Lessons From Rory: Clinical Decision Support in the ED

When Rory Staunton showed up at a New York hospital emergency department, he was just another 12-year-old with seemingly ordinary vomiting and fever symptoms. ED physicians administered fluids for his dehydration and sent him home with instructions to take Tylenol.

Three days later, he died in an intensive care unit. It turns out Rory had septic shock, brought on by an infection that had spread from a cut on his arm obtained when he had played basketball. In this and so many other heart-wrenching cases, the subtle clues of a life-threatening disease went undetected until it was too late.

In the ED's 24/7 data-poor and time-pressed environment, physicians face the unique challenge of providing unscheduled care to patients whom we know little about. Our mission is to assess, diagnose, treat and stabilize the patients and then release or admit them. Appropriate workups and accurate diagnoses are critical as they often determine inpatient care for 24-plus hours after admission. Yet, at the same time, we need to avoid treatment and diagnostic errors which put patients and hospitals at risk.

To help remedy these problems, hospitals can implement clinical decision support tools to provide physicians with timely access to information they need to make better decisions. CDS, however, encompasses a broad category of solutions, including structured templates and referential, diagnostic and active/passive support tools.  

So how can hospitals determine which CDS solutions will make the most difference in driving better patient outcomes in the ED? The following are seven recommendations to help facilities and physicians implement CDS to help speed diagnoses, reduce costs and improve the quality of care.

1. Implement computerized provider order entry. CPOE helps significantly reduce the incidence of medication errors, a leading cause of iatrogenic morbidity. It can also help standardize care through pre-defined order sets.

2. Provide e-prescribing solutions.
These solutions allow physicians to check alternative medication recommendations and insurance formularies to ensure they prescribe the lower-cost drugs that payors are most likely to approve — and patients are most likely to fill. Physicians can also access filled prescriptions histories from most pharmacies across the United States.

3. Use structured documentation.
Structured documentation, ideally delivered through an electronic health record system, can help providers ask pertinent questions, reduce the risk of missing important steps and improve the chances of making the right decisions. Hospitals can further build in appropriate checks and balances to drive consistent care and efficient workflows.

4. Use health information exchanges and data repositories. Access to past diagnostic and treatment information is critical. More than just document repositories, HIEs allow physicians to retrieve filtered data, allowing them to find relevant information rapidly. These repositories can be updated with ED information, enhancing post-discharge care continuity.

5. Equip providers with on-demand access to references.
These referential tools can provide physicians with fast access to up-to-date data, best practice and workup advice and are easy and relatively inexpensive to implement. Referential material linked contextually in your EHR is a plus.

6. Minimize interruptive alerts. We should work to ensure our CDS systems do not needlessly disrupt or create a hard stop in workflows. Instead, we should reserve alerts for those high-risk cases that prevent the release of a patient with abnormal vital signs — as in Rory's case — or inform the provider of a potential dangerous drug interaction.

7. Ask, involve and respect providers.
Engage physicians and other caregivers early in the process of evaluating new CDS solutions. Consult them on how and when they will use the tools and then respectfully listen to their concerns. Above all, choose solutions that are easy to use and non-invasive to the workflow.

For hospitals and ED physicians, clinical decision support should not be some far-off, futuristic goal. There are best practices and technologies we can apply today to improve the speed and accuracy of diagnoses — especially for life-threatening cases like Rory Staunton requiring the right diagnosis within hours or days — while reducing the risk of medical errors.

Most importantly, these decision support tools offer us hope of saving more lives and delivering far better patient outcomes for the next Rory Stauntons seeking treatment in the ED.

As T-System's vice president and chief medical informatics officer, Robert Hitchcock, MD, FACEP, is committed to advancing EHR adoption and healthcare IT public policy to improve the quality, safety and efficiency of emergency medicine. Dr. Hitchcock has more than 20 years of experience in healthcare and has been a practicing emergency physician for more than a decade. He serves on the board of the Emergency Department Practice Management Association.

More Articles on Clinical Decision Support:

5 Steps to Customize Clinical Decision Support Order Sets for Hospitals
As the Spotlight Remains Affixed to EHRs, Hospitals Shine Light on Supporting Technologies

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