The clinical excellence (CE) department at New Hanover Regional Medical Center uses data-driven and multidisciplinary methodology to drive sustainable value in terms of quality, cost, and outcomes. Decision support tools within the organization’s clinical information system are recognized as valuable instruments in translating evidence into practice. These tools, specifically order sets, are being transformed to reduce unwarranted care variation and have led to measurable outcome improvements for congestive heart failure and spinal fusion patients. Ongoing work also shows promise in reducing inappropriate blood utilization and improving stroke and sepsis-related outcomes. The purpose of this presentation is to discuss outcome improvements related to the optimization of order sets using evidence-based care standards and decision-support.
Congestive heart failure: congestive heart failure (CHF) is a chronic, progressive disease characterized by high readmission rates. The CE CHF work team used data to identify unwarranted variation in the care of CHF patients. Initial system evaluation revealed that multiple admission order sets were used by various provider groups who admit CHF patients and inconsistent ordering practices among various provider groups. Utilizing a value-based approach to care delivery (value = outcomes/cost), the team revised the order sets to align with evidence-based care standards and support ideal medication utilization and diagnostic ordering.
An initial order set utilization rate of 46.7% during the intervention month increased to and maintained above 91% within four months of implementation and has sustained for over three months through provide-to-provider communication based on utilization reports. Baseline data was aggregated based on CHF DRGs for eight months prior to order set intervention and for seven months following intervention for the following metrics: average inpatient length of stay which decreased from 5.76 days to 5.46 days, all-cause readmission rates which decreased from 19.07% to 16.83%, and average direct cost per case which decreased from $4,895 to $4,469. Additionally, the American Heart Association’s Get with the Guidelines achievement measures composite compliance was monitored during the same time frame and increased from 76% to 86%.
Spinal fusion, blood utilization, stroke and sepsis: Using a similar approach, outcome data was used to identify opportunities for evidence-based order set redesign. Post-implementation data related to spinal fusion has shown an increase in order set utilization from 34% to 90% and a decrease in IV Tylenol and Exparel ordering, both high cost medications with efficacious alternatives, from 45% to 0% and 62% to 35% respectively. Additionally, the post-operative brace ordering workflow was revised, resulting in a year-to-date $33,656 difference in spend from 2018. Blood utilization, stroke, and sepsis work remains in various stages of revision and data will be available for report within the next 6 months. Results from these initiatives will also be included in the presentation.
Clinical decision support has the potential to drive evidence-based care and improve patient and organizational outcomes. While our clinical excellence program is still in its infancy, data supports the positive impact of our work. Learners will become familiar with decision support strategies for order set optimization using evidence to improve outcomes.