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Randomized trial of a clinical decision support system: impact on the management of children with fever without
Jolt Roukema1, Ewout W Steyerberg, Johan van der Lei
1Department of General Paediatrics, Room SP 1540, Sophia Children's Hospital, Erasmus Medical Centre, P.O. Box 2060 CB Rotterdam, The Netherlands.
Insights
This study assessed a clinical decision support system (CDSS) for children with fever without apparent source. While adherence was high, the CDSS unexpectedly increased emergency department (ED) length of stay and lab tests, leading to discontinuation.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Informatics
- Health Services Research
Background:
- Fever without apparent source (FWS) is common in young children presenting to emergency departments (EDs).
- Clinical decision support systems (CDSS) aim to standardize and improve diagnostic management.
- Evaluating CDSS impact on clinical workflow and patient outcomes is crucial.
Purpose of the Study:
- To evaluate compliance with a CDSS for managing pediatric FWS.
- To determine the effect of CDSS implementation on ED length of stay (LOS) and laboratory test utilization.
Main Methods:
- A CDSS was used by ED nursing staff to register children with fever.
- Children aged 1-36 months with FWS were randomized into intervention (CDSS advice for labs, n=74) or control (physician decision for labs, n=90) groups.
- Compliance with registration and adherence to CDSS lab recommendations were measured.
Main Results:
- Registration compliance was 50%; adherence to CDSS lab advice was 82%.
- The intervention group had a median ED LOS of 138 minutes versus 123 minutes in the control group.
- Laboratory tests were significantly more frequent in the intervention group (82%) compared to the control group (44%).
Conclusions:
- CDSS implementation for pediatric FWS demonstrated good compliance and adherence.
- The CDSS had unintended consequences, increasing ED LOS and laboratory test use.
- The specific CDSS evaluated was discontinued due to these unexpected outcomes.
Objective:
To assess compliance with a clinical decision support system (CDSS) for diagnostic management of children with fever without apparent source and to study the effects of application of the CDSS on time spent in the emergency department (ED) and number of laboratory tests.
Design:
The CDSS was used by ED nursing staff to register children presenting with fever. The CDSS identified children that met inclusion criteria (1-36 months and fever without apparent source (FWS)) and provided patient-specific diagnostic management advice. Children at high risk for serious bacterial infection were randomized for the 'intervention' (n = 74) or the 'control' (n = 90) group. In the intervention group, the CDSS provided the advice to immediately order laboratory tests and in the control group the ED physician first assessed the children and then decided on ordering laboratory tests.
Results:
Compliance with registration of febrile children was 50% (683/1,399). Adherence to the advice to order laboratory tests was 82% (61/74). Children in the intervention group had a median (25(th)-75(th) percentile) length of stay at the ED of 138 (104-181) minutes. The median length of stay at the ED in the control group was 123 (83-179) minutes. Laboratory tests were significantly more frequently ordered in the intervention group (82%) than in the control group (44%, p < 0.001, chi(2) test).
Conclusion:
Implementation of a CDSS for diagnostic management of young children with fever without apparent source was successful regarding compliance and adherence to CDSS recommendations, but had unexpected effects on patient outcome in terms of ED length of stay and number of laboratory tests. The use of the current CDSS was discontinued.
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