Infection Control & Hospital Epidemiology
Table 1. Intervention Phases Phase
Dates Phase 1 1/2011–6/2012
Phase 2 (A) 7/2012–7/2014 (B) 7/2012–10/2013
Phase 3 (A) 8/2014–9/2014 (B) 2/2014–9/2014a
Phase 4 10/2014–9/2015
903
Intervention
Standardization and training
Real-time electronic tracking
Triggered pop-up alert reminder
(1) Automated removal (2) Placement criteria
Description
Epidemiology and nurse management led a hospital-wide effort to train staff in standardized best practices techniques for catheter placement and maintenance. The EHR began requiring documentation of catheters every 12 h.
Clinicians had access to a new optional quality checklist tool within the EHR that automatically tracked the presence and duration of catheters.
The quality checklist tool became a mandatory pop-up reminder of the presence of remaining catheters. The alert was triggered when clinicians initiated a daily progress note.
(1) Catheter orders expired automatically at noon on day 2 after placement, triggering catheter removal. (2) A new electronic order set required clinicians to consider alternatives to catheterization and select an appropriate indication.
NOTE. EHR, electronic health record; A, EHR installation A; B, EHR installation B. aPhases 2 and 3 were implemented asynchronously at different hospital campuses in EHR installations A and B. In EHR installation B, there was a transition phase (T) between phases 2 and 3
(10/2013 to 2/2014) during which multiple version of the mandatory pop-up checklist were tested before the final version went live, marking the start of phase 3. Data from this transition phase were excluded from statistical analysis. Phase 2 ended later in installation A (7/2014) than in installation B (10/2013), and installation A had no transition period prior to phase 3.
individualized patient care. Most prior interventions have been tested in a single setting, limiting generalizability. These reports rarely describe the evolution of the intervention, nor do they employ an iterative design, and they generally lack long-term follow-up. In this study, we aimed to describe the phased implementation
of CDS interventions targeting the full life cycle of urinary catheters at a multicampus academic medical center using iterative design.
Methods Study population and setting
All patients admitted or under observation at New York- Presbyterian Hospital (NYPH), a 2,600-bed, multicampus, aca- demic medical center in New York City, were included for ana- lysis. All interventions were implemented as part of quality improvement initiatives with modifications to the existing elec- tronic health record (EHR) system, Eclypsis Sunrise Clinical Manager (Allscripts, Chicago, IL). Two separate installations of the EHR are used at different campuses of NYPH, hereafter referred to as the A and B subgroups. The institutional review board approved the protocol for this retrospective analysis.
Interventions and timeline
The intervention had 4 distinct phases (Table 1). Department representatives from hospital administration, quality improve- ment, epidemiology, biomedical informatics, house staff, and nursing designed and implemented each phase in an iterative process between January 2011 and September 2015. The deployment date for interventions sometimes differed between subgroups A and B. With limited exception, silver alloy catheters were used routinely during the observation period. In phase 1, representatives fromnursemanagement and hospital
epidemiology led a training initiative to reinforce best practices for proper placement and maintenance of catheters according to the Centers for Disease Prevention and Control (CDC) guidelines,11 as well as the documentation of catheters in the EHR. A custom module was implemented within the EHR that required nurses to document the presence and appropriate maintenance of an IUC every 12 hours. An IUC order or nurse opening an electronic flow- sheet to document urinary output triggered the module.
During phase 2, real-time electronic tracking of IUCs was made
available to clinicians as an optional checklist tool. Clinicians could access a tab in the patient’s electronic chart called the “Quality Checklist” to visualize a real-time, customized list of a patient’s active lines and catheters and their duration (Fig. S1). Information in the tab was updated automatically, based on the custom module fromphase 1. Clinicians could elect to update the status of each line or catheter from a drop-down menu with the options: “maintain,” “already removed,” or “remove today.” In phase 3, the real-time electronic tracking tool became a
triggered pop-up reminder that needed to be viewed and assessed by a clinician daily (Fig. S2). To reach the appropriate clinician at a convenient time, the reminder was linked to the initiation of a daily progress note, which is required to be completed by the patient’s designated primary clinician daily. The mandatory pop- up prevented the clinician from entering text into a note until updating the catheter status or opting out by selecting “not pri- mary clinician.” To minimize inappropriate or duplicative reminders, once a provider assessed all lines and catheters, pro- gress notes no longer triggered reminders until the following day. Phase 4 comprised 2 interventions: (1) a nurse-driven auto-
matic IUC stop order and (2) a clinician-driven selection of placement criteria. First, IUC orders began automatically expiring at 1200 (noon) on day 2 after placement, at which point the corresponding electronic flow sheet would lock. Thus, nurses were charged with removing catheters in patients that did not meet criteria for prolonged use or obtaining a renewal order from clinicians to complete their charting. The reminder system from phase 3 continued and also warned clinicians of the impending order expiration time (Fig. S3). The second intervention in phase 4 consisted of a new IUC
order, which required clinicians to consider catheter alternatives and to select an appropriate indication for IUC placement. The order used drop-down menus and branch logic (Fig. S4) to navigate the clinician through the decision-making process. Criteria for placement and prolonged use were based on CDC guidelines.11
Outcome measures
We abstracted CAUTI incidence from EHR data using a validated epidemiology decision support system called “EpiPortal”12 with definitions established by the National Health Safety Network of the Centers for Disease Control and Prevention.13,14 Notably, the
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