Abstract
Background Recognizing that alert fatigue poses risks to patient safety and clinician wellness,
there is a growing emphasis on evaluation and governance of electronic health record
clinical decision support (CDS). This is particularly critical for interruptive alerts
to ensure that they achieve desired clinical outcomes while minimizing the burden
on clinicians. This study describes an improvement effort to address a problematic
interruptive alert intended to notify clinicians about patients needing coronavirus
disease 2019 (COVID) precautions and how we collaborated with operational leaders
to develop an alternative passive CDS system in acute care areas.
Objectives Our dual aim was to reduce the alert burden by redesigning the CDS to adhere to best
practices for decision support while also improving the percent of admitted patients
with symptoms of possible COVID who had appropriate and timely infection precautions
orders.
Methods Iterative changes to CDS design included adjustment to alert triggers and acknowledgment
reasons and development of a noninterruptive rule-based order panel for acute care
areas. Data on alert burden and appropriate precautions orders on symptomatic admitted
patients were followed over time on run and attribute (p) and individuals-moving range control charts.
Results At baseline, the COVID alert fired on average 8,206 times per week with an alert
per encounter rate of 0.36. After our interventions, the alerts per week decreased
to 1,449 and alerts per encounter to 0.07 equating to an 80% reduction for both metrics.
Concurrently, the percentage of symptomatic admitted patients with COVID precautions
ordered increased from 23 to 61% with a reduction in the mean time between COVID test
and precautions orders from 19.7 to −1.3 minutes.
Conclusion CDS governance, partnering with operational stakeholders, and iterative design led
to successful replacement of a frequently firing interruptive alert with less burdensome
passive CDS that improved timely ordering of COVID precautions.
Keywords
clinical decision support systems - alert fatigue - patient safety - clinical governance
