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New decision support system reduced pneumonia mortality rate by 38%

Intermountain Healthcare researchers have demonstrated the clinical effectiveness of an electronic decision support system (eNPa) for patients with pneumonia.

According to a new study by researchers at Intermountain Healthcare in Salt Lake City, a new electronic decision support system helped clinicians at community hospitals deliver best practice care for emergency department patients with pneumonia, more effective antibiotic use, and 38% lower mortality rates.

Pneumonia has been the main cause of death from infectious illnesses in the United States since before the start of the COVID-19 pandemic.

Dr. Nathan Dean, chief of pulmonary and critical care medicine at Intermountain Medical Center, said in a news release, “Treating pneumonia in emergency departments is challenging, especially in community hospitals that don’t see severe pneumonia as often as urban academic medical centers.”

Over the last 2 years, the team of researchers installed the health system’s electronic clinical decision support (ePNa) system to 16 of its community hospitals for the study. During that time, there were 6,848 pneumonia cases in those hospitals, and the decision support system was utilized by a bedside physician in 67% of eligible patients.

The electronic decision support tool collects important patient indicators such as age, fever, oxygen saturation, laboratory and chest imaging data, and vital signs to provide treatment recommendations, such as antibiotic treatment, culture tests, and care setting suggestions.

The use of the eNPa resulted in a 38% reduction in mortality 30 days after receiving a pneumonia diagnosis, with the greatest decrease in mortality rates in patients admitted directly to the ICU, a 17% increase in outpatient disposition, significantly reduced ICU admissions, and a shortened average time from emergency department admission to first antibiotic administered.

Dr. Nathan Dean added, “In giving clinicians a real-time assessment tool that pulls together over 50 factors that can determine how a patient will do with pneumonia, our study found that clinicians were able to make better treatment decisions with this resource. Some of our community hospitals have as little as 20 beds. We wanted to validate the effectiveness of ePNa in very different healthcare settings.”

Dr. Dean went on to say that not only did ePNa provide physicians with useful advice, but it also allowed them to be more organized and consistent in their judgments concerning pneumonia patients.

The study was published in ATS Journals on March 7th, 2022.

Abstract. Care of emergency department patients with pneumonia can be challenging. Clinical decision support may decrease unnecessary variation and improve care. Objectives: Report patient outcomes and processes of care following deployment of ePNa: comprehensive, open loop, real-time clinical decision support embedded within the electronic health record. Methods: Pragmatic, stepped-wedge, cluster-controlled trial with deployment at 2-month intervals into 16 community hospitals. ePNa extracts real-time and historical data to guide diagnosis, risk stratification, microbiology studies, site of care and antibiotic therapy. We included all adult emergency department patients with pneumonia over three years identified by ICD-10 discharge coding confirmed by chest imaging. Measurements and Main Results: Median age of the 6848 patients was 67 years (interquartile range 50-79), 48% 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 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). Mean time from emergency department admission to first antibiotic was 159.4 (156.9, 161.9) minutes at baseline and 150.9 (144.1, 157.8) after deployment (P<0.001). Outpatient disposition from the emergency department increased from 29.2% to 46.9% while 7-day secondary hospital admission was unchanged, 5.2% versus 6.1%. ePNa was utilized by emergency department clinicians in 67% of eligible patients. Conclusions: ePNa deployment was associated with improved processes of care and lower mortality.

Dean NC, Vines CG, Carr JR, Rubin JG, Webb BJ, Jacobs JR, Butler AM, Lee J, Jephson AR, Jenson N, Walker M, Brown SM, Irvin JA, Lungren MP, Allen TL. A Pragmatic Stepped-wedge, Cluster-controlled Trial of Real-time Pneumonia Clinical Decision Support. Am J Respir Crit Care Med. 2022 Mar 8. doi: 10.1164/rccm.202109-2092OC. Epub ahead of print. PMID: 35258444.

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