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The objective of our study was to determine the impact of embedding a pretest probability rule that is required during the computerized physician order-entry (CPOE) process on the appropriateness of CT angiography (CTA) of the pulmonary arteries for the diagnosis of pulmonary embolism (PE) in the emergency department (ED).Data were obtained from the electronic medical records of all adults who visited the ED from October 17, 2010, through October 17, 2012 (n = 96,507). The primary outcome was the appropriateness of pulmonary CTA. Logistic regression was used to test whether rates of appropriate use, overuse, and underuse of pulmonary CTA improved significantly after the implementation of the decision support tool when controlling for other patient characteristics.Pulmonary CTA was appropriately used in 67.2% of patients with a modified Wells score of ≥ 4, a positive d-dimer test result, or both. CTA was overused in 19.3% of patients and underused in 13.5% of patients. Each additional month after the start of the intervention was associated with a 4-percentage point increase in the odds that the modified Wells score would indicate CTA had been used appropriately (odds ratio [OR] = 1.04; 95% CI, 1.01-1.07) and significantly lowered the odds of overuse of CTA (OR = 0.93; 95% CI, 0.90-0.96) based on the modified Wells score. These changes were not associated with any significant alteration in the level of CTA utilization or the positivity rate.The addition of a mandatory field in the CPOE record was associated with a significant improvement in the appropriate ordering of pulmonary CTA but did not change the PE positive rate or CTA utilization. It seems likely that physicians gradually inflated the modified Wells scores in spite of the fact that a threshold modified Wells score was not required to perform pulmonary CTA.

BACKGROUND Data suggest that delays in discharges from inpatient units affect hospital throughput and contribute to emergency department crowding. Lean/Six Sigma (LSS) has been shown to improve inefficiencies in other industries. There are no published data on what impact LSS can have on advancing and sustaining earlier patient discharges. OBJECTIVE Determine the impact LSS has on advancing times of placement of discharge order and patient discharge compared to control. Secondary outcomes were length of stay (LOS) and readmission rates. DESIGN Prospective quality study with concurrent controls. SETTING Academic medical center. PATIENTS Hospitalized pediatric patients compared to remainder of the children's hospital services. INTERVENTIONS Staff reallocation, creation of standard workflow, multidisciplinary predischarge planning, and creation of a discharge checklist. MEASUREMENTS Median time of discharge order entry and median time of actual patient discharge, proportion of patients discharged before noon and 2 pm, and LOS and readmission rates. RESULTS The median time of order entry was 10:45 compared to 14:05, and the median time of discharge was 14:15 compared to 15:48. The LOS and the readmission rates remained the same in both cohorts. The control group had faster baseline discharge order entry and patient discharge, but discharge performance did not improve, despite a significantly lower average daily census. CONCLUSIONS We determined that Lean approaches can have an immediate and sustained impact on advancing patient discharges, with no negative affect on LOS or readmission rates. Our intervention generated consistent results independent of personnel during the busiest months of the year at a tertiary care children's hospital. Journal of Hospital Medicine 2015;10:220–227. © 2014 Society of Hospital Medicine

Background : Venous thromboembolism (VTE) prophylaxis is underutilized in hospitalized medical patients. Underutilization might occur as a result of resident practice variation incurred by using a complex risk assessment tool. Objective : To examine what impact repetitive exposure to an electronic point-based VTE risk assessment tool has on resident inter-rater reliability and protocol adherence. Design : Pre and post intervention cross-sectional cohort study. Setting : Single academic center. Patients : Convenience samples of Internal Medicine residents. Interventions : Residents completed clinical vignettes before and after any exposure to an electronic risk assessment tool and reminder alert. They were asked to make three determinations using a point-based VTE risk assessment tool: risk stratification, identify contraindications, and VTE prevention strategy. Measurements : Inter-rater reliability for risk assessment, contraindications, and VTE prophylaxis strategy and protocol adherence. Results : Kappa scores for VTE risk assessment did not change, but improved for VTE plan increasing from 0.28 to 0.37. Protocol adherence improved from 71% in 2008 to 79% (P = 0.06). There was a significant decrease in under-prophylaxis (22% to 6%, P 0.0001) but a significant increase in over-prophylaxis (7% to 16%, P = 0.001). Conclusions : Using clinical vignettes, we determined that daily exposure to an electronic risk assessment tool did not improve the inter-rater reliability of a point-based risk assessment tool when used by medical residents. This might be due to inexperienced providers using a complex point-based tool. Overall, adherence improved, and under-prophylaxis decreased, but over-prophylaxis increased. Clinical vignettes are a generalizable method to monitor resident prophylaxis practices and way to identify educational and process improvement opportunities. doi:10.4021/jocmr766w

We present the only reported case of an immunocompetent pediatric patient in the literature to have fulminate gas gangrene of the lower extremity and concomitant gastrointestinal tract infection due to Clostridium septicum coinfected with Clostridium difficile colitis respectively. The patient survived with aggressive medical and surgical treatment.

Computer-based tools to assess venous thromboembolism (VTE) risk have been shown to increase VTE pharmacoprophylaxis rates and decrease VTE incidence in high-risk hospitalized patients. However, VTE risk may be underestimated using computer-based tools alone. We tested the effect of a provider-enhanced clinical decision support (CDS) tool on VTE pharmacoprophylaxis and VTE incidence in patients who would have been deemed "low risk" using a computer-based risk-assessment tool alone.The study sample was adult patients hospitalized during a 13-month period who were determined to be at low risk for VTE with a computer-based risk-assessment tool. The provider-enhanced CDS tool was implemented 4 months into the study period and required providers to stratify patients as being at high, moderate, or low risk for VTE. We compared rates of VTE pharmacoprophylaxis and VTE incidence before and after implementation of the provider-enhanced CDS tool.There were 1322 patients in the 4-month pre-implementation period and 3347 patients in the 9-month post-implementation period who were determined to be at low risk for VTE based on a computer-based risk-assessment tool. Using the provider-enhanced CDS tool, providers stratified 31% of these computer-assigned low-risk patients as being at moderate risk for VTE and 7% as being at high risk for VTE. The rate of VTE pharmacoprophylaxis increased from 27% to 34% (P0.01). The venous thromboprophylaxis rate decreased from 0.98% to 0.42% after implementation of the provider-enhanced CDS tool (P0.02).Patients identified as being at low risk for VTE solely by computer-based algorithms may include patients whom providers determine to be at risk for VTE. Provider-enhanced CDS tools may outperform computer-based VTE risk-stratification algorithms.

BACKGROUND: Venous thromboembolic events (VTE) are a significant cause of mortality in hospitalized medical and surgical patients. Despite recommendations and guidelines, current evidence demonstrates that VTE prophylaxis remains underutilized in at-risk patients. The process of providing VTE prophylaxis begins with assessing each patient's VTE risk. Using an individualized, point-based protocol in the assessment process is a complex task, and might contribute to variability in VTE prescribing behavior. There are no published data on how reliably residents can perform risk assessment and prophylaxis using a point-based VTE risk assessment tool. OBJECTIVE: Our aim was to determine inter-rater reliability of a point-based risk assessment tool by residents early in the academic year. DESIGN: The design was a cross-sectional-cohort observational study. SETTING: The site was an academic medical center. PATIENTS: Case-based clinical vignettes were used. INTERVENTIONS: Verbal instructions were given to medical residents about how to apply our hospital's point-based VTE risk assessment tool. MEASUREMENTS: Interobserver agreement was measured of: 1) risk score, 2) risk-stratification, 3) identification of contraindications, 4) VTE prophylaxis plan, and 5) resident adherence to the protocol. RESULTS: The intra-class correlation (ICC) for the total risk score was 0.66 and the kappa coefficient for risk stratification was 0.51. The kappa scores for absolute and relative contraindications were 0.29 and 0.23, respectively. The kappa score for the VTE plan was 0.28. CONCLUSIONS: We determined that, following brief instructions early in the academic year, a point-based VTE risk assessment tool has only fair to moderate inter-rater reliability, with suboptimal adherence to the protocol. Both might lead to underutilization of VTE prevention strategies. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.