scholarly journals COVID-19 Diagnostic Clinical Decision Support: a Pre-Post Implementation Study of CORAL (COvid Risk cALculator)

2021 ◽  
Author(s):  
Caitlin M Dugdale ◽  
David M Rubins ◽  
Hang Lee ◽  
Suzanne M McCluskey ◽  
Edward T Ryan ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Total Duration ◽  
Diagnostic Algorithm ◽  
Clinical Decision ◽  
Work Hours ◽  
Nucleic Acid Amplification ◽  
Transmission Risk ◽  
Risk Calculator ◽  
Physician Work

Abstract Background Isolation of hospitalized persons under investigation (PUIs) for COVID-19 reduces nosocomial transmission risk. Efficient PUI evaluation is needed to preserve scarce healthcare resources. We describe the development, implementation, and outcomes of an inpatient diagnostic algorithm and clinical decision support system (CDSS) to evaluate PUIs. Methods We conducted a pre-post study of CORAL (COvid Risk cALculator), a CDSS that guides frontline clinicians through a risk-stratified COVID-19 diagnostic workup, removes transmission-based precautions when workup is complete and negative, and triages complex cases to Infectious Diseases (ID) physician review. Pre-CORAL, ID physicians reviewed all PUI records to guide workup and precautions. Post-CORAL, frontline clinicians evaluated PUIs directly using CORAL. We compared pre- and post-CORAL frequency of repeat SARS-CoV-2 nucleic acid amplification tests (NAATs), time from NAAT result to PUI status discontinuation, total duration of PUI status, and ID physician work-hours, using linear and logistic regression, adjusted for COVID-19 incidence. Results Fewer PUIs underwent repeat testing after an initial negative NAAT post-CORAL than pre-CORAL (54% vs. 67%; aOR 0.53, 95% CI: 0.44-0.63, p<0.01). CORAL significantly reduced average time to PUI status discontinuation (adjusted difference: -7.4 [SE 0.8] hours/patient; p<0.01), total duration of PUI status (adjusted difference: -19.5 [SE 1.9] hours/patient; p<0.01), and average ID physician work-hours (adjusted difference: -57.4 [SE 2.0] hours/day; p<0.01). No patients had a positive NAAT within 7 days after discontinuation of precautions via CORAL. Conclusions CORAL is an efficient and effective CDSS to guide frontline clinicians through the diagnostic evaluation of PUIs and safe discontinuation of precautions.

scholarly journals 1982. A Diagnostic Stewardship Intervention for Clostridioides difficile: Impact of Stool Toxin Testing on Treatment of Adult Inpatients

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S663-S663
Author(s):  
Jason Moss ◽  
Derek W Forster ◽  
Vaneet Arora ◽  
David Burgess ◽  
Katie Wallace ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Hospital Medicine ◽  
Electronic Record ◽  
Clinical Decision ◽  
Marrow Transplant ◽  
Nucleic Acid Amplification ◽  
Solid Organ ◽  
Clostridioides Difficile ◽  
Toxin Test

Abstract Background Testing for Clostridioides difficile infection has been the subject of recent debate. Guidelines from the Infectious Diseases Society of America now support the addition of a stool toxin test to a positive nucleic acid amplification test (NAAT) as part of a multi-step testing algorithm. In November 2017, the University of Kentucky HealthCare system added stool toxin testing to any specimen positive for C. difficile by NAAT. This change was accompanied by face to face education with provider groups and clinical decision support in the form of interpretive verbiage added to the results that are reported into the electronic record. The objective of this study was to assess whether this diagnostic stewardship intervention made an impact on C. difficile treatment Methods We performed a retrospective review of adult patients admitted to UK HealthCare from November 1, 2017 through October 31, 2018 who tested positive by NAAT but negative by stool toxin test to determine whether or not they were treated. We also assessed treatment by service line to see whether there were treatment differences among these groups. A cost analysis was also performed. Results A total of 300 adult inpatients were positive for C. difficile by NAAT during the study period with 71% (213 patients) having a negative stool toxin test. Of those, 58% (123) were never started on C. difficile therapy and an additional 14% (30) had their therapy stopped after 48 hours. Only 28% (60) of these patients received a full course of therapy. Hospital medicine had the highest rate of non-treatment at 82%. Conversely, our solid-organ and bone marrow transplant services had the lowest rate of non-treatment at 31%. Overall, this approach was associated with an estimated 1470 oral vancomycin days avoided (5,880 doses) and a cost savings of $6,278. Conclusion The addition of stool toxin testing to NAAT combined with education and clinical decision support lead to a dramatic reduction of treatment for NAAT positive but toxin-negative patients. This form of diagnostic stewardship had a significant impact on therapy decisions and can be a powerful antimicrobial stewardship approach to decrease unnecessary treatment of C. difficile colonization. Disclosures All authors: No reported disclosures.

scholarly journals Patient Outcomes With Prevented vs Negative Clostridioides difficile Tests Using a Computerized Clinical Decision Support Tool

2020 ◽  
Vol 7 (4) ◽  
Author(s):  
Gregory R Madden ◽  
Kyle B Enfield ◽  
Costi D Sifri
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Medical Center ◽  
Decision Support Tool ◽  
Clinical Decision ◽  
Nucleic Acid Amplification ◽  
Retrospective Case ◽  
Support Tool ◽  
Clostridioides Difficile ◽  
Clinical Decision Support Tool

Abstract Background Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses. Methods This retrospective case–control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile–active antibiotics after implementation of the computerized clinical decision support tool. Results Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified. Conclusions Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.

scholarly journals Clinical Decision Support Trees Can Help Optimize Utilization of Anaplasma phagocytophilum Nucleic Acid Amplification Testing

2021 ◽  
Author(s):  
R Hamilton ◽  
T Pandora ◽  
J Parsonnet ◽  
I. W. Martin
Keyword(s):  
Platelet Count ◽  
Decision Support ◽  
Nucleic Acid ◽  
Clinical Decision Support ◽  
Anaplasma Phagocytophilum ◽  
Chart Review ◽  
Clinical Symptoms ◽  
Acute Infection ◽  
Clinical Decision ◽  
Nucleic Acid Amplification

Introduction: Anaplasmosis, a tick-borne illness caused by Anaplasma phagocytophilum (AP), presents with nonspecific clinical symptoms including fever and headache and is often accompanied by laboratory abnormalities of leukopenia, thrombocytopenia and mildly elevated liver function tests (LFTs). Laboratory confirmation of acute infection occurs with nucleic acid amplification (NAAT) testing. This retrospective cohort study aimed to develop a clinical decision support algorithm to aid in decision-making about test ordering. Methods: A dataset was constructed with AP NAAT results and time-adjacent complete blood count and LFT results for adult patients tested for AP in a 12.5-year period. A second, smaller dataset matched each patient with a positive AP NAAT to two patients with negative tests. Chart review for clinical symptoms was performed on this smaller dataset. A decision tree algorithm was deployed to identify patient clusters with negative AP NAAT results. Results: 137/1204 (11%) patients tested positive by NAAT for AP. In the larger, laboratory-only dataset (n=1204), patients with a platelet count > 177 x 10^ 3 /mcL and age < 48 years had a negative AP NAAT (204/1204, 17%, p <0.05). In the smaller, cohorted dataset with chart review (n=402), patients with a platelet count > 188 x 10^ 3 /mcL and no fever or chills also did not have positive AP NAAT (58/402, 14%, p <0.05). Conclusion: We generated two decision trees that can help determine the utility of AP NAAT using readily available clinical and laboratory data. These have the potential to significantly reduce unnecessary AP testing.

Clinical decision support

2013 ◽  
Vol 46 (2) ◽  
pp. 52
Author(s):  
CHRISTOPHER NOTTE ◽  
NEIL SKOLNIK
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Clinical Decision

Architectures for Architects

1993 ◽  
Vol 32 (01) ◽  
pp. 12-13 ◽  
Author(s):  
M. A. Musen
Keyword(s):  
Decision Support ◽  
Decision Support Systems ◽  
Clinical Decision Support ◽  
Support Systems ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Design And Development

Abstract:Response to Heathfield HA, Wyatt J. Philosophies for the design and development of clinical decision-support systems. Meth Inform Med 1993; 32: 1-8.

Characterizing Decision Support Telemedicine Systems

2006 ◽  
Vol 45 (05) ◽  
pp. 523-527 ◽  
Author(s):  
A. Abu-Hanna ◽  
B. Nannings
Keyword(s):  
Decision Support ◽  
Decision Support Systems ◽  
Clinical Decision Support ◽  
Literature Search ◽  
Support Systems ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Problem Dimension ◽  
Process Dimension

Summary Objectives: Decision Support Telemedicine Systems (DSTS) are at the intersection of two disciplines: telemedicine and clinical decision support systems (CDSS). The objective of this paper is to provide a set of characterizing properties for DSTSs. This characterizing property set (CPS) can be used for typing, classifying and clustering DSTSs. Methods: We performed a systematic keyword-based literature search to identify candidate-characterizing properties. We selected a subset of candidates and refined them by assessing their potential in order to obtain the CPS. Results: The CPS consists of 14 properties, which can be used for the uniform description and typing of applications of DSTSs. The properties are grouped in three categories that we refer to as the problem dimension, process dimension, and system dimension. We provide CPS instantiations for three prototypical applications. Conclusions: The CPS includes important properties for typing DSTSs, focusing on aspects of communication for the telemedicine part and on aspects of decisionmaking for the CDSS part. The CPS provides users with tools for uniformly describing DSTSs.

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