A Pilot Quality Improvement Project to Introduce Utilization of an Electronic Bone Health Order Set in a Population of Hospitalized Pediatric Patients Identified at Risk for Fractures

Abstract

Heightened risk for secondary osteoporosis and subsequent vulnerability to low impact fractures is often observed in children with complex health needs (CCHNs). This susceptibility, and an increased incidence of low-impact fractures in a population at a pediatric practice site, prompted development of a practice change to support bone health and reduce fractures in these patients. The purpose of this pilot, quality improvement project (QIP) was to evaluate physician and nurse practitioner (MD/NP) utilization of a clinical decision support rule, i.e., an electronic bone health order set (e-BHOS), as a mechanism to promote bone health in a population of hospitalized CCHNs at risk for fracture. MD/NP attitudes and levels of satisfaction using an e-BHOS were also measured.

Synthesis of evidence revealed that best practices to support bone health in CCHNs plays a role in improving their quality of life and potential to prevent fractures. Such practices include baseline diagnostic testing, a regimen of nutritional support, musculo-skeletal stimulation and pharmaceutical therapies. No study or report was identified that investigated use of an e-BHOS as an intervention to promote consistent bone health prescribing practices by MDs/NPs caring for the target population. A pilot, quality improvement project was designed and implemented to determine if introduction of an evidence-based, e-BHOS embedded in the electronic health record at a practice site would influence MD/NP prescribing practices when admitting CCHNs at risk for fracture. Descriptive statistical tests were used to describe MD/NP characteristics, effects of the e-BHOS on their bone health prescriptive practices and levels of satisfaction using this digital intervention. Post-intervention data analysis revealed a proportional increase in two of the six order set components, fracture risk precautions and bone health medication orders. The post-intervention increase noted in bone health medication orders was statistically significant.

A Likert survey was also administered to participant MDs/NPs at the conclusion of the post-intervention data collection period to evaluate their attitudes and levels of satisfaction with the e-BHOS. Factors assessed on the survey included the training provided on use of the order set, its ease and speed of use, degree of comprehensiveness and clinicians’ desire to incorporate additional orders sets into the organization’s EHR. The maximum score allocated to the agreement scale for each survey question was five. Analysis of MDs/NPs responses revealed a mean of 4.4, which was derived from aggregated scores on all five survey components.

Project planning, implementation and data analysis revealed a variety of facilitators and barriers posed by EHR platforms used for healthcare documentation and to improve patient care. Early and consistent participation of end-users in development and revision of EHRs plays a crucial role in reducing digital barriers to improved patient safety and outcomes.