The Effect of Implementation of Guideline Order Bundles Into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Study

• Type of Material: Article
• Authors: Justine Mrosak, Hennepin Healthcare; Swaminathan Kandaswamy, Emory University; Claire Stokes, Emory University; David Roth, University of Pittsburgh School of Medicine; Jenna Gorbatkin, Emory University; Ishaan Dave, Emory University; Scott Gillespie, Emory University; Evan Orenstein, Emory University
• Language: English
• Date: 2023-01-01
• Publisher: JMIR Publications
• Publication Version: Final Published Version
• Copyright Statement: ©Justine Mrosak, Swaminathan Kandaswamy, Claire Stokes, David Roth, Jenna Gorbatkin, Ishaan Dave, Scott Gillespie, Evan Orenstein. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 21.03.2023.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.2196/42736
• Title of Journal or Parent Work: JMIR Medical Informatics
• Volume: 11
• Start Page: e42736
• End Page: e42736
• Keywords: diagnostic uncertainty; user-centered design; clinical practice guideline; CPG; order bundle; decision support; diagnostic; clinical guideline; clinical decision support
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Oncology

Abstract

Background: Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs’ impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations. Objective: We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of 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 pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission. Results: CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), 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 (28/227, 12.3% vs 19/81, 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 underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.