Clinician attitudes and concordance with self-assessed and actual intravenous fluid prescribing patterns: A single-institution evaluation of survey and electronic prescribing data.

BACKGROUND: Recent studies suggest that balanced fluids improve inpatient outcomes compared to normal saline. The objective of this study was to obtain insights into clinicians' knowledge, attitudes and perceived prescribing practices concerning IV isotonic fluids and to analyze perceived prescribing in the context of actual prescribing. METHODS: This study, conducted at a single center (Medical University of South Carolina), included 1) a cross-sectional survey of physicians and advanced practice providers (APPs) (7/2019-8/2019) and 2) review electronic health record (EHR) claims data (2/2018-1/2019) to quantify the prescribing patterns of isotonic fluids. RESULTS: Clinicians perceived ordering equivalent amounts of normal saline and balanced fluids although normal saline ordering predominated (59.7%). There was significant variation in perceived and actual ordering across specialties, with internal medicine/subspecialty and emergency medicine clinicians reporting preferential use of normal saline and surgical/subspecialty and anesthesia clinicians reporting preferential use of balanced fluids (p < 0.0001). Clinicians who self-reported providing care in an intensive care unit (ICU) reported more frequent use of balanced fluids than non-ICU clinicians (p = 0.03). Actual prescribing data mirrored these differences. Clinicians' self-reported use of continuous infusions (p = 0.0006) and beliefs regarding the volume of fluid required to cause harm (p = 0.003) were also associated with self-reported differences in fluid prescribing. Clinician experience, most clinical considerations (e.g., indications, contraindications, barriers to using a specific fluid), and fluid cost were not associated with differential prescribing. CONCLUSIONS: Persistent normal saline utilization is associated with certain specialties, care locations, and the rate and volume of fluid administered, but not with other clinical considerations or cost. These findings can guide interventions to improve evidence-based fluid prescribing.

Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing.

OBJECTIVE: Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS: This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS: Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION: Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.

Characteristics of Pulmonary Critical Care Medicine and Pulmonary Medicine Applicants and Fellowships.

Background: Little is known about historical and recent application trends for pulmonary critical care medicine (PCCM) or pulmonary medicine (PM) fellowship programs. Describing trends in and characteristics of PCCM and PM applications, applicants, and fellowship programs can help program directors and medical educators understand trainees' interest in and application patterns for these fellowship programs. Objective: The objective of this study was to use National Residency Match Program data to assess recent trends in PCCM and PM fellowship applications and compare characteristics of applicants and fellowship programs. Methods: In 2019, we used National Residency Match Program data to evaluate applicant ranking and matching in PCCM and PM fellowship programs and to compare applicant and fellowship program characteristics. Results: From 2008 through 2019, the majority of applicants (59.1%) matched into PCCM were graduates of U.S. allopathic or osteopathic medical schools, whereas 87% of PM fellows were non-U.S. graduates. PCCM was the preferred specialty for 90.8% of matched applicants versus only 31.6% of matched PM applicants (P < 0.001). The match rate for PCCM applicants was 67.2% versus 23.8% for PM applicants (P < 0.001). Of PCCM applicants, 36.6% matched into their top choice versus 10.8% of PM applicants (P < 0.001). There are far fewer PM fellowship positions (n = 23) and programs (n = 12) than PCCM positions (n = 450) and programs (n = 131). The mean fill rates from the 2004 through 2016 appointment years are 94.1% in PCCM and 97.4% in PM (P = 0.009). Conclusion: PCCM is a prevailing specialty choice over PM among residency graduates, with matched applicants more likely to list PCCM than PM as their preferred specialty. Further exploration into applicants' interest in critical care compared with PM may prove beneficial in guiding applicants to programs that will best meet their career goals.