A clinical decision support tool to aid in the management of - - PowerPoint PPT Presentation

A clinical decision support tool to aid in the management of hospitalized cirrhotic patients

Osman Ahmed MD & Mayur MD FRCPC Department of Medicine: Division of Gastroenterology Toronto General Hospital Toronto, Canada

Background

• The complications from cirrhosis often require hospitalizations that

are prolonged and expensive (1.4 billion per year in USA).

• No change in inpatient mortality between 2002-2011 (8.6% and 9.1%

respectively).

• Adherence to diagnostic and therapeutic guidelines is low.

Background

• Clinical Decision Support previously implemented in management of

variceal bleed.

○ Increased overall optimal care from 41% to 65% ○ Increased prophylactic antibiotic use from 57% to 75% ○ Increased somatastatin analog use from 54% to 76% ○ Decreased 30-day readmission rate from 41% to 13%

Kanwal F, Kramer JR, Buchanan P, et al. The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs. Gastroenterology. 2012. Bajaj JS, Reddy KR, Tandon P, Wong F, et al. The Three-Month Readmission Rate Remains Unacceptably High in a Large North American Cohort of Cirrhotic Patients. Hepatology. 2015. Morando F, Maresio G, Piano S, et al. How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists. J Hepatol. 2013. Johnson EA, Spier BJ, Leff JA, Lucey MR, Said A. Optimising the care of patients with cirrhosis and gastrointestinal haemorrhage: a quality improvement study. AlPT. 2013.

Innovation

• First comprehensive standardized order set with associated decision support to

guide initial management of hospitalized patients with decompensated cirrhosis.

Aims

• Primary Aim / Hypothesis:

The utilization of a Liver Care Bundle with standardized order sets and decision support at time of admission will improve clinician adherence to guideline driven management of patients with complications of cirrhosis.

• Secondary Aim:

To assess if the Liver Care Bundle decreases length of stay, decreases 30- day mortality, or decreases 30-day readmission rates in patients admitted with decompensated liver cirrhosis.

Methods: Study Design

• Randomized Control Trial with intention to treat analysis.
• Internal Medicine and Gastroenterology & Hepatology house staff will

be enrolled and randomized into two teams working in parrallel taking care of two separate services:

Control Team: Will not have access to Liver Care Bundle tool Experimental Team: Will receive access and education regarding how to utilize the standard order sets and access the decision support tool Patients will be randomized to either team

Liver Care Bundle Design

ORDER ORDERS: S: [ x] Li ve r Ca r e Bundl e [ ] As c i t e s [ x] Ga s t r oi nt e s t i na l bl e e di ng [ x] Nur s e : Pl a c e 2 La r ge - bor e pe r i phe r a l I Vs ( 18 ga uge or l a r ge r ) [ x] La b: Type & Sc r e e n [ x] La b: CBC q8hr [ x] La b: I NR q8hr [ ] Bl ood pr oduc t s : pa c ke d RBC * [ ] Bl ood pr oduc t s : pl a t e l e t s * [ ] Bl ood pr oduc t s : f r e s h f r oz e n pl a s m a * [ x] Di e t : NPO [ x] M e d: pa nt opr a z ol e 40 m g I V BI D * [ x] M e d: oc t r e ot i de gt t ( 50 m c g l oa d, t he n 50 m c g/ hr ) f or 5 da ys * [ x] M e d: c e f t r i a xone 1gm I V da i l y f or 7 da ys * [ ] Pa r a c e nt e s i s , s m a l l vol um e ( 50 m L) * [ ] La b: Ce l l Count [ ] La b: Cul t ur e [ ] La b: Gr a m s t a i n [ ] La b: Al bum i n [ ] Pr oc e dur e : Es opha goga s t r oduode nos c opy * [ ] He pa t i c Enc e pha l opa t hy [ ] Spont a ne ous Ba c t e r i a l Pe r i t oni t i s [ ] Ac ut e Ki dne y I nj ur y The use of short-term prophylactic antibiotics in patients with cirrhosis and GI hemorrhage with or without ascites has been shown not only to decrease the rate of bacterial infections but also to increase

• survival. Link to guideline.

Budget

Resource Purpose Cost (USD) Programming Development of code for liver bundle $15,000 Support Staff Research aid, support of physicians

$5,000

Research Staff Salary support of research fellow

$60,000

Computer equipment Development tools and software

$5,0000

Statistician Statistical analysis

$5,0000

Overhead Miscellaneous

$20,000

Total Request Funding source: TBD $110,000

Reflections

• Funding sources easiest part of starting project.
• Institutional buy in was key.
• Engaging stakeholders was difficult and time consuming.