Order sets for COPD inpatients improved steroid dosing

Electronic order sets helped lower the dosage of corticosteroids given to inpatients with acute exacerbation of chronic obstructive pulmonary disease, bringing doses more in line with clinical guidelines, a study found.


Electronic order sets helped lower the dosage of corticosteroids given to inpatients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), bringing doses more in line with clinical guidelines, a study found.

Researchers at a tertiary care academic institution studied 420 inpatients over age 40 years who were discharged with a primary diagnosis of AECOPD between Jan. 1, 2009, and Sept. 30, 2012, and who had received at least 1 dose of systemic corticosteroids while hospitalized. They developed a standardized order set, which was embedded in their electronic health record (EHR), to use on admission of patients with a possible diagnosis of AECOPD. It included management options during the inpatient stay and orders for scheduling follow-up.

The pre-intervention period was 25 months; the post-intervention period was 18 months. In the first 6 months of the intervention, the order set usage was just 40%, so the researchers implemented a “best practices advisory” in the EHR to alert clinicians to a possible AECOPD diagnosis. After that, order set usage exceeded 70%. The study's main outcome was corticosteroid dosage given in the first 48 hours of hospitalization.

The median amount of corticosteroid administered in the first 48 hours of hospitalization was significantly lower after the intervention was implemented (306.2 mg vs. 156.25 mg; P<0.0001); it was also lower during the whole hospitalization (352.5 mg vs. 175 mg; P<0.0001). Hospital follow-up rates, length of stay, and 30-day readmission rates didn't differ before and after the intervention. Follow-up appointments were made for about 90% of patients, though only two-thirds kept the appointments. Results were published online June 10 by JAMA Internal Medicine.

The researchers noted that their hospital's length of stay before the intervention was shorter than the national median of 4.5 days, which may explain why there was no reduction after the intervention was in place. Future studies should explore how to improve care transitions in order to increase follow-up visits, they wrote. Overall, they wrote, embedding clinical practice guidelines into the EHR seemed to standardize and reduce variation in care for AECOPD inpatients.