Impact of an Electronic Clinical Decision Support Tool for Emergency Department Patients With Pneumonia.
OBJECTIVE
Despite evidence that guideline adherence improves clinical outcomes, management of pneumonia patients varies in emergency departments (EDs). We study the effect of a real-time, ED, electronic clinical decision support tool that provides clinicians with guideline-recommended decision support for diagnosis, severity assessment, disposition, and antibiotic selection.


METHODS
This was a prospective, controlled, quasi-experimental trial in 7 Intermountain Healthcare hospital EDs in Utah's urban corridor. We studied adults with International Classification of Diseases, Ninth Revision codes and radiographic evidence for pneumonia during 2 periods: baseline (December 2009 through November 2010) and post-tool deployment (December 2011 through November 2012). The tool was deployed at 4 intervention EDs in May 2011, leaving 3 as usual care controls. We compared 30-day, all-cause mortality adjusted for illness severity, using a mixed-effect, logistic regression model.


RESULTS
The study population comprised 4,758 ED pneumonia patients; 14% had health care-associated pneumonia. Median age was 58 years, 53% were female patients, and 59% were admitted to the hospital. Physicians applied the tool for 62.6% of intervention ED study patients. There was no difference overall in severity-adjusted mortality between intervention and usual care EDs post-tool deployment (odds ratio [OR]=0.69; 95% confidence interval [CI] 0.41 to 1.16). Post hoc analysis showed that patients with community-acquired pneumonia experienced significantly lower mortality (OR=0.53; 95% CI 0.28 to 0.99), whereas mortality was unchanged among patients with health care-associated pneumonia (OR=1.12; 95% CI 0.45 to 2.8). Patient disposition from the ED postdeployment adhered more to tool recommendations.


CONCLUSIONS
This study demonstrates the feasibility and potential benefit of real-time electronic clinical decision support for ED pneumonia patients.
Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT. Electronic address: nathan.dean@imail.org.
Nathan C
NC
Dean
Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT.
Barbara E
BE
Jones
Clinical Intelligence and Decision Support-Kaiser Permanente, Pasadena, CA.
Jason P
JP
Jones
Homer Warner Center for Informatics Research, Murray, UT.
Jeffrey P
JP
Ferraro
Homer Warner Center for Informatics Research, Murray, UT.
Herman B
HB
Post
Department of Biomedical Informatics, Vanderbilt University, Nashville, TN.
Dominik
D
Aronsky
Department of Emergency Medicine, Intermountain Medical Center, Murray, UT.
Caroline G
CG
Vines
Department of Emergency Medicine, Intermountain Medical Center, Murray, UT; Institute for Healthcare Delivery and Research, Intermountain Healthcare, Salt Lake City, UT.
Todd L
TL
Allen
Homer Warner Center for Informatics Research, Murray, UT.
Peter J
PJ
Haug
D017714:Community-Acquired Infections / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D011446:Prospective Studies; D012720:Severity of Illness Index; D014589:Utah / Q000453:epidemiology