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Objective: Computer-aided decision tools may speed recognition of acute respiratory distress syndrome (ARDS) and promote consistent, timely treatment using lung-protective ventilation (LPV). This study evaluated implementation and service (process) outcomes with deployment and use of a clinical decision support (CDS) synchronous alert tool associated with existing computerized ventilator protocols and targeted patients with possible ARDS not receiving LPV. Materials and Methods: We performed an explanatory mixed methods study from December 2019 to November 2020 to evaluate CDS alert implementation outcomes across 13 intensive care units (ICU) in an integrated healthcare system with >4000 mechanically ventilated patients annually. We utilized quantitative methods to measure service outcomes including CDS alert tool utilization, accuracy, and implementation effectiveness. Attitudes regarding the appropriateness and acceptability of the CDS tool were assessed via an electronic field survey of physicians and advanced practice providers. Results: Thirty-eight percent of study encounters had at least one episode of LPV nonadherence. Addition of LPV treatment detection logic prevented an estimated 1812 alert messages (41%) over use of disease detection logic alone. Forty-eight percent of alert recommendations were implemented within 2 h. Alert accuracy was estimated at 63% when compared to gold standard ARDS adjudication, with sensitivity of 85% and positive predictive value of 62%. Fifty-seven percent of survey respondents observed one or more benefits associated with the alert. Conclusion: Introduction of a CDS alert tool based upon ARDS risk factors and integrated with computerized ventilator protocol instructions increased visibility to gaps in LPV use and promoted increased adherence to LPV.
RESUMO
STUDY OBJECTIVE: To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS: Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS: During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION: Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
