Developing Clinical Decision Support Order Swaps to Increase the Use of Alternatives to Opioid Analgesics in the Emergency Department

NAT TRUSZCZYNSKI, PhD
University of Colorado Department of Emergency Medicine

Opioid analgesic administration and prescribing in Emergency Departments (EDs) has been identified as a contributor to the opioid epidemic. Evidence-based practices using alternatives to opioids (ALTs) exist, however utilization of ALTs remains low, and opioids remain the primary analgesic choice by ED providers. CDS order swaps are a tool to influence provider behavior. CDS cane be a non-intrusive way to change practice within providers’ workflow. Our objective is to increase the use of alternatives to opioids by iteratively developing and implement two electronic health record (EHR) embedded CDS that encourage the use of ALT clinical care pathways and suggest providers select alternatives to opioids.

This is a program implementation project implemented at a large healthcare system with 12 EDs and 450,000 visits per year.

Two separate CDS tools were created with the goal of decreasing opioid use and increasing use of ALTs. The first (pathway) is a non-interruptive reminder for providers to access existing condition-specific clinical care pathways which prioritize ALTs. These pathways had already been created but existed outside the usual workflow and suffered from low utilization despite the high prevalence of their applicable clinical conditions (back pain, headache, vomiting/abdominal pain, dental pain, musculoskeletal pain, and nephrolithiasis). Users are prompted within their usual workflow to “Consider XXX pathway” based on chief complaint and discrete patient factors. The second CDS (order swap) is an interruptive alert that is triggered by the provider searching for any opioid to order. The CDS alert allows the original order but suggests multiple alternatives within the same order.

Both CDS tools were developed and disseminated iteratively to allow for provider feedback and ensure high functionality. The pathway CDS was altered after its first iteration received overwhelming feedback that it was cumbersome and confusing. Due to the multiple screens of the initial design, using the pathway CDS caused providers to take more “clicks” to get to the corresponding pathway. The second iteration became a banner that prompted providers to “Consider the XXX pathway”. The order swap CDS was released after being redesigned based on pre-release focus group feedback from providers. After implementation other feedback about order labels was received and the CDS changed. Data collected on the program outcomes to help assess the impact of CDS is ongoing. Initial analysis from data collection is being used to troubleshoot CDS.

EHR CDS offer a promising way of creating behavior change among providers. Successful implementation of workflow CDS with real-time monitoring of changes in process (CDS utilization) and patient centered outcomes (medication use) will quantify the impact of CDS on behavior change regarding choice of analgesics in the ED.