eSIMPLER: A Dynamic, Electronic Health Record–Integrated Checklist for Clinical Decision Support During PICU Daily Rounds

Abstract

OBJECTIVES: Design, implement, and evaluate a rounding checklist with deeply embedded, dynamic electronic health record integration. DESIGN: Before-after quality-improvement study. SETTING:Quaternary PICU in an academic, free-standing children's hospital. PATIENTS:All patients in the PICU during daily morning rounds. INTERVENTIONS:Implementation of an updated dynamic checklist (eSIMPLER) providing clinical decision support prompts with display of relevant data automatically pulled from the electronic health record. MEASUREMENTS AND MAIN RESULTS:The prior daily rounding checklist, eSIMPLE, was implemented for 49,709 patient-days (7,779 patients) between October 30, 2011, and October 7, 2018. eSIMPLER was implemented for 5,306 patient-days (971 patients) over 6 months. Checklist completion rates were similar (eSIMPLE: 95% [95% CI, 88-98%] vs eSIMPLER: 98% [95% CI, 92-100%] of patient-days; p = 0.40). eSIMPLER required less time per patient (28 ± 1 vs 47 ± 24 s; p < 0.001). Users reported improved satisfaction with eSIMPLER (p = 0.009). Several checklist-driven process measures-discordance between electronic health record orders for stress ulcer prophylaxis and user-recorded indication for stress ulcer prophylaxis, rate of venous thromboembolism prophylaxis prescribing, and recognition of reduced renal function-improved during the eSIMPLER phase.CONCLUSIONS: eSIMPLER, a dynamic, electronic health recordinformed checklist, required less time to complete and improved certain care processes compared with a prior, static checklist with limited electronic health record data. By focusing on the "Five Rights" of clinical decision support, we created a well-accepted clinical decision support tool that was integrated efficiently into daily rounds. Generalizability of eSIMPLER's effectiveness and its impact on patient outcomes need to be examined.

Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review

“…Rationales included removing the burden from clinicians in complex situations (eg, monitoring antibiotic use [ 77 ]). Other rationales cited for implementing a CDSS included the following: the CDSS as a separate intervention to address a clinical need or context (eg, reducing the incidence of hospital-acquired infections [ 64 ]), increasing workflow efficacy [ 79 ], improving adherence to clinical guidelines [ 82 ], transforming time-consuming paper versions of a CDSS to a digital version [ 81 , 87 , 104 ], engaging or collaborating with health care workers [ 78 ], and decreasing duplication of tests or health resource waste (eg, duplicates of magnetic resonance imaging scans) [ 84 ]. Other authors noted that their study was a scale-up or modification of an initial pilot of a CDSS [ 80 , 82 , 98 ], that there was existing evidence that validated the use of a CDSS [ 66 ], and contextual factors of the health system (eg, rapid turnover of clinicians) required the implementation of a CDSS [ 70 ].…”

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

“…Involving staff in technology design (103,104) and implementation planning was recognized as a necessary strategy for improving implementation and sustainability efforts (104), which aligns with many process models in implementation science (105). Although, no studies directly evaluated algorithm implementation into the electronic health record, one study evaluating an integrated rounding checklist in the PICU showed improved outcomes for patients across many of the measured outcomes (106). During implementation planning, the identification of barriers and facilitators is undisputed to facilitate implementation efforts, as highlighted by determinant frameworks (105).…”

Editor’s Choice Articles for May

“…Another article about rounding discussions in this issue examines the impact of unit census and patient acuity on effective discussion (14). Why not enhance your review of the literature on the topic of rounds by looking at similar work in recent issues of PCCM (15–17).…”