Background: Nebraska Medicine is dedicated to the continuous, goal-directed improvement of: 1. Central venous catheter (CVC) duration
2. Indwelling urinary catheter (IUC) duration
3. Telemetry duration
4. VTE prophylaxis
5. Non-violent restraint order renewal
Clinical decision support (CDS) is a cornerstone of quality improvement efforts despite historically sub-optimal response rates. After 2 years of improvements in each domain, provider response rate to CDS was targeted as an opportunity for incremental improvement. The quality metric checklist (QMC) is an accurate, dynamic, actionable CDS tool designed to improve the assessment and appropriate management of these goals. It was developed and integrated into the local electronic health record (EHR) with an optional workflow that also informs provider documentation.
The primary goal of this project was decreased CVC, IUC and telemetry duration.
The secondary goal of this project was decreased CDS alert volume and increased provider alert response rate
Methods: This observational quality improvement project began in 12/2016. Participants included system quality leadership, clinical leadership, bedside providers, informaticians, training and reporting resources. Project goals were determined based on stakeholder input and past performance. A steering committee managed the project details. Development and education concluded in 6/2016. The QMC went “live” on 7/1/2017.
Data collection occurred during fiscal year 2018 (7/1/2017-6/30/2018) for all inpatients at the Nebraska Medical Center using previously validated quality reporting methodology and was compared to fiscal year 2017. CDS tools were audited by EHR reports. A cost estimate of $40 per patient per day of telemetry was used to calculate telemetry cost. CAUTI and CLABSI attributable cost per case estimates were $10,822 and $46,000, respectively.
Results: Total CVC duration was reduced (6.1%)
Total IUC duration was reduced (5.8%)
Mean telemetry duration was reduced (16.9%)
CDS alert volume decreased (23.8%)
CDS alert response rate increased (624%)
Conclusions: An optimized inpatient CDS tool reduced CVC, IUC and telemetry duration with cost savings. A clinically focused CDS workflow designed to address common shortcomings was observed to reduce alert volume and increase provider response rate. The significance of these observations are limited by the study design. Our observations suggest that evaluation and enhancement of CDS tools may have multiple benefits even in the setting of active, successful quality improvement initiatives.