Assessment of physician knowledge and practices concerning Shiga toxin-producing Escherichia coli infection and enteric illness, 2009, Foodborne Diseases Active Surveillance Network (FoodNet).

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) infections cause acute diarrheal illness and sometimes life-threatening hemolytic uremic syndrome (HUS). Escherichia coli O157 is the most common STEC, although the number of reported non-O157 STEC infections is growing with the increased availability and use of enzyme immunoassay testing, which detects the presence of Shiga toxin in stool specimens. Prompt and accurate diagnosis of STEC infection facilitates appropriate therapy and may improve patient outcomes. METHODS: We mailed 2400 surveys to physicians in 8 Foodborne Diseases Active Surveillance Network (FoodNet) sites to assess their knowledge and practices regarding STEC testing, treatment, and reporting, and their interpretation of Shiga toxin test results. RESULTS: Of 1102 completed surveys, 955 were included in this analysis. Most (83%) physicians reported often or always ordering a culture of bloody stool specimens; 49% believed that their laboratory routinely tested for STEC O157, and 30% believed that testing for non-O157 STEC was also included in a routine stool culture. Forty-two percent of physicians were aware that STEC, other than O157, can cause HUS, and 34% correctly interpreted a positive Shiga toxin test result. All STEC knowledge-related factors were strongly associated with correct interpretation of a positive Shiga toxin test result. CONCLUSIONS: Identification and management of STEC infection depends on laboratories testing for STEC and physicians ordering and correctly interpreting results of Shiga toxin tests. Although overall knowledge of STEC was low, physicians who had more knowledge were more likely to correctly interpret a Shiga toxin test result. Physician knowledge of STEC may be modifiable through educational interventions.

Expert clinical rules automate steps in delivering evidence-based care in the electronic health record.

A working framework is presented for interdisciplinary professionals for designing, building, and evaluating clinical decision support rules (expert rules) within the electronic health record. The working framework outlines the key workflow processes for eight health system organizations for selecting, designing, building, activating, and evaluating rules. In preparation, an interdisciplinary team selected expert rules for their organizations. A physician, a nurse, and/or pharmacy informatics specialists led the team for each organization. The team chose from a catalog of expert rules that were supported by regulatory or clinical evidence. The design process ensured that each expert rule followed evidence-based guidelines and was programmed to automate steps in planning and delivering patient care. Expert rules were prioritized when improving the safety and quality of care. Finally, clinical decision support rules were evaluated for abilities to improve the consistency and currency of assessments and follow-through on patient findings from these assessments. The informatics specialists from each of the health system organizations also participated in a health system oversight group to construct the key processes for this beginning framework. The group refined the processes for the selection, design, construction, activation, and evaluation of expert rules over the past 3 years. These steps offered direction to subsequent clinic and hospital organizations in a similar situation. This case study identified four key considerations when implementing and evaluating the clinical decision support expert rules within care delivery. In summary, the processes for decision support expert rules required rigorous development and change control processes to support operation.