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Redesigning Clinical Decision Support for Retinopathy of Prematurity Screening After Alert Failure
Mikael Carl Gustav Guzman Karlsson1,2,3, Lauren M Hess1,4, Amy L Jeppesen1
1Texas Children's Hospital, Houston, Texas, United States.
Insights
An interruptive alert for retinopathy of prematurity (ROP) screening failed to identify at-risk infants during readmissions. Data analysis led to a switch to a more effective, non-interruptive surveillance dashboard.
Area of Science:
- Pediatric ophthalmology
- Clinical informatics
- Healthcare quality improvement
Background:
- Retinopathy of prematurity (ROP) is a leading cause of preventable childhood blindness in premature infants.
- Current screening guidelines target infants with gestational age < 31 weeks or birthweight ≤ 1500g.
- Timely ROP screening during post-birth readmissions presents significant logistical challenges.
Purpose of the Study:
- To evaluate the performance of an interruptive clinical decision support (CDS) alert for ROP screening in readmitted premature infants.
- To analyze how data from the alert's performance informed the transition to a non-interruptive surveillance dashboard.
Main Methods:
- An interruptive alert was implemented for patients aged 1-365 days requiring ROP screening during hospital readmissions.
- Alert metrics, user responses, patient demographics, and ophthalmology consultations were extracted from the hospital's data warehouse.
- Statistical process control charts analyzed ophthalmology consultation rates before, during, and after alert implementation.
Main Results:
- The alert triggered 3309 times across 2194 patient encounters.
- Only 43% of encounters resulted in an "Accept and place order" response, with just 11% leading to an ophthalmology consult.
- A significant portion of consultations (34%) occurred despite alternative user responses, indicating alert inefficiency.
Conclusions:
- An analysis of the underperforming interruptive alert led to its deimplementation and replacement with a targeted, non-interruptive surveillance dashboard.
- This transition highlights the critical need to align CDS tools with clinical workflows, data availability, and user decision-making processes.
- Effective governance is essential for successful CDS implementation and optimization in healthcare settings.
Abstract:
Retinopathy of prematurity (ROP) is the leading cause of preventable childhood blindness. Guidelines recommend screening for infants with gestational age at birth <31 weeks or birth weight ≤1,500 g. However, ensuring timely screening during readmissions after birth is challenging.To analyze the performance of an interruptive alert at a large academic pediatric hospital for identifying premature infants needing ROP screening upon hospital readmission and to describe how data informed the transition to a non-interruptive dashboard.The alert appeared for patients 1 to 365 days of age hospitalized in acute care or pediatric intensive care and instructed providers to order an ophthalmology consult from within the alert and to call ophthalmology for at-risk patients. For quality improvement, the clinical decision support (CDS) advisory group evaluated the effectiveness and efficiency of the alert. We extracted alert metrics from the hospital's enterprise data warehouse, including the user response and feedback, patient characteristics (age, birth gestational age, and birth weight), and any ophthalmology consultations. We analyzed the percentage of encounters seen by ophthalmology using a statistical process control chart during alert implementation and 6 months before and after.The alert appeared 3,309 times during 2,194 patient encounters usually. Users chose "Accept and place order" for 43% (943/2,194) of encounters, but only 11% (102/943) had an ophthalmology consult; 34% (53/155) of ophthalmology consultations occurred in encounters with a final response other than "Accept and place order." The intervention was redesigned using a non-interruptive surveillance dashboard with greater specificity, and the alert was de-implemented.Analysis of a failed interruptive alert for identifying patients at risk for ROP led to a transition to targeted surveillance using a dashboard. This case emphasizes the importance of aligning the CDS modality to the clinical workflow, information availability, and user decision-making needs and should be supported by governance.
