Quality Improvement Initiative to Improve Order Set Usage in a Pediatric Emergency Department (PED)

Purpose/Objectives: Electronic order sets, or collections of clinically related laboratory, radiologic, medication, and patient care orders grouped for a specific purpose or patient presentation, have become widely available on many computerized provider order entry (CPOE) systems. Although the use of electronic order sets has been shown to reduce medication errors, promote adherence to evidence-based guidelines, as well as significantly improve both the quality and efficiency of patient care, relatively few studies have described the initial implementation and utilization of order sets. Understanding the most effective methods for promoting the use of order sets as a novel quality initiative has the potential to vastly improve patient care and outcomes, as well as resident education and Emergency Department operations. Our primary objective was to improve order set usage from 1% to at least 5% of patients presenting to the PED by June 30, 2021.

Design/Methods: This is a single-center, prospective quality improvement (QI) project targeting PED patients. A multi-disciplinary physician task force met to discuss barriers to order set usage outlined in a Key Driver Diagram (Figure 1). We collected 12 months of data on order set usage prior to the launch of a quality improvement project in September 2020. Multiple Plan-Do-Study-Act (PDSA) ramps were enacted. During PDSA cycle 1, we worked to improve order set usability. This included the ability to find all order sets by entering “ED P” in the EMR order bar and beginning to reformat the orders sets into a more user-friendly interface. Cycle 2 involved education to both residents (Pediatrics, Emergency Medicine, and Surgery) and PED faculty and fellows via email and various conferences. During cycle 3, we added reminder lists of all available order sets to each computer in the PED. Monthly recognition awards were also initiated for the highest resident user. Cycle 4 involved further education of residents during PED block orientation and reminder emails being sent at the start of each block. Interventions continued for 9 months through June 2021.

Results: At baseline (January 2019 - September 2020, prior to the launch of the QI project), the overall order set usage in the pediatric ED was 0.95% of all patients (n=89,410). Order set use significantly increased over the run period (October 2020-June 2021), rising to 8.39% (n=30,710) (p < 0.0001, chi-square test). Two center line shifts were demonstrated in the desired direction (Figure 2).

Conclusion/Discussion: This quality improvement initiative was associated with a significant increase in the usage of electronic order sets in the PED, specifically highlighting the benefits of multiple educational modalities. Further studies will be conducted to assess knowledge of providers and improvement in times to medication and dispositions.