title: Implementation of Clinical Decision Support Rules to Reduce Repeat Measurement of Serum Ionized Calcium, Serum Magnesium, and N-Terminal Pro-B-Type Natriuretic Peptide in Intensive Care Unit Inpatients.
abstract: We assessed the impact of clinical decision support (CDS) rules within the electronic health record for ionized calcium (iCa), serum magnesium (Mg), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in intensive care unit (ICU) inpatients at a large academic center.
  
  
  
  A repeat order for measurement of iCa or Mg placed within 24 (iCa) or 48 (Mg) h of a previously nonactionable result, or additional orders for NT-proBNP beyond 1 within a single hospitalization, triggered a CDS pop-up alert showing the prior result and offering the opportunity to cancel the order or to place the order after entering an indication for repeat testing. The number of tests performed for each of these analytes and incidence of adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia were compared between the 90-day period before CDS implementation and two 90-day periods immediately following.
  
  
  
  iCa test volumes decreased by 48%, Mg by 39%, and NT-proBNP by 28% in the 90-day period immediately following implementation and remained decreased by 54%, 49%, and 22%, respectively, during the following 90-day period (all P values <0.0002). Adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia did not increase (all P-values >0.17).
  
  
  
  Implementation of CDS dramatically decreased repeat testing of iCa, Mg, and NT-proBNP without adversely impacting clinical outcomes in the ICU. Expansion of the rules from the ICU units to include the entire hospitalized patient population and expansion to additional analytes is expected to lead to further reductions in testing.
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Ann M
authors.initials: AM
authors.lastname: Moyer
authors.affiliation: Department of Laboratory Medicine and Pathology, University of Minnesota Health, Minneapolis, MN;
authors.forename: Amy K
authors.initials: AK
authors.lastname: Saenger
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Maria
authors.initials: M
authors.lastname: Willrich
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Leslie J
authors.initials: LJ
authors.lastname: Donato
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Nikola A
authors.initials: NA
authors.lastname: Baumann
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Darci R
authors.initials: DR
authors.lastname: Block
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Chad M
authors.initials: CM
authors.lastname: Botz
authors.affiliation: Department of Systems and Procedures, Mayo Clinic, Rochester, MN.
authors.forename: Munawwar A
authors.initials: MA
authors.lastname: Khan
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Allan S
authors.initials: AS
authors.lastname: Jaffe
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
authors.forename: Curtis A
authors.initials: CA
authors.lastname: Hanson
authors.affiliation: Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; karon.bradley@mayo.edu.
authors.forename: Brad S
authors.initials: BS
authors.lastname: Karon
mesh_terms: D015415:Biomarkers / Q000097:blood; D002118:Calcium / Q000097:blood*; D020000:Decision Support Systems, Clinical; D006801:Humans; D007362:Intensive Care Units; D008274:Magnesium / Q000097:blood*; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010446:Peptide Fragments / Q000097:blood*
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D008274:Magnesium; D002118:Calcium