A Pragmatic, Stepped-Wedge, Cluster-controlled Clinical Trial of Real-Time Pneumonia Clinical Decision Support

Abstract

Rationale: Care of emergency department (ED) patients with pneumonia can be challenging. Clinical decision support may decrease unnecessary variation and improve care. Objectives: To report patient outcomes and processes of care after deployment of electronic pneumonia clinical decision support (ePNa): a comprehensive, open loop, real-time clinical decision support embedded within the electronic health record. Methods: We conducted a pragmatic, stepped-wedge, cluster-controlled trial with deployment at 2-month intervals in 16 community hospitals. ePNa extracts real-time and historical data to guide diagnosis, risk stratification, microbiological studies, site of care, and antibiotic therapy. We included all adult ED patients with pneumonia over the course of 3 years identified by International Classification of Diseases, 10th Revision discharge coding confirmed by chest imaging. Measurements and Main Results: The median age of the 6,848 patients was 67 years (interquartile range, 50-79), and 48% were female; 64.8% were hospital admitted. Unadjusted mortality was 8.6% before and 4.8% after deployment. A mixed effects logistic regression model adjusting for severity of illness with hospital cluster as the random effect showed an adjusted odds ratio of 0.62 (0.49-0.79; P < 0.001) for 30-day all-cause mortality after deployment. Lower mortality was consistent across hospital clusters. ePNa-concordant antibiotic prescribing increased from 83.5% to 90.2% (P < 0.001). The mean time from ED admission to first antibiotic was 159.4 (156.9-161.9) minutes at baseline and 150.9 (144.1-157.8) minutes after deployment (P < 0.001). Outpatient disposition from the ED increased from 29.2% to 46.9%, whereas 7-day secondary hospital admission was unchanged (5.2% vs. 6.1%). ePNa was used by ED clinicians in 67% of eligible patients. Conclusions: ePNa deployment was associated with improved processes of care and lower mortality. Clinical trial registered with www.clinicaltrials.gov (NCT03358342).

Keywords: antibiotic use; clinical decision support; emergency department; mortality; pneumonia.

Figure 1.

Stepwise deployment into six hospital clusters at 2-month intervals. The predeployment period was 18 months before deployment in each cluster. The postdeployment period began after the 2-month washout period and ended in June 2019. The number of pneumonia patients per cluster per period is contained within the bars. Three larger urban hospitals with ICUs staffed by critical care physicians are included in clusters 1–3; five medium-sized hospitals in smaller cities and suburbs with ICUs staffed by hospitalists in consultation with telemedicine critical care physicians are included in clusters 2–5; eight smaller rural hospitals whose family practice clinicians transfer patients to hospitals with ICUs in consultation with telemedicine critical care physicians are included in clusters 2–6.

Figure 2.

Severity-adjusted mortality by site of care after emergency department (ED) discharge. Severity-adjusted mortality before ePNa deployment versus after ePNa deployment was 1.4% versus 2.0% for patients with outpatient disposition, 6.0% versus 4.6% for hospital ward disposition, and 15.0% versus 7.4% for ICU disposition. ePNa = electronic pneumonia clinical decision support.

Figure 3.

Electronic pneumonia clinical decision support use based on individual case reviews by cluster at intervals after the washout periods.