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Article history: Objective: The use of evidence-based guidelines can improve the care for asthma patients.
Received in revised form We implemented a computerized asthma management system in a pediatric emergency
22 July 2014 department (ED) to integrate national guidelines. Our objective was to determine whether
Accepted 31 July 2014 patient eligibility identication by a probabilistic disease detection system (Bayesian net-
work) combined with an asthma management system embedded in the workow decreases
Keywords: time to disposition decision.
Asthma Methods: We performed a prospective, randomized controlled trial in an urban, tertiary care
Emergency medicine pediatric ED. All patients 218 years of age presenting to the ED between October 2010
Medical informatics and February 2011 were screened for inclusion by the disease detection system. Patients
Pediatrics identied to have an asthma exacerbation were randomized to intervention or control. For
Clinical decision support intervention patients, asthma management was computer-driven and workow-integrated
including computer-based asthma scoring in triage, and time-driven display of asthma-
related reminders for re-scoring on the electronic patient status board combined with
guideline-compliant order sets. Control patients received standard asthma management.
The primary outcome measure was the time from triage to disposition decision.
Results: The Bayesian network identied 1339 patients with asthma exacerbations, of
which 788 had an asthma diagnosis determined by an ED physician-established reference
standard (positive predictive value 69.9%). The median time to disposition decision did
not differ among the intervention (228 min; IQR = (141, 326)) and control group (223 min;
Abbreviations: CPOE, Computerized Provider Order Entry; ED, Emergency Department; EMR, Electronic Medical Record; NHLBI, National
Hearth Lung and Blood Institute.
Corresponding author at: Division of Emergency Medicine, Cincinnati Childrens Hospital Medical Center, MLC 2008, 3333 Burnet
Avenue, Cincinnati, OH 45229-3039, United States. Tel.: +1 513 803 2962; fax: +1 513 803 2581.
E-mail address: Judith.Dexheimer@cchmc.org (J.W. Dexheimer) .
http://dx.doi.org/10.1016/j.ijmedinf.2014.07.008
1386-5056/ 2014 Published by Elsevier Ireland Ltd.
806 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 805813
IQR = (129, 316)); (p = 0.362). The hospital admission rate was unchanged between inter-
vention (25%) and control groups (26%); (p = 0.867). ED length of stay did not differ
among intervention (262 min; IQR = (165, 410)) and control group (247 min; IQR = (163, 379));
(p = 0.818).
Conclusions: The control and intervention groups were similar in regards to time to disposi-
tion; the computerized management system did not add additional wait time. The time to
disposition decision did not change; however the management system integrated several
different information systems to support clinicians communication.
2014 Published by Elsevier Ireland Ltd.
Fig. 1 Computerized provider order entry pediatric asthma respiratory distress scoring screen.
The pediatric ED clinical team identied optimization of board provided prompts for when a patient was due for
asthma treatment as a high priority for quality improve- reassessment.
ment. A multidisciplinary respiratory distress committee The electronic patient status board prompts were passive
was formed approximately 2 years prior to implementation, reminders for the respiratory therapist and physician. The
including pediatric ED faculty and fellows, nursing staff, respi- respiratory therapists were given a new column for patient
ratory therapy, pharmacy, and informatics personnel. The sign-in. Respiratory therapy scoring was required hourly per
committee iteratively developed and rened an evidence- protocol. For intervention patients, the column background
based practice guideline, which was combined with an asthma would turn yellow when a new respiratory distress score was
care ow sheet and severity-based order sets. The ow sheet due within 15 min. The background of the column would turn
and paper-based guideline have been described previously red when a new respiratory distress score was due or past
[17]. The paper-based guideline is a local adaptation of the due. Entering a new score into the respiratory therapy charting
NHLBI guidelines for the emergency treatment of asthma exa- system would clear the column and restart the timer.
cerbations. The severity-based order sets for use in the CPOE Physicians were required to reassess and rescore their
system were created using the paper-based guideline and the patients every 2 h. Similar to the respiratory therapists
NHLBI guidelines. The two guidelines were combined to cre- reminder, if an assessment and score were due within 15 min,
ate 3 severity-based order sets for mild, moderate, and severe the background of the column was yellow. If an assessment
asthma. The computerized order sets were available as both was due or past due, the background of the column was red. If
text-based order sets accessible by all physicians and as an the patient met the criteria for making a disposition decision,
automatic prompt for intervention patients after the physician the column would ash dark blue. Patients were considered
assigned an asthma score. eligible for a disposition decision when they had been in the
For intervention patients identied by the detection sys- ED at least four hours, with two scores either in the same cate-
tem, the electronic triage summary page required the nurse gory, indicating that treatment effect does not result in further
to perform an initial asthma score on the patient. When changes, or the scores are improving (e.g., moderate to mild
complete, a computer-generated page was sent to respira- categorization). When the physician clicked on the column, a
tory therapy containing the patients information and asthma pop-up box would inform them that it was time to make a dis-
score, and the reminders were turned on in the electronic position decision on the patients. The physicians could defer
patient status board and CPOE systems. The electronic this decision for 2 h. When a discharge or bed request for hos-
patient status board [13] acted as a communication point pital admission was entered in for the patient, the column
among the clinical care team. A new column was added turned green, indicating that a disposition decision had been
for displaying the asthma scores and related information. made and the patients care in the ED had reached stabilization
Each time a respiratory distress score was recorded elec- for either admission or discharge.
tronically, the patient status board column updated with When the physician opened the CPOE session on the
the new score and a trend arrow. The trend arrow looked patient, a pop-up required asthma scoring for the patient
only at the last two scores and displayed whether the (Fig. 1). This pop-up displayed the asthma scoring matrix along
patient was worsening (down arrow), improving (up arrow), with the most recent asthma score recorded and time. The
or remaining stable (equals sign). By hovering-over the col- physician had the option of turning off all asthma-related
umn with the mouse, a graph of the patients asthma severity prompts. If the patient was presenting with an asthma exac-
scores was displayed. This graph was updated each time erbation, the physician carried through with scoring. Based
a new score was recorded. The electronic patient status upon this score, a severity-based order set was provided to the
808 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 805813
clinician. The order sets were mild, moderate, or severe and system for asthma care. The study period took place over ve
had pre-selected items the pediatric ED recommended for months: October 1, 2010February 28, 2011, three weeks of
asthma care. By selecting boxes, the physicians could order the which was excluded due to an informatics error. Patients iden-
asthma treatments. Once ordering was complete, a summary tied by the Bayesian network [9,15,16] were randomized. The
page was displayed to elucidate the new orders, continuing control group received the paper-based protocol at the end of
orders, and discontinued orders. All prompts remained on triage when the nurse automatically printed the triage sum-
through the patients stay in the ED regardless of disposition mary page. The electronic triage summary page displayed a
decision unless turned off in the CPOE system. required click-box reminder to acknowledge that the patient
In automatically detected eligible patients, either the com- presented with symptoms compatible with an asthma exac-
puterized management system alerts were turned on or erbation and that the protocol would print. The intervention
the paper-based asthma protocol was automatically printed group was enrolled in the computerized management system.
out and placed with the triage document in the patients The unit of randomization was the patient with an automated,
chart. A multidisciplinary respiratory distress committee cre- computerized 6-patient block randomization schema. Clini-
ated guideline-adapted severity-based order-sets that were cians were blinded to patients randomization assignment,
available on paper and in the CPOE system. After the auto- although prompts were visible on the electronic patient status
matic disease detection system identies patients, scoring board.
reminders and the order sets are displayed to help maintain
guideline compliance. Table 1 shows a brief description of the
2.6. Selection of participants
key parts of the asthma management system and when these
parts were available.
All patients presenting to the pediatric ED during the study
period were screened for inclusion using the Bayesian network
2.3. Educational effort
system [9,15,16]. The computerized disease detection system
In the two months prior to the study a considerable edu- screens all patients for inclusion using a probabilistic algo-
cational effort was completed: a) physicians were informed rithm (Bayesian network). The detection systems algorithm
about the study in the operational emergency management, includes past medical history from the EMR, and the comput-
faculty, and monthly resident meetings; b) an email from erized triage application for details relating to the current visit
the ED director (division chair) describing and supporting the [9,16]. The detection system requires no additional data entry
study was sent out to the ED staff; c) respiratory therapists and operates in real-time. All patients presenting to the ED
were informed during their monthly management meetings; were screened for an asthma exacerbation during triage and
and d) for a week prior to the study the nurse leadership the Bayesian network detection threshold was set to reduce
informed the nursing staff through the twice-daily meetings alert fatigue. Patients identied through the Bayesian network
before the start of each shift. At all of these meetings, an inves- were eligible and randomized for the study.
tigator explained the study and answered any questions that Patients were included if they were 218 years of age
arose. and were identied by the Bayesian network. Patients were
excluded if they (a) had an Emergency Severity Index = 1 (most
2.4. Follow-up survey severe, life-threatening condition), (b) had no electronic triage,
or (c) eloped or left the ED prior to being seen by a physician. A
After study completion a one-page, a 10-question follow-up sample size of 313 patients per group was needed to detect a
survey was administered to the respiratory therapists, nurses, difference in throughput time of 10% with a power of 0.8 and
and attending and resident physicians, and who worked shifts = 0.05. The study was approved by the institutional review
in the ED during the study period. The survey evaluated the use board and registered on clinicaltrials.gov.
of the paper-based ow diagram and electronic management
system and protocol during the study period.
2.7. Outcomes
2.5. Study design
The primary outcome measure was the time from ED triage
We conducted a prospective, randomized controlled trial to to disposition decision. Either a discharge or hospital admis-
evaluate a computerized disease detection and management sion order (bed request order) in the patient tracking board
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was considered a disposition decision. Secondary outcomes management system (intervention) and time from ED triage
were guideline adherence measures such as asthma education to disposition decision, with comparison to the standard care
ordered, protocol found on chart, asthma scoring performed, system (control). The visit was the unit of analysis. Descriptive
ED length of stay, and hospital admission rate. statistics, including means, standard deviations, and ranges
Data on each visit were collected from the available ED for continuous variables such as time to disposition decision,
information system including the electronic medical record length of stay, and age, as well as percentages and frequen-
[10], electronic triage application [11] and ED patient status cies for categorical variables such as race, gender, insurance
board [13]. A sensitivity of 85% was chosen for the Bayesian type, were provided to describe the study sample. Differ-
network to minimize alert fatigue while still capturing the ences between group means for continuous variables were
maximum number of asthma patients. Based on historical examined using ANOVA or Wilcoxon rank-sum test. Pearson
data this would result in a specicity of 93.6%, positive pre- chi-square tests were used to assess the categorical variables.
dictive value of 65.3%, and negative predictive value of 98.7% All tests of signicance were based on two-sided probabili-
[14]. To establish a reference standard for the diagnosis of an ties, at P values less than .05. Logistic regression was used to
asthma exacerbation, a pediatric emergency medicine board- estimate the odds ratios (ORs) and 95% condence intervals
certied physician examined each patient visit within 7 days (CIs) for patients disposition status, representing the over-
of the visit and determined whether an asthma exacerbation all odds of being admitted associated with the management
was present. To collect study data, a pediatric ED charge nurse system, and to adjust for potential confounding variables,
performed chart reviews on all patient visits. To ascertain data including age, gender, race, insurance, language, acuity, and
quality, a second, independent pediatric emergency medicine mode of arrival in the multivariate analysis. KaplanMeier
board-certied physician established a diagnosis for 20% of curves were presented with log-rank test results to determine
randomly selected patients charts (k = 0.8837; 95% CI: 0.817, whether there were differences in the observed time to dis-
0.950). position decision as well as length of stay. Cox proportional
hazards models were used for time to decision and length
2.8. Analysis of stay separately, to determine whether there is a signi-
cant difference in the outcome variables between intervention
Primary analysis focused on detecting the associations and control, adjusting for the potential confounding variables.
between the use of an integrated electronic asthma The adjusted p-values and the corresponding 95% condence
810 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 805813
3. Results
3.1. Characteristics of study subjects Fig. 4 Time to disposition decision for outpatients.
seeing it (p = 1.0). Nurses who saw the protocol were not any It is possible that earlier and more frequent reminders would
more likely to use it than those who never reported seeing it have helped encourage the physicians to make a disposition
(p = 0.41). Physicians who saw the paper-based protocol were decision quicker, the rules were created to prompt the physi-
not any more likely to use it compared to those who did not cians only when a disposition decision should have already
see the protocol (p = 0.166). Clinician survey results are shown been made.
in Table 4. The guideline adherence measures were also not different
between intervention and control groups. It is possible that
the clinical staff are already providing care that adheres to
4. Discussion the NHLBI guidelines. We examined charts for some of the
guideline measures that may help to decrease ED re-visits:
The study examined the automatic detection of eligible asthma education and a prescription for an inhaled corticoste-
patients and the implementation of a fully computerized roid [18]. Asthma education was already at 95% in the pediatric
asthma management system to guide care compared to ED and remained high throughout the study. Take-home pre-
printing out the existing paper-based asthma protocol and scriptions of inhaled corticosteroids were charted in 8284%
attaching it to the chart. The goal of the study was to decrease of the asthma patients. The paper-based protocol was rarely
time to disposition decision, and examine length of stay and found in the patients chart. This is similar to the phase 1
guideline adherence measures such as asthma education, the study [17]. If the paper-based protocol was not written on,
protocol found on the chart, asthma scoring, and hospital it may not have made it into the medical record. As eluci-
admission rate. The study did not nd a signicant differ- dated in the rst study, the protocols were frequently used
ence between the computerized management system and the as a guideline to reference and not a means of documenta-
paper-based system in time to disposition decision, length of tion.
stay, or the rate of hospital admission. There was no differ- This study was phase 2 in a two phase study design
ence between the two groups in any of the guideline adherence [14], where phase 1 compared the printed paper-based pro-
measures. Despite a thorough educational element and sup- tocol to the standard of care [17]. Given an assumption
port from the ED clinicians, the management system did not that the system may be effective but have cross contam-
show a signicant effect. ination, we compared phase 1 and phase 2 using phase
The average time to disposition decision was 3.8 h, below 1 as a historical control. Neither study had a statistically
the NHLBI guideline goal of 46 h. This is a marked decrease signicance difference in time to disposition decision (aver-
from our previous study, in which the time to disposition deci- age = 288 min in phase 1, average = 224 min in phase 2) or ED
sion was 4.8 h and also within the recommended range [17]. length of stay (average = 331 min in phase 1, average = 255 min
The patients time to disposition decision may be determined in phase 2). However, the operational characteristics of the
by the disease progression and response to treatment. It is pos- ED during the two study periods including occupancy rate,
sible that even with earlier scoring and treatment initiation, average patient acuity, number of boarding patients, and
the disease progression would not be signicantly changed. average length of stay of boarding patients was signi-
However, the triage score was automatically paged to the cantly different (p < 0.001) so no direct comparison can be
respiratory therapist and the therapist was able to start aerosol made.
treatment via standing order before physician assessment. Clinician follow-up interviews revealed that most clini-
This standing order applied to all patients and respiratory cians used the computerized management system in some
therapists may have taken initiative to help start all patient form. More than half of the clinicians reported using the
treatments earlier regardless of the paged reminder. computerized patient status board portion of the asthma
The system did not provide an intent to admit option management system. The computerized patient status board
for the physicians. If a patient needed to be admitted but scores were available for all clinicians to see, regardless
it was known that there were no beds open in the hospital, of patient intervention. This may have contributed to a
it is possible that a bed request was not placed. Therefore, Hawthorne effect [19,20] suggesting that the clinical staff were
these patients would benet from an intent to admit option aware of being studied due to the unblinded nature of the com-
indicating the clinician has made a disposition decision but puterized patient status board display, and therefore reducing
is unable to act on it yet. We did not provide disposition the possible intervention differences between the two
reminders until the patients length of stay was at least 4 h. groups.
812 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 805813
[5] P.V. Scribano, T. Lerer, D. Kennedy, M.M. Cloutier, Provider CPOE experience at Vanderbilt, J. Biomed. Inform. 38 (Dec
adherence to a clinical practice guideline for acute asthma (6)) (2005) 469485.
in a pediatric emergency department, Acad. Emerg. Med. 8 [13] D. Aronsky, I. Jones, K. Lanaghan, C.M. Slovis, Supporting
(December (12)) (2001) 11471152. patient care in the emergency department with a
[6] J.W. Dexheimer, T.R. Talbot, D.L. Sanders, S.T. Rosenbloom, computerized whiteboard system, J. Am. Med. Inform.
D. Aronsky, Prompting clinicians about preventive care Assoc. 15 (MarchApril (2)) (2008) 184194.
measures: a systematic review of randomized controlled [14] J.W. Dexheimer, D.H. Arnold, T.J. Abramo, D. Aronsky,
trials, J. Am. Med. Inform. Assoc. 15 (MayJune (3)) (2008) Development of an asthma management system in a
311320. pediatric emergency department, AMIA Annu. Symp. Proc.
[7] L.J. Hoeksema, A. Bazzy-Asaad, E.A. Lomotan, D.E. Edmonds, 2009 (2009) 142146.
G. Ramirez-Garnica, R.N. Shiffman, et al., Accuracy of a [15] D.L. Sanders, D. Aronsky, Prospective evaluation of a
computerized clinical decision-support system for asthma Bayesian Network for detecting asthma exacerbations in a
assessment and management, J. Am. Med. Inform. Assoc. 18 Pediatric Emergency Department, AMIA Annu. Symp. Proc.
(May (3)) (2011) 243250. (2006) 1085.
[8] E.A. Lomotan, L.J. Hoeksema, D.E. Edmonds, G. [16] D.L. Sanders, W. Gregg, D. Aronsky, Identifying asthma
Ramirez-Garnica, R.N. Shiffman, L.I. Horwitz, Evaluating the exacerbations in a pediatric emergency department: a
use of a computerized clinical decision support system for feasibility study, Int. J. Med. Inf. 76 (July (7)) (2007) 557564.
asthma by pediatric pulmonologists, Int. J. Med. Inf. 81 [17] J.W. Dexheimer, T.J. Abramo, D.H. Arnold, K.B. Johnson, Y.
(March (3)) (2012) 157165. Shyr, F. Ye, et al., An asthma management system in a
[9] D.L. Sanders, D. Aronsky, Detecting asthma exacerbations in pediatric emergency department, Int. J. Med. Inform. 82
a pediatric emergency department using a Bayesian (April (4)) (2013) 230238.
network, AMIA Annu. Symp. Proc. 68 (2006) 48. [18] D.D. Sin, S.F. Man, Low-dose inhaled corticosteroid therapy
[10] D.A. Giuse, Supporting communication in an integrated and risk of emergency department visits for asthma, Arch.
patient record system, AMIA Annu. Symp. Proc. (2003) Intern. Med. 162 (July (14)) (2002) 15911595.
1065. [19] E. Mayo, The Human Problems of an Industrial Civilization,
[11] S. Levin, D. France, R.S. Mayberry, S. Stonemetz, I. Jones, D. Routledge, London; New York, 2003.
Aronsky, The effects of computerized triage on nurse work [20] F.J. Roethlisberger, W.J. Dickson, H.A. Wright, C.H.
behavior, AMIA Annu. Symp. Proc. (2006) 1005. Pforzheimer, Western Electric Company, Management and
[12] R.A. Miller, L.R. Waitman, S. Chen, S.T. Rosenbloom, The the Worker: An Account of a Research Program conducted
anatomy of decision support during inpatient care provider by the Western Electric Company, Hawthorne Works,
order entry (CPOE): empirical observations from a decade of Chicago, Harvard University Press, Cambridge, MA, 1939.