- Email: [email protected]
Electronic Order Set Use and Heart Failure Outcomes in a Metropolitan Health Care System
S258
Canadian Cardiovascular Society (CCS) Vascular 2013 Oral ORGANIZING HEALTH SYSTEMS TO DELIVER OPTIMAL VASCULAR CARE Friday, October 18, 2013 433 TIME-CRITICAL CARDIOVASCULAR CARE IN QUÉBEC: ADVANTAGES OF A NOVEL COLLABORATIVE INITIATIVE TO IMPROVE OUTCOMES FOR BOTH ACUTE MYOCARDIAL INFARCTION AND ISCHEMIC STROKE LJ Lambert, L Clément, LJ Boothroyd, C Beauchamp, C Carroll, P Bogaty Montréal, Québec BACKGROUND:
Cardiovascular disease is a major burden for Canadians and for the health care system. In 2008-09, two field evaluations of care were conducted in Québec: one for acute STelevation myocardial infarction (STEMI), by our cardiology evaluation unit, and one for stroke, by the Canadian Stroke Network. Both indicated the need for improved processes of care and reduced treatment delays for these time-critical events. In response, the Québec Health Ministry mandated our unit to collaborate with its Stroke Program to conduct an expanded, combined, province-wide evaluation. This joint initiative will aim to measure processes of care in the hyperacute phase for both STEMI and ischemic stroke, and to measure outcomes. METHODS AND RESULTS: Distinct expert working groups will be created to select quality indicators (QI) and appropriate process-of-care variables to be measured. To ensure complete and systematic collection of patients, only those with a hospital admission for STEMI or ischemic stroke will be included. Several critical elements have been identified as common for both events. The prehospital phase of care is essential due to 1) the clinical significance of the delay from onset of symptoms to first medical contact (including emergency medical services, EMS); 2) the potential for prehospital diagnosis and pre-arrival alert to receiving emergency departments (ED); and 3) the organization of ambulance transport to the closest hospital or to a designated centre. Once in the ED, a number of delays are crucial: time from triage to diagnostic test (ECG for STEMI, computerized tomography scan for ischemic stroke); and time from diagnosis to treatment option (i.e. on-site fibrinolysis, transfer to a specialized centre or no reperfusion therapy). For fibrinolysis, the established QI is door-to-needle time 30 min for STEMI and 60 min for ischemic stroke. For both events, EMS personnel and ED teams must collaborate effectively with each other and with designated centres, to create regional networks offering seamless, high-quality care. CONCLUSION: In the hyperacute phase of care, STEMI and ischemic stroke share similar clinical challenges and goals. A combined evaluation of care and outcomes for these timecritical events will maximize efficient use of resources for data collection and knowledge transfer, since the same clinical teams will be targeted (EMS and ED staff). System-level
Canadian Journal of Cardiology Volume 29 2013
interventions and quality improvement initiatives, implemented in response to the results of the evaluation, are likely to have a powerful impact on delays and health outcomes in both STEMI and ischemic stroke patients. 436 ELECTRONIC ORDER SET USE AND HEART FAILURE OUTCOMES IN A METROPOLITAN HEALTH CARE SYSTEM JG Howlett, S Aggarwal, J Eisner Calgary, Alberta BACKGROUND: Care pathways and other decision support tools such as electronic medical records (EMR) have been advocated for use in management of acute heart failure. We sought to determine the clinical impact of introduction of a specifically designed order set for acute heart failure in a health care region with electronic charting. METHODS: Data from a metropolitan hospital group for all unique hospitalizations with a primary diagnosis of acute heart failure from January 2010 to December 2012 were reviewed. Anelectronic chart was universally employed for all ordering and testing functions, and included clinical documentation supplemented by paper record. The heart failure order set was created by a multidisciplinary team and tested for compatibility within the EMR by dedicated personnel. Elements in the order set (in addition to routine admission orders) included items and reminders relating to standard investigations and treatments as well as discharge planning and post discharge follow up. All clinical orders and results were recorded in the EMR and interrogated for this study. RESULTS: Demographic and clinical data were collected on 3946 unique individuals. There were 2045 (52%) females, the average age 75.5 years, creatinine 131 umol/L and heart rate 81 bpm. The median length of stay was 10 days. The electronic order set was utilized in 705 cases and was associated with cardiology involvement as attending or consulting physician (41% vs. 29%, p, 0.001). No other baseline differences were seen. Overall, in-hospital mortality was 10% and 30 day readmission rate 20%. In unadjusted analysis, use of the order set was associated with 1 less day length of stay and 7% lower 7 and 30 day readmission rates. After adjustment for demographic and clinical variables, there persisted a significantly lower 7 and 30 day composite clinical (mortality plus all cause readmission) rates, driven by outcomes occurring in the first 7 days post discharge. CONCLUSION: Introduction of an electronic heart failure order set within the context of a hospital medical record is associated with lower early rehospitalization and mortality, primarily driven by outcomes in the first week post discharge. Further studies are warranted to evaluate the impact of a larger implementation of this order set.
Canadian Cardiovascular Society (CCS) Vascular 2013 Oral ORGANIZING HEALTH SYSTEMS TO DELIVER OPTIMAL VASCULAR CARE Friday, October 18, 2013 433 TIME-CRITICAL CARDIOVASCULAR CARE IN QUÉBEC: ADVANTAGES OF A NOVEL COLLABORATIVE INITIATIVE TO IMPROVE OUTCOMES FOR BOTH ACUTE MYOCARDIAL INFARCTION AND ISCHEMIC STROKE LJ Lambert, L Clément, LJ Boothroyd, C Beauchamp, C Carroll, P Bogaty Montréal, Québec BACKGROUND:
Cardiovascular disease is a major burden for Canadians and for the health care system. In 2008-09, two field evaluations of care were conducted in Québec: one for acute STelevation myocardial infarction (STEMI), by our cardiology evaluation unit, and one for stroke, by the Canadian Stroke Network. Both indicated the need for improved processes of care and reduced treatment delays for these time-critical events. In response, the Québec Health Ministry mandated our unit to collaborate with its Stroke Program to conduct an expanded, combined, province-wide evaluation. This joint initiative will aim to measure processes of care in the hyperacute phase for both STEMI and ischemic stroke, and to measure outcomes. METHODS AND RESULTS: Distinct expert working groups will be created to select quality indicators (QI) and appropriate process-of-care variables to be measured. To ensure complete and systematic collection of patients, only those with a hospital admission for STEMI or ischemic stroke will be included. Several critical elements have been identified as common for both events. The prehospital phase of care is essential due to 1) the clinical significance of the delay from onset of symptoms to first medical contact (including emergency medical services, EMS); 2) the potential for prehospital diagnosis and pre-arrival alert to receiving emergency departments (ED); and 3) the organization of ambulance transport to the closest hospital or to a designated centre. Once in the ED, a number of delays are crucial: time from triage to diagnostic test (ECG for STEMI, computerized tomography scan for ischemic stroke); and time from diagnosis to treatment option (i.e. on-site fibrinolysis, transfer to a specialized centre or no reperfusion therapy). For fibrinolysis, the established QI is door-to-needle time 30 min for STEMI and 60 min for ischemic stroke. For both events, EMS personnel and ED teams must collaborate effectively with each other and with designated centres, to create regional networks offering seamless, high-quality care. CONCLUSION: In the hyperacute phase of care, STEMI and ischemic stroke share similar clinical challenges and goals. A combined evaluation of care and outcomes for these timecritical events will maximize efficient use of resources for data collection and knowledge transfer, since the same clinical teams will be targeted (EMS and ED staff). System-level
Canadian Journal of Cardiology Volume 29 2013
interventions and quality improvement initiatives, implemented in response to the results of the evaluation, are likely to have a powerful impact on delays and health outcomes in both STEMI and ischemic stroke patients. 436 ELECTRONIC ORDER SET USE AND HEART FAILURE OUTCOMES IN A METROPOLITAN HEALTH CARE SYSTEM JG Howlett, S Aggarwal, J Eisner Calgary, Alberta BACKGROUND: Care pathways and other decision support tools such as electronic medical records (EMR) have been advocated for use in management of acute heart failure. We sought to determine the clinical impact of introduction of a specifically designed order set for acute heart failure in a health care region with electronic charting. METHODS: Data from a metropolitan hospital group for all unique hospitalizations with a primary diagnosis of acute heart failure from January 2010 to December 2012 were reviewed. Anelectronic chart was universally employed for all ordering and testing functions, and included clinical documentation supplemented by paper record. The heart failure order set was created by a multidisciplinary team and tested for compatibility within the EMR by dedicated personnel. Elements in the order set (in addition to routine admission orders) included items and reminders relating to standard investigations and treatments as well as discharge planning and post discharge follow up. All clinical orders and results were recorded in the EMR and interrogated for this study. RESULTS: Demographic and clinical data were collected on 3946 unique individuals. There were 2045 (52%) females, the average age 75.5 years, creatinine 131 umol/L and heart rate 81 bpm. The median length of stay was 10 days. The electronic order set was utilized in 705 cases and was associated with cardiology involvement as attending or consulting physician (41% vs. 29%, p, 0.001). No other baseline differences were seen. Overall, in-hospital mortality was 10% and 30 day readmission rate 20%. In unadjusted analysis, use of the order set was associated with 1 less day length of stay and 7% lower 7 and 30 day readmission rates. After adjustment for demographic and clinical variables, there persisted a significantly lower 7 and 30 day composite clinical (mortality plus all cause readmission) rates, driven by outcomes occurring in the first 7 days post discharge. CONCLUSION: Introduction of an electronic heart failure order set within the context of a hospital medical record is associated with lower early rehospitalization and mortality, primarily driven by outcomes in the first week post discharge. Further studies are warranted to evaluate the impact of a larger implementation of this order set.