Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: A Quasi-Experimental Study | JoVE Visualize

Area of Science:

Clinical Informatics
Pharmacology
Hospital Administration

Background:

Inpatient serum phosphate replacement practices exhibit significant variability, leading to overuse.
Electronic health record (EHR) interventions with clinical decision support (CDS) can standardize care and reduce unnecessary treatments.
Overuse of hypophosphatemia correction contributes to increased healthcare costs and potential patient harm.

Purpose of the Study:

To implement and evaluate CDS tools within an EHR system to decrease the overuse of intravenous (IV) phosphate repletion.
To guide clinicians toward appropriate phosphate repletion strategies based on established clinical guidelines.
To reduce the incidence of unnecessary IV phosphate administration in a large safety-net healthcare system.

Main Methods:

Enhanced an existing EHR order set for phosphate repletion with CDS, incorporating severity-based guidance and simplified ordering.
Implemented a Best Practice Advisory (BPA) within the EHR to alert clinicians when IV phosphate was ordered for mild/moderate hypophosphatemia without a nil per os (NPO) status.
Measured the primary outcome: the rate of IV phosphate replacement in patients with mild to moderate hypophosphatemia (1.0-1.9 mg/dL) without NPO orders per 1,000 patient-days.

Main Results:

A 53.0% reduction in IV phosphate replacement for mild to moderate hypophosphatemia without NPO orders (from 7.22 to 3.40 per 1,000 patient-days; p < 0.001).
A concurrent 38.8% increase in oral phosphate replacement for this patient group (from 6.39 to 8.87 per 1,000 patient-days; p < 0.001).
Significant reductions observed in IV and oral phosphate replacement for patients with phosphate levels ≥ 2.0 mg/dL as well.

Conclusions:

A two-pronged EHR intervention utilizing CDS effectively reduced inpatient IV phosphate replacement by 53.0% in patients with mild to moderate hypophosphatemia.
The intervention successfully shifted treatment patterns towards more appropriate repletion strategies in a large safety-net setting.
CDS tools integrated into EHR systems are valuable for optimizing clinical practice and reducing medication overuse.