Reorganizing Emergency Department Information Systems to Reduce Physician Cognitive Load

https://digitalcommons.unmc.edu/com_emerg_pres/1003/thumbnail.jp

Discrepancies in Written Versus Calculated Durations in Opioid Prescriptions: Pre-Post Study.

BACKGROUND: The United States is in the midst of an opioid epidemic. Long-term use of opioid medications is associated with an increased risk of dependence. The US Centers for Disease Control and Prevention makes specific recommendations regarding opioid prescribing, including that prescription quantities should not exceed the intended duration of treatment. OBJECTIVE: The purpose of this study was to determine if opioid prescription quantities written at our institution exceed intended duration of treatment and whether enhancements to our electronic health record system improved any discrepancies. METHODS: We examined the opioid prescriptions written at our institution for a 22-month period. We examined the duration of treatment documented in the prescription itself and calculated a duration based on the quantity of tablets and doses per day. We determined whether requiring documentation of the prescription duration affected these outcomes. RESULTS: We reviewed 72,314 opioid prescriptions, of which 16.96% had a calculated duration that was greater than what wasdocumented in the prescription. Making the duration a required field significantly reduced this discrepancy (17.95% vs 16.21%,P CONCLUSIONS: Health information technology vendors should develop tools that, by default, accurately represent prescription durations and/or modify doses and quantities dispensed based on provider-entered durations. This would potentially reduce unintended prolonged opioid use and reduce the potential for long-term dependence

Understanding subscription-based automated electronic notification usage in hospitals: a qualitative study

Introduction: The potential exists for patient harm when clinicians do not respond to clinical results in a timely manner. Much of the research on asynchronous electronic notifications (pager, cellphone or wearable devices) comes from home-grown electronic health records (EHR). Little is known about factors influencing notifications from vendor-based EHRs and the effect of subscription-based notifications, where providers select which results for notification. This study investigates what factors influence a clinician’s decision to order result notifications, the perceived role of these notifications in the clinical setting, and ways to improve notifications in a vendor-based EHR. Methods: We queried the EHR to identify clinicians using the “bell” notification functionality of Epic (Epic Systems, Verona WI) in an academic health system comprised of one tertiary care center and one community hospital. We distributed an online survey to individuals identified to have used the functionality via retrospective review of clinical results over a 12-month period. We received completed surveys from a diverse group of clinical staff, and we used descriptive statistics to analyze the survey data. Results: Via retrospective review, we identified 874 individuals who used the system. Of these, we received 67 (7.7%) survey responses. Of those who responded, 72% reported the functionality is “likely to help” patients, and 66% of respondents believe the functionality “speeds up workflow.” Additionally, 41% of clinicians stated they had experiences where the “bell” notification “improved patient outcomes.” Discussion: A majority of clinicians viewed the subscription-based “bell” notification functionality favorably, would recommend it to other clinicians, and stated that it has a positive impact on workflow. However, only a minority of clinicians identified specific instances where the functionality improved patient care. Further research should prospectively identify what factors impact how and why healthcare providers use subscription-based notifications and if use of these systems can improve patient outcomes

Provider Use of Risk Stratification Tools for PE and CTA Ordering Practices

Aims for Improvement Quantify utilization of clinical decision tools, D-dimer and CTA-PE at TJUH and compare to benchmark and implement the logic seen in the adjacent QR code to an EPIC pop-u

Assessing Sentiment Towards Opioid Use Disorder at Jefferson: Characterizing Non-Clinical Emergency Department Staff

Purpose: To characterize emergency department (ED) staff regard toward opioid use disorder (OUD) and analyze variation based on job category. The closure of Hahnemann Hospital, in combination with the increasing prevalence of OUD, is exacerbating the previously inadequate network of resources for these patients. Jefferson is strategically positioned to improve the care provided to this patient population, especially in an ED setting, and ultimately increase linkage to long-term recovery programs. Methods: Sentiment toward this patient population was measured utilizing the Medical Condition Regard Survey (MCRS). This questionnaire was previously validated to subjectively, but quantitatively, assess regard toward a defined patient population with scores ranging from 11 (lowest regard) to 66 (highest regard). Scores were collected for 425 ED employees, of which 303 were classified as providers and 70 as non-clinical staff. Given the variety of healthcare professionals involved in treating patients in the ED, the targeted population of potential learners is broad and encompassing. Results and Conclusions: While the average MCRS score of 47.3 ± 8.4 is relatively positive and generally consistent across job categories, there is significant variation in scores between individuals. The inconsistency of sentiment toward OUD among Jefferson ED staff is highlighted by MCRS scores at both the positive and negative extremes. Interestingly, most patients usually only interact with a single individual in each job role, reinforcing the potential for inconsistent care. This information will inform the development of educational materials to target shortcomings, highlight strengths and improve staff competency in successfully treating these patients

Hepatitis A Vaccination Program in Jefferson Emergency Departments

Aims for Improvement Increase the rate of hepatitis A vaccination in high-risk patients (homeless and drug users) who present to Thomas Jefferson University Hospital and Jefferson Methodist emergency departments over a 5 month period starting on 9/4/2019

Understanding Clinical Staff Attitudes Towards Patients Presenting to the Emergency Department with Opioid Use Disorder

Purpose: Significant stigma surrounds patients with opioid use disorder (OUD). This stigma repeatedly follows patients into the ED and negatively influences care. All ED staff impact the patient journey in the ED and the success with which OUD patients receive a warm handoff to a recovery organization. What is the current attitude of Jefferson’s clinical staff towards patients with OUD? Methods: The authors developed and deployed a survey to Jefferson’s ED clinical staff members through Qualtrics. The survey was informed by the validated Medical Condition Regard Scale (MCRS) to capture staff sentiments towards patients with OUD. Respondents job category, job description, campus key and name were collected at the start of each survey. Results and Conclusions: Results are in progress. To date, 398 ED clinical staff members completed the survey. The average MCRS score is 47.3 (66 max). The average of most job categories surveyed exhibited an MCRS score close to the global mean with the exception of the “Pharmacy” and “Patient Access” categories in which the MCRS score was higher (low 50s). The results suggest that there is room for improvement of clinical staff attitudes towards this vulnerable patient population. As the epidemic continues to escalate, educators will need to identify methods to engage staff members in order to improve outcomes of patients with OUD who present to the ED

Design and Implementation of an Opioid Scorecard for Hospital System-Wide Peer Comparison of Opioid Prescribing Habits: Observational Study

BACKGROUND: Reductions in opioid prescribing by health care providers can lead to a decreased risk of opioid dependence in patients. Peer comparison has been demonstrated to impact providers\u27 prescribing habits, though its effect on opioid prescribing has predominantly been studied in the emergency department setting. OBJECTIVE: The purpose of this study is to describe the development of an enterprise-wide opioid scorecard, the architecture of its implementation, and plans for future research on its effects. METHODS: Using data generated by the author\u27s enterprise vendor-based electronic health record, the enterprise analytics software, and expertise from a dedicated group of informaticists, physicians, and analysts, the authors developed an opioid scorecard that was released on a quarterly basis via email to all opioid prescribers at our institution. These scorecards compare providers\u27 opioid prescribing habits on the basis of established metrics to those of their peers within their specialty throughout the enterprise. RESULTS: At the time of this study\u27s completion, 2034 providers have received at least 1 scorecard over a 5-quarter period ending in September 2021. Poisson regression demonstrated a 1.6% quarterly reduction in opioid prescribing, and chi-square analysis demonstrated pre-post reductions in the proportion of prescriptions longer than 5 days\u27 duration and a morphine equivalent daily dose of \u3e50. CONCLUSIONS: To our knowledge, this is the first peer comparison effort with high-quality evidence-based metrics of this scale published in the literature. By sharing this process for designing the metrics and the process of distribution, the authors hope to influence other health systems to attempt to curb the opioid pandemic through peer comparison. Future research examining the effects of this intervention could demonstrate significant reductions in opioid prescribing, thus potentially reducing the progression of individual patients to opioid use disorder and the associated increased risk of morbidity and mortality

Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre-Post Study

BACKGROUND: The United States is in an opioid epidemic. Passive decision support in the electronic health record (EHR) through opioid prescription presets may aid in curbing opioid dependence. OBJECTIVE: The objective of this study is to determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system. METHODS: We performed a quasi-experimental retrospective pre-post analysis of a 24-month period before and after modifications to our EHR\u27s opioid prescription presets to match Centers for Disease Control and Prevention guidelines. We included all opioid prescriptions prescribed at our institution for nonchronic pain. Our modifications to the EHR include (1) making duration of treatment for an opioid prescription mandatory, (2) adding a quick button for 3 days\u27 duration while removing others, and (3) setting the default quantity of all oral opioid formulations to 10 tablets. We examined the quantity in tablets, duration in days, and proportion of prescriptions greater than 90 morphine milligram equivalents/day for our hospital system, and compared these values before and after our intervention for effect. RESULTS: There were 78,246 prescriptions included in our study written on 30,975 unique patients. There was a significant reduction for all opioid prescriptions pre versus post in (1) the overall median quantity of tablets dispensed (54 [IQR 40-120] vs 42 [IQR 18-90]; PPP\u3c.001). CONCLUSIONS: Modifications of opioid prescribing presets in the EHR can improve prescribing practice patterns. Reducing duration and quantity of opioid prescriptions could reduce the risk of dependence and overdose

Tranq Dope: Characterization of an ED Cohort Treated With a Novel Opioid Withdrawal Protocol in the Era of Fentanyl/Xylazine

BACKGROUND: Treating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as \u27tranq dope,\u27 is poorly described in literature. Inadequate withdrawal treatment results in a disproportionately high rate of patient-directed discharges (also known as against medical advice dispositions, or AMA). This study aimed to describe a cohort of individuals who received a novel order set for suspected fentanyl and xylazine withdrawal in the ED. METHODS: This is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications. RESULTS: There were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p \u3c 0.001). The AMA rate for this cohort was 3.9 %, whereas the baseline for the population with OUD was 10.7 %. Recorded adverse effects were few and resolved without complication. CONCLUSIONS: Fentanyl and xylazine withdrawal are challenging for patients and providers. A novel tranq dope withdrawal order set may reduce both COWS scores and rate of patient-directed discharge in this cohort of patients, though further investigation is needed to confirm findings