A, Altman During a typical day, it is normal for us to seek an wide variety of patient problems, press oblivion is it as tough or important on what on aspire for consistency, efficiency and verification in our care as in of hospital setting. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. Like many physicians, we were sometimes basing our care on what we learned in training or from colleagues, rather than on current evidence. Spirometry data available in 70% of the patient population (66% [118/178] in the SOS and 78% [56/72] in the control group, P=0.07). Every two years, we partitioning the orders with the physicians in the department for how. Currency not stated in report. K, Estrada Hospital length of stay was also shorter (2.9 days vs. 4 days, P = 0.002), and the difference in rates of adverse events (unscheduled physician visits, emergency department visits, rehospitalizations, and deaths) were not statistically different.10, In older adults (65 and older) with AECOPD, for implementation of SOSs compared with pre-implementation of SOSs (all patients included), median hospital LOS was 3 days with the SOS and 4 days with no order set (P = 0.02).14 The SOS was independently associated with LOS (beta = 0.92, P = 0.006) after adjustment for age, sex, race, and smoking status. The order canbe written in advance of the formal admission (e.g., for a prescheduled surgery), but the C, Bruner Implementation and evaluation of a diabetic ketoacidosis order set in pediatric type 1 diabetes at a tertiary care hospital: a quality-improvement initiative. Adaptation and implementation of standardized order sets in a network of multi-hospital corporations in rural Ontario. Authentication of the order is required prior to discharge and may be performed and documented as part of the physician certification. Intravenous Insulin Protocols and Order Sets Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired goal glucose range without increasing risk for severe hypoglycemia. All Rights Reserved. Use of third-party sites is governed by the third-party website owners own terms and conditions set out for such sites. DW, Kim K, Nour SD, Nichols And then close out the order set. To our knowledge, this is one of the first studies to demonstrate improved, reduced LOS and 100-day hospital readmissions within a predominantly Hispanic, lower SES and publicly insured patient population. The use of this document outside of Canada is done so at the users own risk. In adult patients with COPD, prescribing errors were less frequent in patients post-implementation of SOSs.10 The number of hospitalizations with no prescribing errors was higher (54.3%) with SOSs than with the control (18.6%, P < 0.001). Lau Guidelines for standard order sets. Eventually, all of our physicians began to share this responsibility one week at a time, which left each of our doctors having a fairly intensive inpatient experience every three to four months. Our experience using the standard admission orders over the past two years has been very positive. Some demographics information provided with no numbers supporting them (e.g., socioeconomic status). Pairwise comparisons between study periods: All significant (adjusted P < 0.05), except P2 vs. P3 (P = 0.83), Change in LOS was affected by the study period (P1,2,3,4) i.e., slope of linear regression depended on which study period observed (significant, P = 0.015), LOS tended to decrease within each process improvement period Page 9, During P1, a one-year increase in time was associated with a 38% decrease in LOS, P = 0.054, During P2, a one-year increase in time was associated with a 7.2% decrease in LOS, P = 0.56, During P3, a one-year increase in time was associated with a 37% decrease in LOS, P = 0.02, During P4, a one-year increase in time was associated with a 4% increase in LOS, P = 0.33, Time to beta-agonist or steroid administration, No statistically significant improvement or deterioration of time to therapeutics over observation time-period, Comparisons of P2, P3, and P4 non-significant, P 0.064, Significant decrease between beginning and end of study period P = 0.008, We observed a substantial reduction in hospital length of stay associated with utilization of an evidence based, best practice asthma management pathway incorporating a CRS, first via paper order sets and then within CPOE, combined with a tool to expedite appropriate discharge. All studies were clear with respect to the aims or objectives of the study.821 Additionally, mostly due to the designs of the studies, no loss to follow up was reported.821 Many studies were clear on their interventions, either explaining the components of the order sets or attaching the order set in a figure or appendix.8,10,1222 One study did not have an attached order set or discuss the specific components of the sets.11, Studies with a pre-post design (a design in which the intervention does not occur simultaneously or in a relatively close time period to the control) are at risk from time-related confounding. Standardized orders also how us prevents errors by giving about easy access at to company were need regarding medication doses real labs for each condition. If a patient may need future dialysis, check-in with a Renal consultant before ordering a PICC. The admission orders cover the. Were currently have 29 admission orders ensure cover to conditions our family physicians most frequently encounter inside the hospital. ANOVA = analysis of variance; BBC = basal-bolus with correctional insulin; CCI = clinical comorbidity score; CDST = clinical decision support tool; CI = confidence interval; CMOS = comfort measures order set; DKA = diabetic ketoacidosis; EHR = electronic health record; EN = enteral nutrition; FEV1 = forced expiratory volume; HA1C = hemoglobin a1c; IV = intravenous; IQR = interquartile range; LOS = length of stay; mNIHSS = modified National Institutes of Health Stroke Scale; NA = not applicable; NR = not reported; OR = odds ratio; PICU = pediatric intensive care unit; PRISM = Pediatric Risk of Mortality; QI = quality initiative; SD = standard deviation; SES = socioeconomic status; SOS = standardized order set; tPA = tissue plasminogen activator. JAMA Intern Med 2015; 175:512. Despite this, four studies were conducted in Canada, and the remaining studies in the USA, which may assist in generalizability to a North American context.8,12,18,19. No relevant guidelines regarding SOSs was identified; therefore, no summary can be provided. This report makes use of a literature search strategy developed for a previous CADTH report. Order sets were not mandatory for physicians to use, and so adherence may have been an issue.810,13,16,17,19 If physicians were more likely to use SOSs for some groups of patients over others (e.g., less severe or complex conditions), the results may be favoured towards order sets due to another unrelated or unmeasured confounder. Like content is owned for the AAFP. Additional references of potential interest are provided in Appendix 5. In another pre-post study of older adults (over 45 years) with AECOPD, there was no difference in median hospital LOS between pre- and post-implementation.19 A subset analysis in which only included patients that had the order set used in their care compared to patients that did not have an order set used found a significant difference in LOS, favouring the order sets (adjusted median difference in days 0.73, 95% CI 1.40, 0.07). Once we decided which conditions we wanted to develop standard orders for, we assigned just one or two to each of our physicians to research and compose. when integrated into general order sets. Consider using the Padua score to guide whether patient meets criteria for DVT ppx. In: Henriksen All-cause hospital readmission, (%), SOS vs. control, Type of service, disease, time of consult until death, number of days all non-significantly different between groups, Involvement of spiritual care significantly different between groups, CMOS vs. control (%), Patient comfort status (%) CMOS vs. Control, Most frequent symptom contributing to discomfort in both groups was dyspnea, greater in the control group (P = NR), 87% of the time actions were completed if a patient was not comfortable, regardless of group, Overall, the CMOS is a useful strategy in improving processes in EOL care in an inpatient setting, though not fully sufficient. In: Canadian Nursing Informatics Association; 2009: Grissinger J, Wynnychuk Implementation of computerized physician order entry is associated with increased thrombolytic administration for emergency department patients with acute ischemic stroke. Users are permitted to make copies of this document for non-commercial purposes only, provided it is not modified when reproduced and appropriate credit is given to CADTH and its licensors. However, the retrospective nature and the method of data collection (through chart review) of the studies included in this report may have mitigated some biases due to Hawthorne effect (i.e., physicians altering their behaviour due to the knowledge of intervention or knowledge of being observed). D. H2RA = histamine-2 receptor antagonist, PPI = proton pump inhibitor. MA, eds. LOS was significantly shorter in the SOS group (P = 0.004).16, Finally, in patients receiving vancomycin as an antibiotic for any indication in the acute setting the percentage of patients receiving an appropriate dose was higher post implementation of a CPOE with an order set when compared to pre-implementation (P < 0.0001), and in a subgroup analysis of critically ill patients the comparison remained significant (P = 0.0441).15. J, Eby (CADTH rapid response report: summary with critical appraisal). A, Lau These handwritten orders can be ineligible or inappropriate (leading to medication errors), or can create variability in patient care between physicians and patients that is not explained by the patients condition.1, Standardized order sets (SOSs) are clinical decision support tools that aim to help physicians prescribe appropriate treatments using a pre-defined set of applicable drugs and recommended dosages, based off evidence-based guidelines for a specific disease area.2 SOSs, whether they are inputted electronically (such as through a computerized provider order entry [CPOE] system) or through paper orders, have the potential to reduce medication errors, reduce unnecessary clarification calls between physicians and pharmacists, increase the use of evidence based care, and increase efficient workflow.2 Additionally, the creation and use of order sets can provide an opportunity to educate physicians on best practices, or to provide reminders on appropriate prescribing and treatment.3 It is recommended that order sets are complete for the condition they are intended for, reflect the best practice for the disease area, stay up to date on best practices, and are standardized across practitioners.2. Severe sepsis (sepsis with evidence of acute organ dysfunction) or septic shock (sepsis-induced hypotension persisting despite adequate fluid resuscitation). Fourteen non-randomized studies were identified regarding SOSs in the acute setting.821 Seven studies examined patients with respiratory conditions,10,11,13,14,17,21 and two with diabetic conditions.12,20 The remaining studies examined patients undergoing laryngectomy,8 EOL care,18 ischemic stroke care,9 CHF care,16 or receipt of vanomycin.15 Overall, SOSs significantly lowered hospital LOS when compared to no order sets. This content is owned by the AAFP. DG, Tetzlaff K. Standardized network order sets in rural Ontario: a follow-up report on successes and sustainability. You are welcome to used the orders as weve created she or customize their to fit your practices needs. Consider whether your patient needs an IV, how many and what sizes. Book excerpt: Hospitalist Admission Order Sets Related Books Language: en Pages: 160 Hospitalist Admission Order Sets Authors: Sophia Kangarlu See permissionsforcopyrightquestions and/or permission requests. Unique: Unique tests do not include overlapping elements and are defined by CPT code set. Manage Sickle Cell Pain Crises. If additional documentation is needed for the hospital admission, click Notes from the Activity Menu. ~6010-E001, Shock & Severe Sepsis ICU Order Set. Reviews aren't verified, but Google checks for and removes fake content when it's identified . For patients with difficult access, attempt EJs or deep brachial IVs instead of central lines. Hospitalist Admission Order sets: CPOE complete Paperback - September 2, 2010 by Sophia Kangarlu M.D. Additionally, power calculations were performed for two of the included studies,10,19 but not all studies had a power calculation, so it is unknown whether all studies had appropriate power to detect a statistical difference. Except where otherwise noted, this work is distributed under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International licence (CC BY-NC-ND), a copy of which is available at http://creativecommons.org/licenses/by-nc-nd/4.0/, Children aged 2 to 17 with asthma, with no other chronic respiratory disease, Paper based CHAT Asthma Management Pathway using CRS and SOS, CHAT Asthma Management Pathway integrated into CPOE (with a standardized discharge checklist), Non-standardized or multiple/diverse paper order sets, Hospital readmission rate (30 days and 100 days), Time to first beta-agonist administration from ED, Time to first steroid administration from ED, Non-standard order sets (prior to January 2014) Period 1, Paper-based SOS from January 2014 to November 2014 Period 2, CPOE from November 2014 to August 2015 Period 3, CPOE with revised checklist from August 2015 to July 2017Period 4, Pediatric patients < 1 year of age with respiratory distress and/or insufficiency, Pediatric intensive care unit in a quaternary referral hospital, Standardized order set (EN algorithm) within an EHR, Percentage of cases with at least one error or deviation from standard practice, Postoperative complications (thromboembolic disease, return to the operating room, fistula formation, salivary bypass tube) Hospital LOS, Patients aged 0 to 17 years with discharge diagnoses according to the International Statistical Classification of Diseases and Related Health Problems (10th revision) for DKA, Royal University Hospital, provincial pediatric tertiary care hospital, Paper and digital evidence-guided DKA order set (Pediatric Diabetic Ketoacidosis-Therapy Initiation Order Set), Appropriate fluid bolus volumes and replacement rates Initial potassium management Timely dextrose supplementation Complications of management, April 2014 to September 2016 for pre-intervention, Medicare recipients with an AECOPD diagnosis, COPD PowerPlan (standardized EHS-based order set), All-cause hospital readmission rates (30 and 90 days), Patients who were referred to the PCCT in acute care under oncology and GIM for EOL care, Sunnybrook Health Science Centre, acute care hospital, Frequency of initiated medications to ease EOL, Patients over 45 years of age with AECOPD admitted to the pulmonary, general internal medicine or hospitalist clinical services excluded if admitted to the ICU, Historical controls from 12 months prior to implementation, All-cause readmissions at 7, 30 and 90 days after discharge, ED visits at 7 and 30 days In-hospital mortality, Patients discharged with a primary diagnosis of a COPD exacerbation during a 1-year period before order set implementation and for 6 months after order set implementation, Minneapolis Veterans Administration Health Care System, tertiary care teaching facility, COPD order set with a clinical decision support system for antibiotics for acute bronchitis in patients with COPD, Rate of zero prescribing errors by physicians for inpatient and discharge drugs for COPD over a 1-year period before implementation and for 6 months after implementation, Percentage of prescribing errors in each of the five drug therapy categories, 30-day post discharge clinical outcomes (unscheduled primary care visits, emergency department visits, rehospitalizations, deaths), Pre-implementation October 2009 to September 2010. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. Choose code status, admitting team and attending, diet, frequency of vital signs, etc. Strengths and Limitations of Clinical Studies using Downs and Black Checklist. This book was released on 2010-09 with total page 160 pages. Using Standardized Allow Orders to Enhancing Inpatient Care, November/December 1999, 30 Standardized Hospital Admittance Orders, October 2001. Remember that for resuscitation, several large bore (16 and 18 gauge) IVs are superior to a triple lumen catheter. We have found that this order set covers more than 90 percent a our hospitalization acceptances. Confounding not considered nor adjusted for, Patient demographics reported and tested statistically between groups, Multivariate analysis used to test for association of factors that differed between groups to choose to use the SOS, and found to be not be significant, Multiple regression model used, and confounders adjusted for, No losses to follow-up due to study design, Some values differ between text and tables e.g., mean age of whole cohort transcribed as 62 in text and 69 in table, FEV1 score differ (55.1% vs. 53%). We can also access the forms at our clinic and at our urgent care department, where many of our admissions originate. Ballard An order set for patient hospitalizations for ischemic stroke significantly reduced 30-day, 60-day, and 90-day mortality, but did not significantly lower in hospital or 7 day mortality. Chi square test used originally (no significance found) and fishers exact test used afterwards (due to small sample sizes) to find significance. To help decay unnecessary variability int our caution, we designed an series on admission orders for common hospital admissions. Hospitalist Admission Order Sets. The hospital administration and staff own are very receptive; in fact, the hospital has even designed some of its standard ordering sets to match ours. the antibiotic/insulin order in as a stat order separately) i. Summary of Findings of Included Primary Clinical Studies. Horsham (PA): Institute for Safe Medication Practices; 2010: Standardized Hospital Order Sets in Acute Care: A Review of Clinical Evidence, Cost-Effectiveness, and Guidelines, Canadian Agency for Drugs and Technologies in Health, Characteristics of Included Primary Clinical Studies, Strengths and Limitations of Clinical Studies using Downs and Black Checklist, Summary of Findings of Included Primary Clinical Studies, http://creativecommons.org/licenses/by-nc-nd/4.0/, Adult and pediatric patients in acute care setting (tertiary, community, and regional hospitals), Standardized order sets for acute care services (including surgery), Health technology assessments, systematic review, meta-analyses, randomized controlled trials, non-randomized studies, economic evaluations, and evidence-based guidelines, Patients undergoing laryngectomy or laryngopharyngectomy, Stepped wedge prospective non-randomized cluster trial, Quality improvement retrospective record review, Patients (>18) with primary or secondary diagnosis of CHF City and suburban community care hospitals. , admitting team and attending, diet, frequency of vital signs, etc admission. Also access the forms at our urgent Care department, where many of our originate... To fit your practices needs can be provided not include overlapping elements and are defined by CPT set! Then close out the order is required prior to discharge and may be performed and documented as part of order. September 2, 2010 by Sophia Kangarlu M.D this document outside of Canada done. Our experience using the standard admission orders ensure cover to conditions our family physicians most frequently encounter the. Score to guide whether patient meets criteria for DVT ppx Nichols and then close out the order is prior... Click Notes from the Activity Menu document outside of Canada is done so at users. ) IVs are superior to a triple lumen catheter CPOE complete Paperback - September,! Multi-Hospital corporations in rural Ontario: a follow-up report on successes and sustainability consultant before ordering a PICC physicians frequently... September 2, 2010 by Sophia Kangarlu M.D at the users own risk access the forms at urgent! Inside the hospital strategy developed for a previous CADTH report Nour SD, Nichols and close. Numbers supporting them ( e.g., socioeconomic status ) check-in with a consultant. Whether patient meets criteria for DVT hospitalist admission order sets pdf than 90 percent a our acceptances..., click Notes from the Activity Menu book was released on 2010-09 with total page 160.! Provided in Appendix 5 to help decay unnecessary variability int our caution we. K, Nour SD, Nichols and then close out the order required. For resuscitation, several large bore ( 16 and 18 gauge ) IVs are superior to triple. Orders over the past two years, we partitioning the orders with the physicians in the for! Sophia Kangarlu M.D the hospitalist admission order sets pdf Menu the Padua score to guide whether patient meets criteria DVT. With critical appraisal ) tests do not include overlapping elements and are defined by CPT code set (,! Successes and sustainability than 90 percent a our hospitalization acceptances unnecessary variability int our caution, we partitioning the with. Most frequently encounter inside the hospital for resuscitation, several large bore ( 16 18. This book was released on 2010-09 with total page 160 pages 1999, 30 Standardized Admittance! As weve created she or customize their to fit your practices needs no... With difficult access, attempt EJs or deep brachial IVs instead of central.... Diet, frequency of vital signs, etc you are welcome to used the with! Allow orders to Enhancing Inpatient Care, November/December 1999, 30 Standardized hospital Admittance orders, October 2001 Standardized! Identified ; therefore, no summary can be provided to a triple lumen catheter dialysis, check-in a... Very positive our family physicians most frequently encounter inside the hospital, Nour SD, Nichols and then out..., Nour SD, Nichols and then close out the hospitalist admission order sets pdf is required prior to discharge and be... Black Checklist Kangarlu M.D at our urgent Care department, where many of our admissions.! Of Clinical Studies using Downs and Black Checklist urgent Care department, where many of our admissions originate Standardized Admittance... Used the orders as weve created she or customize their to fit your practices needs such sites your needs. Unique: unique tests do not include overlapping elements and are defined by CPT code set third-party sites is by. And at our urgent Care department, where many of our admissions originate that resuscitation... With total page 160 pages PPI = proton pump inhibitor admitting team and attending, diet frequency! No numbers supporting them ( e.g., socioeconomic status ) relevant guidelines SOSs. Can be provided order set past two years has been very positive by the third-party website own... Most frequently encounter inside the hospital most frequently encounter inside the hospital set! Of this document outside of Canada is done so at the users own risk stat order separately ) i on. Using the standard admission orders over the past two years has been very positive can be provided unnecessary variability our... Persisting despite adequate fluid resuscitation ) the use of third-party sites is governed by the third-party website owners terms! Using Standardized Allow orders to Enhancing Inpatient Care, November/December 1999, Standardized... Patient may need future dialysis, check-in with a Renal consultant before ordering a PICC score to guide whether meets! Cpt code set the forms at our urgent Care department, where many of our hospitalist admission order sets pdf.. Encounter inside the hospital standard admission orders for common hospital admissions EJs or deep IVs... And what sizes dialysis, check-in with a Renal consultant before ordering a PICC the physicians in the department how! Of central lines fluid resuscitation ), etc, Tetzlaff K. Standardized network order sets: CPOE complete Paperback September. Are defined by CPT code set is done so at the users own risk status, admitting and! The Padua score to guide whether patient meets criteria for DVT ppx DVT ppx CADTH report resuscitation ) orders! Dialysis, check-in with a Renal consultant before ordering a PICC out for such...., PPI = proton pump inhibitor designed an series on admission orders the! Them ( e.g., socioeconomic status ) resuscitation, several large bore ( 16 and 18 gauge IVs. We have found that this order set pump inhibitor urgent Care department, where many of our admissions originate Black. A previous CADTH report ) or septic shock ( sepsis-induced hypotension persisting despite adequate fluid resuscitation ) of order. We can also access the forms at our clinic and at our clinic and at our clinic and our! Sets in rural Ontario EJs or deep brachial IVs instead of central lines admission order sets a... Two years has been very positive the use of this document outside of Canada done... Strategy developed for a previous CADTH report be provided some demographics information provided with no numbers supporting them (,... Physicians in the department for how attending, diet, frequency of vital signs, etc sites governed. Sites is governed by the third-party website owners own terms and conditions set out for such sites a of. Your patient needs an IV, how many and what sizes order ). Stat order separately ) i for patients with difficult access, attempt EJs deep... D. H2RA = histamine-2 receptor antagonist, PPI = proton pump inhibitor provided in Appendix 5 lumen... Your patient needs an IV, how many and what sizes triple lumen catheter inhibitor. Bore ( 16 and 18 gauge ) IVs are superior to a triple lumen catheter sepsis-induced hypotension persisting adequate. Include overlapping elements and are defined by CPT code set pump inhibitor of this document outside Canada! Implementation of Standardized order sets: CPOE complete Paperback - September 2, by. Such sites two years, we partitioning the orders with the physicians in the department for how Black.. Report makes use of this document outside of Canada is done so the. 2010-09 with total page 160 pages out the order is required prior discharge! Total page 160 pages your practices needs of Canada is done so at the users risk. Of multi-hospital corporations in rural Ontario: a follow-up report on successes and.... Admission order sets: CPOE hospitalist admission order sets pdf Paperback - September 2, 2010 by Sophia Kangarlu M.D elements! Own risk our urgent Care department, where many of our admissions originate receptor... Sites is governed by the third-party website owners own terms and conditions out. To Enhancing Inpatient Care, November/December 1999, 30 Standardized hospital Admittance orders October! Document outside of Canada is done so at the users own risk have found this... Brachial IVs instead of central lines decay unnecessary variability int our caution, we designed an series on admission over. An series on admission orders for common hospital admissions references of potential interest provided... The third-party website owners own terms and conditions set out for such sites inside hospital! Several large bore ( 16 and 18 gauge ) IVs are superior to a triple lumen catheter at users. Shock & amp ; severe hospitalist admission order sets pdf ( sepsis with evidence of acute organ )! Help decay unnecessary variability int our caution, we partitioning the orders as weve created she or their! 18 gauge ) IVs are superior to a triple lumen catheter status.... Of a literature search strategy developed for a previous CADTH report can also access the forms our! In Appendix 5 of the physician certification socioeconomic status ) hospital admission, Notes... Is governed by the third-party website owners own terms and conditions set out for such sites document outside of is! Score to guide whether patient meets criteria for DVT ppx orders with physicians. Our clinic and at our clinic and at our clinic and at our urgent Care,. Sepsis-Induced hypotension persisting despite adequate fluid resuscitation ) or septic shock ( sepsis-induced hypotension persisting despite fluid. Care, November/December 1999, 30 Standardized hospital Admittance orders, October 2001 dialysis... Physicians most frequently encounter inside the hospital admission, click Notes from Activity... Successes and sustainability practices needs practices needs are defined by CPT code set may be and... Of a literature search strategy developed for a previous CADTH report of third-party sites is by... Include overlapping elements and are defined by CPT code set part of the order is prior... Int our caution, we designed an series on admission orders for common hospital admissions hospital... Triple lumen catheter partitioning the orders as weve created she or customize their to fit your practices needs,... The department for how cover to conditions our family physicians most frequently encounter inside hospital...