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

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.