Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting

Leis, Benjamin; Frost, Andrew; Bryce, Rhonda; Coverett, Kelly

doi:10.1136/bmjqs-2017-006898

Cited by 11 publications

(8 citation statements)

References 7 publications

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“…Other order sets can place tests that are not always required based on patient presentation, often leading to inappropriate ordering. As described by Leis et al, a standard order set in the CCU contained BNP and TSH and were often ordered on admission without clinical indication. They removed the lab tests from a test order set and noted that TSH and BNP were no longer ordered or added on to patients’ blood work.…”

Section: Forcing Functionsmentioning

confidence: 99%

Decreasing daily blood work in hospitals: What works and what doesn't

Jalbert

Gob

Chin‐Yee

2019

Int J Lab Hematology

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Recurrent, inappropriate laboratory testing is a costly and wasteful use of healthcare resources. Recognizing this problem, the American Board of Internal Medicine, Canadian Society of Internal Medicine, and the Canadian Association of Pathologist all supported the Choosing Wisely campaign to reduce laboratory investigations in patients who demonstrate clinical and laboratory stability. In this narrative, we review studies looking at a variety of approaches to reduce excessive testing including education, audit and feedback, computerized physician order entry system changes, and forcing functions. Each type of intervention has its own unique advantages and disadvantages, varying in complexity, disruptiveness, effectiveness, and sustainability. Before implementing any quality improvement project, it is important to analyze the local context to identify the root causes for the practice behavior and aim to use the minimal amount of intervention to achieve the desired result. Change is often incremental and will seldom occur with a single intervention or Plan‐Do‐Study‐Act cycle. Garnering the support of opinion leaders and a quality improvement team will help make the process and intervention a success.

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Section: Forcing Functionsmentioning

confidence: 99%

Decreasing daily blood work in hospitals: What works and what doesn't

Jalbert

Gob

Chin‐Yee

2019

Int J Lab Hematology

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“…The first was that a solution as simple as order set design can have a large impact, without the undesirable consequences of alarm fatigue/popup fatigue/change fatigue. Two recent studies demonstrated how the mere presence of an order on an admission order set makes it inherently more likely to be ordered 11 12. Interventions explored in the literature had either a modest (policy change alone) or unsustained (education alone) effect, or required a significant amount of effort to upkeep (audit and feedback).…”

Section: Discussionmentioning

confidence: 99%

Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative

et al. 2019

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Background/contextDespite Choosing Wisely recommendations for single unit red blood cell transfusion orders, ~50% of orders on the oncology ward at London Health Sciences Centre (LHSC) were for two units. The oncology ward at LHSC is a 60 bed tertiary care unit. In mid 2016, LHSC was 18 months into its implementation of computerised provider order entry (CPOE).Aim/objectivesBy December 2017, increase the proportion of one-unit red cell transfusion orders on the oncology ward from 50% to 80%MeasuresOutcome: % one-unit red cell transfusion orders (aggregated monthly).Improvement/innovation/change ideasOur initial theory was that unawareness of the guidelines (established in 2014) and subscription to the obsolete doctrine of two-unit transfusions were the primary behavioural drivers. Initial change ideas included an educational/awareness blitz including rounds presentations, memos and posters. Failure led us to revisit our hypothesis and carry out a real-time audit, where our team was notified on each two-unit transfusion. This revealed the true root cause: the overwhelming majority of two-unit transfusions could be traced back to standing orders that were entered on an admission order set. After provider engagement, we proceeded to remove all admission order sets containing two-unit transfusions.Impact/lessons learned/resultsAfter order set removal, our one-unit transfusion rate rose to 86% and was sustained for 17 months. We learnt two primary lessons. First that CPOE and poor order set design combined to perpetuate poor ordering practices. Second that revisiting our hypothesis and engaging in thoughtful root cause analysis that included direct observation ultimately led to an effective, sustainable solution.Discussion/spreadOur study underscores the importance of executing root cause analysis on a microsystem level. We would expect the factors driving poor performance to be completely different on a service such as general internal medicine. Our study also highlights the potential pitfalls of CPOE and the importance of regular order set review to ensure adherence to current evidence.

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“…Munigala et al 17 found that removing urine tests other than the default test from the 'frequently ordered' window of the emergency department electronic order set decreased ordering of urine cultures. Leis e t al 18 found that whether or not a test was included as part of a standard admission order set strongly influenced whether the test was ordered at all even if there was no explicit prohibition on ordering it. Our study adds important data to this literature; it is the only randomised controlled trial that we are aware of to study the use of default option nudges in a clinical context, although through the use of vignettes.…”

Section: Discussionmentioning

confidence: 99%

Effect of two behavioural ‘nudging’ interventions on management decisions for low back pain: a randomised vignette-based study in general practitioners

et al. 2018

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Objective‘Nudges’ are subtle cognitive cues thought to influence behaviour. We investigated whether embedding nudges in a general practitioner (GP) clinical decision support display can reduce low-value management decisions .MethodsAustralian GPs completed four clinical vignettes of patients with low back pain. Participants chose from three guideline-concordant and three guideline-discordant (low-value) management options for each vignette, on a computer screen. A 2×2 factorial design randomised participants to two possible nudge interventions: ‘partition display’ nudge (low-value options presented horizontally, high-value options listed vertically) or ‘default option’ nudge (high-value options presented as the default, low-value options presented only after clicking for more). The primary outcome was the proportion of scenarios where practitioners chose at least one of the low-value care options.Results120 GPs (72% male, 28% female) completed the trial (n=480 vignettes). Participants using a conventional menu display without nudges chose at least one low-value care option in 42% of scenarios. Participants exposed to the default option nudge were 44% less likely to choose at least one low-value care option (OR 0.56, 95%CI 0.37 to 0.85; p=0.006) compared with those not exposed. The partition display nudge had no effect on choice of low-value care (OR 1.08, 95%CI 0.72 to 1.64; p=0.7). There was no interaction between the nudges (OR 0.94, 95% CI 0.41 to 2.15; p=0.89).InterpretationA default option nudge reduced the odds of choosing low-value options for low back pain in clinical vignettes. Embedding high value options as defaults in clinical decision support tools could improve quality of care. More research is needed into how nudges impact clinical decision-making in different contexts.

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Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting

Cited by 11 publications

References 7 publications

Decreasing daily blood work in hospitals: What works and what doesn't

Decreasing daily blood work in hospitals: What works and what doesn't

Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative

Effect of two behavioural ‘nudging’ interventions on management decisions for low back pain: a randomised vignette-based study in general practitioners

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