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Electronic records with decision support help optimize emergency care

The timely administration of a clot-dissolving treatment for emergency department patients with acute ischemic stroke nearly doubled following the introduction of new technology that enabled electronic order entry and offered care-decision support for physicians, according to a study published today in the Annals of Emergency Medicine.

The study was conducted during the staged implementation of computerized physician order entry when integrated into electronic health records across 16 Kaiser Permanente Northern California medical centers from 2007 to 2012. After implementation, emergency department stroke guidelines were made available to physicians using an electronic template, known as an „order set.” Order sets are designed to provide standardized laboratory, radiographic and drug ordering, as well as information to help guide doctors in making clinical decisions.

„This study demonstrates that computerized physician order entry generally – and an order set embedded with decision support specifically – can facilitate the delivery of time-sensitive interventions for stroke while minimizing errors,” said lead author Dustin Ballard, MD, an emergency medicine physician at the Kaiser Permanente San Rafael (California) Medical Center and an adjunct researcher at the Kaiser Permanente Division of Research. „In this case, the investigation showed that these tools can safely lead to more frequent administration of medication to thin blood and break up blood clots in the brain, a treatment that has been associated with better neurological recovery after stroke.”

Stroke is a major cause of death and a leading cause of serious long-term disability in the United States. Ischemic stroke, the most common type, is caused by a clot obstructing the flow of blood and oxygen to the brain, which can result in the death of brain cells. Consequently, time is of the essence in assessment and emergency treatment.

„While the technology is not likely to be solely responsible for the improved outcomes observed in this study, it may represent a proxy measure for optimum care for certain patients, in particular those for whom the speed of initiating therapy, the completeness of information available to the clinician, and the intensity of inpatient care make a real difference in short-term outcomes,” added co-author David Vinson, MD, an emergency medicine physician at the Kaiser Permanente Roseville (California) Medical Center.

A systematic approach to the acute management of patients with ischemic stroke – including the timely administration of intravenous tissue plasminogen activator (or IV tPA) for eligible patients – can help avoid complications and improve outcomes. IV tPA helps to thin the blood and dissolve clots, with the goal of restoring blood flow through blocked arteries in the brain. Emergency department evaluation of patients with suspected stroke is focused on rapidly assessing eligibility for time-sensitive interventions such as IV tPA, which has been shown to improve neurological outcomes for acute ischemic stroke.

Of the 10,081 patients examined during the study period, 6,686 (66.3 percent) were treated in medical centers after computerized physician order entry had been implemented. IV tPA was administered in the emergency department to 8.9 percent of these patients, compared to 3.3 percent of patients in emergency departments at medical centers without the new technology – more than doubling the rate of IV tPA administration. When the stroke order set was employed in combination with the computerized physician order entry, IV tPA administration increased to 12.7 percent – a nearly three-fold increase. Even after accounting for variable factors, these differences held steady.

Together, Drs. Ballard and Vinson are co-founders of the Clinical Research in Emergency Services and Treatments (CREST) Network, a group of emergency medicine physician-researchers affiliated with the Kaiser Permanente Division of Research.

„Ultimately, we see the order set itself as optimizing the confluence of two separate processes – a robust computerized physician order entry that integrates care across many providers and locations while limiting errors of omission, combined with a quality initiative that has identified disease-specific best practices and guidelines,” Dr. Ballard wrote. „We believe that our findings represent a dawning era of electronic health records, one that blends decision support and best practices.”

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The study shows patients received recommended and proven therapy safely and more consistently; © panthermedia.net/Arne Trautmann
The study shows patients received recommended and proven therapy safely and more consistently; © panthermedia.net/Arne Trautmann
Reclame

Higher risk of death at the weekend

Patients admitted to hospital at the weekend are more likely to be sicker and have a higher risk of death, compared with those admitted during the week, finds an analysis published in The BMJ.

The analysis was carried out as a collaboration between University Hospital Birmingham NHS Foundation Trusts and University College London, and included Sir Bruce Keogh, National Medical Director of NHS England. It examined the effect of hospital admission day on death rates across NHS England hospitals for 2013-2014.

The results confirm findings from an analysis they undertook for 2009-2010.

In the latest analysis, the authors found that around 11,000 more people die each year within 30 days of admission to hospital on Friday, Saturday, Sunday, or Monday compared with other days of the week (Tuesday, Wednesday, Thursday).

This suggests a generalized „weekend effect” which can be partly explained by the reduced support services that start from late Friday through the weekend, leading to disruption on Monday morning, say the authors. Patients already in hospital over the weekend do not have an increased risk of death.

These results remained the same even when taking into account the severity of illness.

The authors caution that it is not possible to show that this excess number of deaths could have been prevented, adding that to do so would be „rash and misleading.”

Nevertheless, they say the number is „not otherwise ignorable” and „we need to determine exactly which services need to be improved at the weekend to tackle the increased risk of mortality.”

They also looked at patient characteristics, length of hospital stay, and time to death.

An average of 2.7 million patients was admitted to hospital on each weekday, while an average of 1.2 million patients was admitted on a Saturday and 1 million patients admitted on a Sunday.

Saturday and Sunday admissions were more likely to be emergencies, 50 percent and 65 percent respectively, than on weekdays (29 percent) and length of stay was also higher for patients admitted on a Saturday and Sunday.

A higher proportion of patients admitted on a Saturday and Sunday had diagnoses that placed them in the highest risk of death category, 24.6 percent and 29.2 percent respectively, compared with less than 20 percent of weekday admissions.

The debate on seven day working was reignited following health secretary Jeremy Hunt’s recent call for hospital doctors to work at weekends to improve quality of care and reduce deaths.

But an accompanying feature article by Helen Crump at the Nuffield Trust says it is not clear how or to what extent investment in seven day services will reduce weekend deaths, and that the costs may outweigh any benefits.
She also warns that, unless overall staffing levels increase, ramping up services at the weekend „will leave a gap in the hospital’s weekday rota, with potentially serious consequences across other services.”

In a linked editorial, Paul Aylin, from Imperial College London, suggests more research is needed to determine the „complex” relation between staffing levels and services, and patient safety. He says promised changes to how the NHS provides weekend and out of hours care „will be an ideal opportunity to evaluate their impact on the weekend effect.”

Seven day working has also been a central part of negotiations between the government and doctors about proposed changes to the standard contract for NHS consultants. Hunt announced that the government would remove a clause in the contract that allowed doctors to opt out of non-emergency work at weekends. But figures obtained from freedom of information requests by BMJ Careers show that just 1 percent of consultants have opted out of non-emergency weekend work.

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Fewer patients are admitted at weekends, but are more likely to be sicker and have a higher risk of death from Friday through until Monday; © panthermedia.net/Suphatthra China
Fewer patients are admitted at weekends, but are more likely to be sicker and have a higher risk of death from Friday through until Monday; © panthermedia.net/Suphatthra China

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When will internet kill the traditional TV? I asked myself the same quiz  when we did ePaper vs. Newspaper

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