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Published on: May 6, 2014
Prognostic clinical decision support for pneumonia in the emergency department: A randomized trial
Derek J Williams1, Hui Nian1, Srinivasan Suresh2
1Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Insights
Electronic health record-integrated clinical decision support (CDS) for childhood pneumonia did not improve emergency department (ED) disposition decisions. Low patient enrollment and workflow issues limited the effectiveness of this risk-based intervention.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support Systems
- Health Informatics
Background:
- Childhood pneumonia hospitalization rates exhibit significant variation.
- Risk-based clinical decision support (CDS) interventions show potential for reducing unwarranted clinical variation.
Purpose of the Study:
- To evaluate the effectiveness of electronic health record (EHR)-integrated prognostic CDS in improving emergency department (ED) disposition decisions for children with pneumonia.
- To compare the impact of CDS versus usual care on inappropriate ED disposition and patient safety.
Main Methods:
- A pragmatic randomized trial was conducted in two US pediatric EDs.
- Children (<18 years) with pneumonia were randomized 1:1 to receive usual care or EHR-integrated CDS with a validated pneumonia severity score.
- The primary outcome was inappropriate ED disposition; safety and implementation outcomes were also assessed.
Main Results:
- The study included 536 encounters (269 usual care, 267 CDS).
- Inappropriate disposition rates were similar: 3% in usual care vs. 2% in CDS (aOR 0.99, 95% CI [0.32, 2.95]).
- No significant differences in length of stay or adverse safety outcomes were observed; clinician satisfaction with the CDS tool was high (>70%).
Conclusions:
- EHR-based prognostic CDS did not significantly improve ED disposition decisions for pediatric pneumonia.
- Low subject accrual and workflow integration challenges likely hindered the intervention's effectiveness.
- Despite favorable clinician reception, the tool's impact was limited by implementation barriers, including the global pandemic.
Background:
Hospitalization rates for childhood pneumonia vary widely. Risk-based clinical decision support (CDS) interventions may reduce unwarranted variation.
Methods:
We conducted a pragmatic randomized trial in two US pediatric emergency departments (EDs) comparing electronic health record (EHR)-integrated prognostic CDS versus usual care for promoting appropriate ED disposition in children (<18 years) with pneumonia. Encounters were randomized 1:1 to usual care versus custom CDS featuring a validated pneumonia severity score predicting risk for severe in-hospital outcomes. Clinicians retained full decision-making authority. The primary outcome was inappropriate ED disposition, defined as early transition to lower- or higher-level care. Safety and implementation outcomes were also evaluated.
Results:
The study enrolled 536 encounters (269 usual care and 267 CDS). Baseline characteristics were similar across arms. Inappropriate disposition occurred in 3% of usual care encounters and 2% of CDS encounters (adjusted odds ratio: 0.99, 95% confidence interval: [0.32, 2.95]). Length of stay was also similar and adverse safety outcomes were uncommon in both arms. The tool's custom user interface and content were viewed as strengths by surveyed clinicians (>70% satisfied). Implementation barriers include intrinsic (e.g., reaching the right person at the right time) and extrinsic factors (i.e., global pandemic).
Conclusions:
EHR-based prognostic CDS did not improve ED disposition decisions for children with pneumonia. Although the intervention's content was favorably received, low subject accrual and workflow integration problems likely limited effectiveness. Clinical Trials Registration: NCT06033079.
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