help residents provide smoking cessation counseling in the hospital was feasible, acceptable, and usable. Future work will investigate impacts on patient outcomes. BackgroundSecondhand smoke (SHS) exposure is a significant public health problem with clear negative impacts on children's health, including increased risk of asthma exacerbation, hospitalization, and premature death [1][2][3]. While 17% of US adults smoke cigarettes [4], more than 40% of US children have evidence of SHS exposure [5]. Hospital-initiated tobacco control interventions promote smoking cessation in adults, especially when counseling is combined with nicotine replacement therapy (NRT) [6]. Parents who smoke are receptive to receiving smoking cessation interventions when their child is hospitalized [7]. Inpatient pediatric clinicians, however, rarely provide such treatments to parents who smoke [7,8].Pediatric-based smoking cessation interventions in a variety of care settings may be effective in helping parents quit, but barriers have prevented further adoption and sustainability of such practices [8][9][10]. Time, logistical issues, record-keeping challenges, scope of practice concerns, and lack of insurance reimbursement are cited as barriers to counseling and prescribing NRT [11]. To address these concerns, professional organizations have adopted policy statements and clinical guidelines th...

Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations

“…37,38 Promising research suggests that the use of clinical decision support systems within the electronic health record may help to facilitate the systematic screening and counseling of all caregivers who smoke by healthcare providers in the ED and other settings. 39–43 As healthcare providers find clinical decision support system use both feasible and acceptable, further research is needed to determine how the routine use of these tools impacts future SHSe-related morbidity, visits, and costs in pediatric patients.…”

Interruptive Versus Noninterruptive Clinical Decision Support: Usability Study

“…Noninterruptive CDS tools, which do not require stoppage of other electronic health record (EHR) activity, may be less subject to alert fatigue [6,7]. A number of studies have demonstrated that noninterruptive alerts can increase provider compliance with care measures such as venous thromboembolism prevention in the inpatient setting [8,9], yet this type of alert is generally perceived as less successful at changing provider behavior compared with interruptive alerts [6,7]. Nonetheless, the few studies that compare the relative uptake of interruptive and noninterruptive alerts have not consistently shown interruptive alerts to be superior [10,11].…”

“…Finally, despite assumptions that noninterruptive alerts have less effect on workflow [6,7], there has been little evaluation of the relative usability of interruptive and noninterruptive alerts. Although prior studies have evaluated the usability of either interruptive or noninterruptive alerts [9,12,13], we are unaware of studies that have compared the usability of these 2 implementation approaches. Information about their relative usability can help inform developers of CDS about the relative advantages of interruptive and noninterruptive alerts.…”

An Electronic Health Record−Based Strategy to Address Child Tobacco Smoke Exposure

“…This study adds to the growing literature supporting the use of CDSS to increase standardized TSE screening and interventions in the pediatric healthcare setting. 39–41 This model has the potential to improve the delivery and outcomes of evidence-based TSE screening and treatment in the UC setting. The use of the CDSS resulted in the identification of large numbers of children who were exposed to tobacco smoke and there were increases in the proportion of caregivers who were advised to quit and assessed for readiness to quit.…”