A quantitative study investigating the

effects of computerised clinical decision

support in the emergency department

Paula Bennett – Nurse Consultant

Emergency Department

Objectives

• Quality & safety in ED

• eTriage

• The research

• The future

Stockport

• DGH

• New department in 1995 (63,000)

• 2013 - 90,091

• Pre 2010 no IT in ED at all!

The Quality & Safety Challenge

• Rising attendances

• Increasing elderly population

• Performance (95%)

• Workforce issues

• Economy

Local and international experience

• Increasing numbers of clinical guidelines

• Common

• Rare

• Risky

• If followed

• Risk managed

• Improved patient experience

• Appropriate tests

• Appropriate timely referrals

• If not followed……………………

eTriage

2008 – Discussions began about development

Launch 12/4/2010

by 17/6/13 – 293,206 “eTriaged”

2013 – Results of research

The Study

• Research Question

Does the introduction of a computerised clinical-decision support system improve the quality of triage decisions and safety within the ED?

CCDSS

"Clinical Decision Support systems link health observations with health

knowledge to influence choices by clinicians for improved health care".

Elements of a CCDSS

• Individualized patients data is entered

• Computerised database

• Pt specific recommendations are generated

Systematic Review CCDSS Literature

Acute Care – majority improved process much less likely to improve outcome

Prevention – some positive evidence for screening, less evidence for

outcomes, safety, cost & satisfaction

Chronic Disease – improved processes, some improved patients health

Test ordering – some modify clinicians behaviours

Drug Prescribing – poor evidence – no recommendations to adopt

Drug monitoring – can improve process of care esp. insulin and Vit K. effects

on outcome uncertain

Haynes 2011 http://www.implementationscience.com/series/CCDSS

CCDSS in ED

• 23 studies of computerised decision-support in EDs

• 13 demonstrated significant impact on clinical care with the use of a

CCDSS

• Increased guideline adherence

• Increased “speed”

• Time to antibiotics

• Improved documentation

Quasi-experimental study

Outcome Measures • Quality

• Pain Assessment

• Was pain scored?

• Pain management

• Was appropriate pain relief given?

• Safety

• Triage decision

• Was the right priority allocated?

• Neutropenic sepsis

• Urgent priority

• Immediate FBC

• IV antibiotics <1hr

Research method

• Interrupted time series design

• Pre-eTriage

• 400 randomised records.

• 26 pts with chemotherapy induced neutropenia

• Post-eTriage

• 400 randomised records.

• 18 pts with chemotherapy induced neutropenia

Data collection

points

1

2

3

4

X

5

6

7

8

Time intervals

April 2009

July 2009

Oct 2009

Jan 2009

12th April 2010

April 2011

July 2011

Oct 2011

Jan 2012

• Inter-rater reliability

– >80% agreement

– Kappa

• fair to moderate agreement

• Ethics

– Not required as “service evaluation” not research

• Research Governance

– Safe storage of data

Results

• Chi Square

• Did eTriage improve quality?

• Was there an improvement in pain assessment – YES

• p<0.01

• Was there an improvement in appropriate pain relief – YES

• p<0.01

• Did eTriage improve safety?

• Was there an improvement in prioritisation – YES

• p<0.01

• Was there improvement in the management of patients with Neutropenic sepsis – No significant difference

Results – logistic regression

• Confounding variables

• Age

• Gender

• Mode of arrival

• Triage nurse experience

• Time

• Intervention (eTriage)

• Correct triage priority

– Mode of arrival

• p<0.001

• OR 1.962 [CI 1.298-2.965]

– Intervention

• p<0.034

• OR 14.499 [CI 1.221-172.228]

Logistic regression – time series

Correct triage priority

Limitations

• 1 system

• 1 department

• Judgments of researcher may have led to unintentional bias

• Small sample of “high risk” patients – further research required on larger samples. • Only captured those with confirmed neutropenia not all those

suspected of it

Conclusion

• CCDSS in ED does improve the quality and safety of Triage

decisions

– Consistent safety

– Consistent quality

• The effect on the management of patients with “high risk” conditions

was not shown to be significant

– Further research needed

• In the current ED climate clinicians must harness the potential that

technological solutions can offer

The future……………………

Any questions?