Using ‘nudge’ principles for order set design: a before and after evaluation of an electronic prescribing template in critical care

Bourdeaux, Christopher; Davies, Keith; Thomas, Matthew; Bewley, Jeremy; Gould, T

doi:10.1136/bmjqs-2013-002395

Cited by 51 publications

(66 citation statements)

References 21 publications

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“…[38,46,50,51,59,70,71,72] Six studies showed improvement of user uptake and satisfaction. In a study by Chow and co-workers, the proportion of times when CDS was used when antibiotics were prescribed increased from 23% in phase (1) to 38% in phase (2) and to 87% in phase (3).…”

Section: Resultsmentioning

confidence: 99%

The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review

2017

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BackgroundInappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR.ObjectivesTo evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings.MethodsA systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale.ResultsEighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p ≤ 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted.ConclusionsCDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.

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Section: Resultsmentioning

confidence: 99%

The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review

2017

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“…The careful design of default options has been shown to dramatically change prescribing behaviour and improve compliance with evidence-based interventions. [18][19][20] Although many default settings exist within the ICU, their role is poorly understood, and unless careful attention is applied to them they can result in harm, 21 The default settings on ventilators lead patients to be ventilated on lower TVes for a persistent period of time. Patients who were on default ventilators had significantly lower TVes than patients who were not.…”

Section: Discussionmentioning

confidence: 99%

Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses

Bourdeaux¹,

Thomas²,

Gould³

et al. 2016

BMJ Open

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ObjectivesLow tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. ‘Nudges’ influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU).SettingUniversity Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year.ParticipantsData were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis.Interventions(1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive.Primary outcome measureTVe in mL/kg IBW.FindingsTVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years.ConclusionsThis study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice.

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“…When choice architecture is neglected, defaults may lose power [19,40,41]. Therefore, for defaults to exert their maximal and intended effects, they must be created and implemented with clear attention to exactly how they may change behaviors.…”

Section: Recently Examined Use Of Defaults In Critical Care Medicinementioning

confidence: 99%

Default options in the ICU

Hart

Halpern

2014

Current Opinion in Critical Care

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Purpose of review Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology. Recent findings Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking. Summary Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.

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Using ‘nudge’ principles for order set design: a before and after evaluation of an electronic prescribing template in critical care

Abstract: The presentation of choices within an electronic prescribing system influenced the delivery of evidence-based interventions in a predictable way and the effect was well sustained. This approach has the potential to enhance the effectiveness of computerised order sets.

Cited by 51 publications

References 21 publications

The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review

The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review

Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses

Default options in the ICU

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