Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy
Objective We evaluated the effect on clinical outcomes of implementing a standardised inpatient order set for patients admitted with hepatic encephalopathy (HE).Methods A retrospective review of patients with cirrhosis admitted with HE. Hospital admissions for HE for which the electronic health reco...
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BMJ Publishing Group
2021-10-01
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| Series: | BMJ Open Gastroenterology |
| Online Access: | https://bmjopengastro.bmj.com/content/8/1/e000621.full |
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| author | Qi Wang Mandip KC Andrew P J Olson Nicholas Lim |
| author_facet | Qi Wang Mandip KC Andrew P J Olson Nicholas Lim |
| author_sort | Qi Wang |
| collection | DOAJ |
| description | Objective We evaluated the effect on clinical outcomes of implementing a standardised inpatient order set for patients admitted with hepatic encephalopathy (HE).Methods A retrospective review of patients with cirrhosis admitted with HE. Hospital admissions for HE for which the electronic health record (EHR) order set was used were compared with admissions where the order set was not used. Primary outcome was length of hospital stay (LOS). Secondary outcomes were 30-day readmissions, in-hospital complications, in-hospital and 90-day mortality.Results There were 341 patients with 980 admissions over the study period: 263 patients with 736 admissions where the order set was implemented, and 78 patients with 244 admissions where the order set was not implemented. Median LOS was 4 days (IQR 3–8) in the order set group compared with 3 days (IQR 2–7) (p<0.001); incidence rate ratio 1.37 (95% CI 1.20 to 1.57), p<0.001. 30-day readmissions rate was 56% in the order set group compared with 40%, p=0.01; OR for readmission was 1.88 (95% CI 1.04 to 3.43), p=0.04. Hypokalaemia occurred in 46% of admissions with order set use compared with 36%, when the order set was not used; p=0.003, OR 1.72 (95% CI 1.22 to 2.43), p=0.002. No significant differences were seen for in-hospital mortality and 90-day mortality.Conclusion Implementation of an inpatient EHR order set for use in patients with HE was associated with unexpected clinical outcomes including increased LOS and readmissions. The convenience and advantages of standardisation of patient care should be balanced with a degree of individualisation, particularly in the care of medically complex patients. Furthermore, standardised processes should be evaluated frequently after implementation to assess for unintended consequences. |
| format | Article |
| id | doaj-art-d2ebe5aa22d447248b55c417d4683105 |
| institution | Kabale University |
| issn | 2054-4774 |
| language | English |
| publishDate | 2021-10-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | BMJ Open Gastroenterology |
| spelling | doaj-art-d2ebe5aa22d447248b55c417d46831052024-12-07T15:45:10ZengBMJ Publishing GroupBMJ Open Gastroenterology2054-47742021-10-018110.1136/bmjgast-2021-000621Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathyQi Wang0Mandip KC1Andrew P J Olson2Nicholas Lim3College of Public Administration and Humanities, Dalian Maritime University, Dalian, ChinaDepartment of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA2 Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USADivision of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USAObjective We evaluated the effect on clinical outcomes of implementing a standardised inpatient order set for patients admitted with hepatic encephalopathy (HE).Methods A retrospective review of patients with cirrhosis admitted with HE. Hospital admissions for HE for which the electronic health record (EHR) order set was used were compared with admissions where the order set was not used. Primary outcome was length of hospital stay (LOS). Secondary outcomes were 30-day readmissions, in-hospital complications, in-hospital and 90-day mortality.Results There were 341 patients with 980 admissions over the study period: 263 patients with 736 admissions where the order set was implemented, and 78 patients with 244 admissions where the order set was not implemented. Median LOS was 4 days (IQR 3–8) in the order set group compared with 3 days (IQR 2–7) (p<0.001); incidence rate ratio 1.37 (95% CI 1.20 to 1.57), p<0.001. 30-day readmissions rate was 56% in the order set group compared with 40%, p=0.01; OR for readmission was 1.88 (95% CI 1.04 to 3.43), p=0.04. Hypokalaemia occurred in 46% of admissions with order set use compared with 36%, when the order set was not used; p=0.003, OR 1.72 (95% CI 1.22 to 2.43), p=0.002. No significant differences were seen for in-hospital mortality and 90-day mortality.Conclusion Implementation of an inpatient EHR order set for use in patients with HE was associated with unexpected clinical outcomes including increased LOS and readmissions. The convenience and advantages of standardisation of patient care should be balanced with a degree of individualisation, particularly in the care of medically complex patients. Furthermore, standardised processes should be evaluated frequently after implementation to assess for unintended consequences.https://bmjopengastro.bmj.com/content/8/1/e000621.full |
| spellingShingle | Qi Wang Mandip KC Andrew P J Olson Nicholas Lim Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy BMJ Open Gastroenterology |
| title | Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy |
| title_full | Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy |
| title_fullStr | Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy |
| title_full_unstemmed | Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy |
| title_short | Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy |
| title_sort | unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy |
| url | https://bmjopengastro.bmj.com/content/8/1/e000621.full |
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