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PubMedDate not supplied

Brain injury: analysis of outcome in a post-acute rehabilitation system. Part 1: General analysis.

During the past decade the rehabilitation field has developed new, non-hospital based programmes of cognitive, behavioural, social, educational and vocational treatments to address the higher order cognitive, behavioural and social deficits following brain injury. These new arrays of programmes are referred to under the term 'post-acute' rehabilitation. No comprehensive, methodologically sound study of the effects of these new treatments has been made to date. This paper reports data from brain-injured patients who underwent treatment within a co-ordinated system of post-acute brain-injury rehabilitation programmes. This system consists of a continuum of neurobehavioural, residential, day treatment and community and home programmes, and provides overt components of medical and rehabilitation care: behavioural management; activities of daily living, self-management, substance-abuse, social, academic and vocational skills training; counselling; and family education. The changes in function during the course of treatment by this post-acute sequence of rehabilitation have been obtained and are reported here. A defined total population of N = 192 is examined, with exclusions for appropriate causes (e.g. patients seen only for evaluation) producing a study population of N = 173; of these, follow-up was achieved in 145 cases, a follow-up rate of 83.8%. Time from date of injury to data of admission, severity of deficit at time of admission to programme, and other appropriate independent variables are used to characterize the population. A single-blind interview methodology was employed in obtaining dependent measures of outcome at 6, 12, or 24 month periods post-discharge. Measures of outcome included residential status, level of productivity activity and hours per day of attendant care or supervision required. Dependent variables were analysed for the total study population and a subgroup greater than 1 year from date of injury at entry to treatment and not from a treatment facility. Results are presented in terms of the percentage change in dependent measures from the point of admission to follow-up. Appropriate parametric and non-parametric statistical analyses of significance have been carried out. The results document substantial improvements in function during the post-acute rehabilitation of this population and such improvements are unlikely to be the result of spontaneous improvement alone.

Activities of Daily Living↗
PubMed1999

Evaluation of frequency and type of errors detected by a computerized record and verify system during radiation treatment.

BACKGROUND: Computerized record and verify systems (RVS) have been introduced to improve the precision of radiation treatment delivery. These systems prevent the delivery of ionizing radiations when the settings of the treatment machine do not match the intended parameters within some maximal authorized deviation. PURPOSE: To assess the potential alteration of the frequency of errors associated with the use of RVS during radiation treatment delivery. MATERIALS AND METHODS: The software of the RVS was altered in order to record the settings actually used for radiation treatment delivery whereas the verification function was suppressed. At the end of the study period, the settings used during daily administration of radiation treatment were compared to the parameters recorded in the RVS using the computer. They were also compared with the planned ones written in the patient treatment chart. RESULTS: Out of the 147,476 parameters examined during the study period, 678 (0.46%) were set erroneously. At least one error occurred in 628 (3.22%) of the 19,512 treated fields. An erroneous parameter was introduced in the RVS memory in 22 (1.17%) of the 1885 fields. CONCLUSIONS: RVS has the potential to improve precision of radiation treatment delivery by detecting a significant number of setting errors. However, excessive confidence in RVS could lead to repeated errors as there is a potential for the entry of erroneous parameters into the RVS memory.

Humans↗
PubMed2003

Does the physician order-entry system increase the revenue of a general hospital?

OBJECTIVE: The purpose of this study was to examine whether the physician order-entry system (POE) could increase the outpatient and inpatient revenue of hospitals. METHOD: We analyzed the inpatient and outpatient revenue data of all general hospitals (212) in South Korea obtained from the Korean National Health Insurance Corporation (KNHIC) during the period from 1996 to 1999 using the mixed model for repeated measure data. RESULTS: Analysis of the 4-years' panel data showed that both outpatient and inpatient revenues increased significantly after POE introduction. The hospital characteristics significantly influencing inpatient revenue were the number of beds, number of physicians and the tertiary status of a hospital; whereas those for outpatient revenue were the number of beds, number of physicians, the private status of a hospital, the tertiary status of a hospital and the urban status of a hospital. CONCLUSION: The revenues from both outpatients and inpatients were found to be increased after the introduction of the POE, while controlling for population size, competition, income, hospital location, hospital size, tertiary status and public status.

Financial Management, Hospital↗
PubMed2006

Software design to facilitate information transfer at hospital discharge.

Discharge communication between inpatient and outpatient physicians is often an inefficient and error-prone process. Adverse events result from poor communication at the time of discharge. The objective of this study was to describe development of discharge software to overcome communication barriers. The secondary objective was to assess factors that influence the time to complete tasks with the software. Methods were a performance improvement model and database analysis of 336 discharges. Software design specifications included computerised physician order entry, immediate utility, minimal development and deployment costs, acceptability to physician-users, and satisfaction of primary care physicians, patients and pharmacists. Design features included simple 'just-in-time' prompts and point-of-care prescribing resources. The dependent variable for analysis was physician time to complete discharge prescriptions and instructions while using the software. General linear and mixed-effects regression models adjusted for physician effects and other predictors. Results revealed that physician factors significantly affected the time to complete a discharge while using the software. As the number of accesses (log-ins) and free text typing increased, then time to complete the computerised discharge increased. Patient-related factors that increased physician time were discharge diagnoses, prescriptions and length of stay. In conclusion, discharge software can help inpatient physicians transfer timely, complete and legible information to outpatient physicians, pharmacists and patients. Physician and patient factors influence the time to complete discharges using the software.

Adolescent↗
PubMed2004

Assessing medication prescribing errors in pediatric intensive care units.

OBJECTIVE: To evaluate a matrix for determining the predominant type, cause category, and rate of medication prescribing errors, and to explore the effectiveness of hospital-based improvement initiatives among pediatric intensive care units (PICUs). DESIGN: This study involved the prospective identification of medication errors for categorization and evaluation by using a matrix methodology. A pretest-posttest design without a control group was used to explore the impact of initiatives employed to reduce medication error rates and severity. SETTING: PICUs in nine freestanding, collaborating tertiary care children's hospitals that participated in both baseline and postintervention analyses. METHODS: We evaluated 12,026 PICU medication orders at baseline and 9,187 orders postintervention for prescribing errors, excluding resuscitation orders. A standardized tool and process captured error type, cause category, and severity for 2 wks before and after intervention. Three levels of error detection were used and included pharmacy order entry, PICU nurse order transcription, and team-based overview. Site-specific interventions were implemented, which included predominantly provider education as well as informational (47%) and dosing "assists" via preprinted orders, forcing functions, or prompts (39%). RESULTS: Of baseline orders, 11.1% had at least one prescribing error. The interception of prescribing errors improved 30.9% (1.6% of all orders at baseline, 2.0% post intervention). Preventable adverse drug events were uncommon (0.6% of all medication errors) and of low severity at baseline; most were wrong dose errors. The implementation of improvement initiatives, specific for each facility, resulted in a 31.6% reduction in prescribing errors from 11.1% to 7.6%. However, site results varied considerably. CONCLUSIONS: A benchmark for medication prescribing errors in the PICU was identified among nine children's hospitals. The methodology was successful in accounting for site-specific differences with regard to identifying and documenting errors as well as reporting results of improvement initiatives. Furthermore, the methodology employed was generalizable in the identification of predominant prescribing error types, which helped to track individual hospital improvement initiative development and implementation. Overall improvement in prescribing error rates was noted; however, considerable variation in the success of improvement initiatives was noted and bears further attention.

Drug Therapy, Computer-Assisted↗
PubMed2005

The effect of computerized provider order entry on medical student clerkship experiences.

OBJECTIVE: To describe medical students' attitudes toward placing orders during training, and the effect of computerized provider order entry (CPOE) on their learning experiences. DESIGN: Prospective, controlled study of all 143 Johns Hopkins University School of Medicine students who began the Basic Medicine clerkship between March 2003 and April 2004 at one of three teaching hospitals: one using CPOE, one paper orders, and one that began using CPOE midway through this study. MEASUREMENTS: Survey of students at the start and after the first month of the clerkship. RESULTS: Ninety-six percent of students responded. Students expressed a desire to place 100% of orders for their patients. Ninety-five percent of students believed that placing orders helps students learn what tests and treatments patients need. Eighty-four percent reported that being unavailable due to conferences and teaching sessions was a significant barrier to participating in the ordering process. Students at hospitals using CPOE reported placing significantly fewer of their patients' follow-up orders compared to students at hospitals using paper orders (25% vs. 50%, p < 0.01) and were more likely to report that their resident or intern did not want them to enter orders (40% vs. 16%, p < 0.01). Comparisons of students at hospitals using CPOE to each other showed that these differences were attributable to one of the hospitals. Thirty-two percent of students at both hospitals using CPOE reported that the extra length of time required for housestaff to review their orders in the computer was a significant barrier. CONCLUSION: Hospitals need to ensure that the educational potential of medical students' clinical experiences is maximized when implementing CPOE.

Attitude to Computers↗
PubMed1995

A computer system for epidemiological surveillance.

In epidemiological surveillance, it is imperative that any unusual increase in reported cases be detected as quickly as possible. In the surveillance unit at "Pedro Kourí," it was necessary to create a computer system for the surveillance of transmissible diseases in order to manage such variables as morbidity, mortality, and the circulation of causal agents. As usage flexibility is a fundamental requirement, we developed VIGILA as a system readily adaptable to any level of the country's health organizations (national, provincial, or municipal). VIGILA permits the storage, validation, and statistical analysis of morbidity and mortality data, and it also allows the user to apply these features to causal agent information. These manipulations are all performed in the context of a specific transmissible disease. The stored information can be displayed in different types of statistical formats, such as calculated rates, accumulates and medians. The user can also design his/her own tables for display. In addition, the program offers graphics that depict the endemic forecast for a specific region and age group. Reliable forecasts based on temporal models of an epidemiological indicator are necessary for the prediction of the non-epidemic indicator and for the elaboration of an alert threshold. The endemic forecast or endemic channel is calculated by means of a modified version of R. Serfling's model [1] which adapts to data series with stationary characteristics. In this case, the model is fixed for the medical attention protocol and the circulation of agents of a specific transmissible disease. The parameters of the model are estimated by the least square method. The confidence limits are calculated with the T-Student distribution [2]. To enter information about a specific disease and level of health concern, the user must define the disease under analysis, the principal territory under surveillance and its dependencies, the causal agents of the disease, and the frequency with which the disease is reported. This system stores the number of cases (morbidity) and death (mortality) that occurred in the territories and age groups defined during entry. To facilitate the calculation of morbidity and mortality rates, information pertaining to the number of territory habitants and their age groups is also stored. The laboratory data includes the number of analyzed samples in the territories and age groups defined in the data entry, and the samples that were positive to the defined agents. Among the principal uses of the system are: calculation of cumulative cases, rates, and cumulative rates for the specific period of analysis, territory, and age group; comparison of these health indicators with the previous year's indicators or with the median of the previous years' indicators' calculation of the endemic forecast that permits the user to observe the epidemiological situation by territories and age groups; and the early detection of an increase in disease occurrence. The system also offers a geographical representation of the epidemiological situation in the territories, showing a map with the evaluation of each territory with respect to four possible risk factors. VIGILA is available in both DOS and WINDOWS 3.1 formats. This system allows the evaluation of the situation at a specific point in time in the analyzed territories, and may alert the infection control team to an epidemic early enough to allow implementation of control measures.

Computer Systems↗
PubMed2005

Information retrieval performance of probabilistically generated, problem-specific computerized provider order entry pick-lists: a pilot study.

OBJECTIVE: The aim of this study was to preliminarily determine the feasibility of probabilistically generating problem-specific computerized provider order entry (CPOE) pick-lists from a database of explicitly linked orders and problems from actual clinical cases. DESIGN: In a pilot retrospective validation, physicians reviewed internal medicine cases consisting of the admission history and physical examination and orders placed using CPOE during the first 24 hours after admission. They created coded problem lists and linked orders from individual cases to the problem for which they were most indicated. Problem-specific order pick-lists were generated by including a given order in a pick-list if the probability of linkage of order and problem (PLOP) equaled or exceeded a specified threshold. PLOP for a given linked order-problem pair was computed as its prevalence among the other cases in the experiment with the given problem. The orders that the reviewer linked to a given problem instance served as the reference standard to evaluate its system-generated pick-list. MEASUREMENTS: Recall, precision, and length of the pick-lists. RESULTS: Average recall reached a maximum of .67 with a precision of .17 and pick-list length of 31.22 at a PLOP threshold of 0. Average precision reached a maximum of .73 with a recall of .09 and pick-list length of .42 at a PLOP threshold of .9. Recall varied inversely with precision in classic information retrieval behavior. CONCLUSION: We preliminarily conclude that it is feasible to generate problem-specific CPOE pick-lists probabilistically from a database of explicitly linked orders and problems. Further research is necessary to determine the usefulness of this approach in real-world settings.

Humans↗
PubMed2002

[Assessment of operating theatre procedures and quality of perioperative anaesthesia using a computer system for collecting anaesthesiological data].

BACKGROUND: In order to manage the operating theatre and guarantee constant improvement in the quality of procedures, it is indispensable to be able to have available a computerised workstation to enable the team to collect data and analyse them. METHODS: We used our anaesthesia department's computer workstation to retrospectively analyse operating sessions over a 16 month period during which organisational adjustments were made to optimise patient turnover and maximise the utilisation of operating theatres. Meantime we studied and compared the trend in anaesthesiological quality through the use of certain structural, process and outcome indicators. RESULTS: During the period under study an improvement was noted in the efficiency of operating theatre procedures (reduction in entry time of the first patient into the theatre, time between one case and the next and subutilisation of the operating theatre, p<0.05). As regards data on the quality of anaesthesiological assistance to the patient, no significant differences were noted when comparing the four periods examined. CONCLUSIONS: To make the operating complex work more efficiently, it is necessary to have available a computer system that makes it possible to continuously monitor theatre operation. The improvement initiatives undertaken led to a more effective utilisation of the operating theatre but did not produce a significant increase in productivity. In spite of the increased work load, analysis of the trend in quality indicators as regards anaesthesiological procedures did not reveal any modification.

Anesthesia↗
PubMed2000

Indications for pelvic sonography-Do patients and doctors agree?

PURPOSE: Often, it seems that the patient history provided by the referring clinician on the sonography requisition form differs from that given by the patient during the sonographic examination. Because such a discrepancy in the history may delay the scan and disrupt the daily work flow while the referring clinician is contacted for clarification, we sought to document the incidence and cause of such discrepancies at our institution. METHODS: During a 3-month period, all outpatients who were referred for a pelvic sonographic examination were asked to indicate their understanding of why the examination had been requested. The health care providers' reasons for requesting sonography were recorded using a computer order entry system. Each pair of responses (health care provider and patient) were classified as either concordant or discordant. Patient and physician characteristics were fit into a logistic regression model with concordance of history as the outcome variable. RESULTS: One hundred fifty-six (90%) of the 173 patients enrolled in our study indicated that their health care provider had discussed with them the reason for ordering the sonographic examination. The histories provided by the patient and health care provider were concordant in 134 (77%) of 173 cases. The histories provided by the patient and health care provider were more likely to be concordant if the patient's insurance was a managed care plan or if the patient had a college or graduate level education, had been cared for by the same health care provider for more than 2 years, or had been seen by a female health care provider. Concordance of history was not associated with a higher incidence of abnormal sonographic findings. CONCLUSIONS: It appears that health care providers, despite increased demands on their time, adequately discuss with their patients the reasons for ordering a pelvic sonographic examination. However, our study suggests that health care providers may need to spend additional time with patients whose education is limited and that male physicians may need to pay particular attention to their communication with female patients.

Adult↗
PubMed2006

A critical evaluation of the electronic surgical logbook.

BACKGROUND: The Association of Surgeons of Great Britain and Ireland (ASGBI) devised the electronic surgical logbook (version 2.4) for higher trainees in General Surgery enabling trainees to compile a uniform data set of their operative and training experience. This is in use by higher surgical trainees (HST) in the United Kingdom. This logbook permits trainees to submit data centrally into a Regional Analysis Database (RAD). With the implementation of the European Working Time Directive (EWTD) there is need for reliable data to assess the effects of the directive on training. In order to draw meaningful conclusions from the database the quality of data needs to be validated. We critically analysed the RAD in the Yorkshire region for a one-year period. METHODS: The RAD from the ASGBI for the Yorkshire region was analysed. Data for the period 01/10/2002-30/09/2003 was identified and interrogated using Microsoft Excel (2000 version). The RAD was compared with information obtained from the Regional Surgical Advisor for Yorkshire with respect to hospitals, surgical consultants and HST's in the region during the study period. RESULTS: There were 13,755 operations entered for the study period. 579 corrections to the data had to be made (4.2%) and a further 1140 entries were deleted (8.2%). Following corrections and deletions 12,615 operative entries were available for analysis. Overall 12.5% of the data required either correction or exclusion from the database prior to analysis. CONCLUSION: The RAD has a large dataset useful to monitor and assess training. However, the quality of the data needs to be verified prior to use. Recommendations have been made to develop the ASGBI logbook, which would eventually translate to improved data reliability of the RAD.

Adult↗
PubMed2005

Utilization of evidence-based computerized order sets in pediatrics.

Little is known about utilization of different evidence-based order sets within computerized physician order entry (CPOE) systems. We designed a retrospective study of resident and attending physician order set utilization to evaluate the use of three evidence-based computerized order sets (asthma, post-appendectomy care, and community-acquired pneumonia (CAP)), and examine patient and admission characteristics associated with order set utilization in pediatrics. We studied all 529 asthma patients, 277 appendectomy patients, and 210 CAP patients admitted between 1 November 2001 and 30 November 2003 during implementation of standardized order sets at a large, independent, not-for-profit pediatric institution. We analyzed order set utilization for the three order sets and tested the relationship between order set use and potential factors associated with utilization. Order set utilization varied by condition (X(2)=339.2, p<0.001), with the asthma order set use rate highest (88.1%), followed by appendectomy order set utilization (79.4%), and substantially lower CAP order set use (21.1%). We found that trends in order set utilization also varied by condition. Only the asthma order set showed a trend of increasing use after implementation (z= -3.02, p=0.002). In addition, factors associated with order set utilization varied. Uses of the asthma and post-appendectomy order sets were associated with factors such as admission unit and case complexity. CAP order set utilization was associated with case complexity but not admission source. We conclude that health services organizations looking to implement computerized order sets to reduce unnecessary practice variation while promoting best practices must consider the different factors that may influence the use of each order set rather than relying on a one-size-fits-all implementation strategy. Further, issues such as the level of physician involvement in order set development and consensus around order set content may be particularly important factors influencing order set utilization.

Adolescent↗
PubMed2004

Computerized physician order entry and online decision support.

Computerized physician order entry (CPOE) and decision support systems (DSS) can reduce certain types of error but often slow clinicians and may increase other types of error. The net effect of these systems on an emergency department (ED) is unknown. The consensus participants combined published evidence with expert opinion to outline recommendations for success. These include seamless integration of CPOE and DSS into systems and workflow; ensuring access to Internet-based and other online support material in the clinical arena; designing systems specifically for the ED and measuring their impact to ensure an overall benefit; ensuring that CPOE systems provide error and interaction checking and facilitate weight- and physiology-based dosing; using interruptive alerts only for the highest-severity events; providing a simple, vendor-independent interface for institutional customization of CPOE alert thresholds; maximizing the use of automated systems and passive data capture; and ensuring the widespread availability of CPOE and DSS using secure wireless and portable technologies where appropriate. Decisions regarding CPOE and DSS in the ED should be guided by the ED chair or designee. Much of what is believed to be true regarding CPOE and DSS has not been adequately studied. Additional CPOE and DSS research is needed quickly, and this research should receive funding priority. DSS and CPOE hold great promise to improve patient care, but not all systems are equal. Evidence must guide these efforts, and the measured outcomes must consider the many factors of quality care.

Decision Support Systems, Clinical↗
PubMed1993

Snoring, sympathetic activity and cardiovascular risk factors in a 70 year old population.

In order to describe the relation between snoring, cardiovascular risk factors, metabolic factors and sympathetitic activity, 804 70-year-old males and females were classified according to snoring habits and life-style factors (alcohol and tobacco consumption), blood pressure, body mass index (BMI), plasma lipids (triglycerides, cholesterol, high density lipoprotein), plasma catecholamines (epinephrine, norepinephrine), fasting blood glucose and glucose tolerance test (1 gram glucose per kg body weight given and blood glucose was measured 1 and 2 hours thereafter) were evaluated in all participants. Self-reported snoring was associated with gender (males showed higher prevalence than females, p < 0.05), alcohol consumption (p < 0.01), BMI (p < 0.001), systolic (p < 0.01) and diastolic (p < 0.05) blood pressure, glucose tolerance test (p < 0.01), plasma norepinephrine (p < 0.05) and partly with tobacco consumption (p = 0.08). No associations were found between snoring and fasting glucose, plasma lipids, plasma epinephrine or in the use of antihypertensive medication. In multivariate analysis, with forced entry of gender, BMI, physical activity, alcohol and tobacco consumption, the relation between snoring and blood pressure ceased; only systolic blood pressure was associated with snoring (p < 0.05). Snoring was still associated with plasma norepinephrine (p < 0.001) and abnormal glucose tolerance (p < 0.001). We conclude that, in a 70-year-old population, snoring is associated with gender, BMI and alcohol consumption. Snores showed higher plasma norepinephrine and abnormal glucose tolerance.

Aged↗
PubMed2004

Implementation of hospital computerized physician order entry systems in a rural state: feasibility and financial impact.

OBJECTIVE: The aim of this study was to estimate the costs of implementing computerized physician order entry (CPOE) systems in hospitals in a rural state and to evaluate the financial implications of statewide CPOE implementation. METHODS: A simulation model was constructed using estimates of initial and ongoing CPOE costs mapped onto all general hospitals in Iowa by bed quantity and current clinical information system (CIS) status. CPOE cost estimates were obtained from a leading CPOE vendor. Current CIS status was determined through mail survey of Iowa hospitals. Patient care revenue and operating cost data published by the Iowa Hospital Association were used to simulate the financial impact of CPOE adoption on hospitals. RESULTS: CPOE implementation would dramatically increase operating costs for rural and critical access hospitals in the absence of substantial costs savings associated with improved efficiency or improved patient safety. For urban and rural referral hospitals, the cost impact is less dramatic but still substantial. However, relatively modest benefits in the form of patient care cost savings or revenue enhancement would be sufficient to offset CPOE costs for these larger hospitals. CONCLUSION: Implementation of CPOE in rural or critical access hospitals may depend on net increase in operating costs. Adoption of CPOE may be financially infeasible for these small hospitals in the absence of increases in hospital payments or ongoing subsidies from third parties.

Costs and Cost Analysis↗
PubMed2004

A comprehensive assessment program to improve blood-administering practices using the FOCUS-PDCA model.

BACKGROUND: The Joint Commission on the Accreditation of Healthcare Organizations requires that hospitals have a planned approach to systematically collect data on processes related to the use, ordering, and administering of blood components. This study describes how a comprehensive blood-administering assessment program and the FOCUS-PDCA approach improved overall blood-administering practices. STUDY DESIGN AND METHODS: Nurses were trained to observe blood issuance, blood administering, and patient monitoring steps, and to audit patient's charts to measure compliance with blood-ordering procedures. The observations were recorded on a standardized scannable form, which allowed automatic entry of recorded data directly into a computer database. RESULTS: A total of 982 assessments were completed during the 51-month study period. Documentation of informed consent improved from 80 percent to 100 percent. Compliance with a California law that requires patients to receive information on the risks, benefits, and alternatives to transfusion rose from 30 percent to 100 percent. Physicians' compliance in specifying the rate of blood administration improved from 30 percent to 100 percent, and verification of information on the patient's identification band with the patient's self-identification rose from 50 percent to 100 percent. For all other blood-administering steps, compliance remained high throughout the study period. For the past 9 months, 100-percent compliance has been maintained for all transfusion processes, and during this period no mistransfusions or blood administration near-misses have been reported. CONCLUSION: The blood-administering assessment program described above has improved transfusion practice, reduced the number of near-miss events, and may have prevented mistransfusions.

Blood Transfusion↗
PubMed2005

Interventions to regulate ordering of serum magnesium levels: report of an unintended consequence of decision support.

BACKGROUND: Unintended consequences of computerized patient care system interventions may increase resource use, foster clinical errors, and reduce users' confidence. OBJECTIVE: To evaluate three successive interventions designed to reduce serum magnesium test ordering through a care provider order entry system (CPOE). The second, modeled after a previously successful intervention, caused paradoxical increases in magnesium test ordering rates. DESIGN: A time-series analysis modeled weekly rates of magnesium test ordering, underlying trends, the impact of the three successive interventions, and the impact of potential covariates. The first intervention exhorted users to discontinue unnecessary tests recurring more than 72 hours into the future. The second displayed recent magnesium, calcium, and phosphorus test results, limited testing to one test instance per order, and provided education regarding appropriate indications for testing. The third targeted only magnesium ordering, displayed recent results, limited testing to one instance per order, summarized indications for testing, and required users to select an indication. PARTICIPANTS: Clinicians at Vanderbilt University Hospital, a 609-bed academic inpatient tertiary care facility, from 1998 through 2003. MEASUREMENTS: Weekly rates of new serum magnesium test orders, instances, and results. RESULTS: At baseline, there were 539 magnesium tests ordered per week. This decreased to 380 (p = 0.001) per week after the first intervention, increased to 491 per week (p < 0.001) after the second, and decreased to 276 per week (p < 0.001) after the third. CONCLUSION: A clinical decision support intervention intended to regulate testing increased test order rates as an unintended result of decision support. CPOE implementers must carefully design resource-related interventions and monitor their impact over time.

Blood Chemical Analysis↗
PubMed2002

Value of abdominal CT in the emergency department for patients with abdominal pain.

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted; thus, the net impact of performing CT was to obviate the need for hospital admission in 90 of 536 (17%) of patients with abdominal pain. Prior to CT, 67 of 536 (13%) of all patients would have undergone immediate surgery; however, following CT only 25 (5%) actually required immediate surgery. Among patients with the four most common pre-CT diagnoses (appendicitis, abscess, diverticulitis, and urinary tract stones) CT had the greatest impact on hospital admission and surgical management for patients with suspected appendicitis. For patients with suspected appendicitis, CT reduced the hospital admission rate in 28% (26 of 91) of patients and changed the surgical management in 40% (39 of 91) of patients. Our study demonstrates the advantage of performing abdominal CT in the ED for patients with non-traumatic abdominal pain.

Abdomen, Acute↗