A. Effect of Computerized Triage Support for Evaluation and Treatment of Febrile Bone Marrow Transplant Patients Who Present to the Emergency Department

Background:  Rapid evaluation and antibiotic therapy for febrile bone marrow transplant (BMT) patients is critical to decrease morbidity and mortality from infection, but identifying these patients in a large medical system can be challenging.  This study measures the effect of computerized triage support implemented in an Emergency Department (ED) electronic medical record (EMR) on time to antibiotic administration and other time-sensitive measures. We hypothesize that triage support will decrease time to vitals, blood cultures, antibiotics, and unit transfer.

Methods:  A before-after interventional study was conducted of all adult (age ≥ 18) patients with history of BMT and fever >37.1°C admitted from a 60,000-visit university ED with an active BMT program between October 2011 and July 2014. Cohorts were defined by implementation of a computerized triage support advisory in February 2013. This system was comprised of a best practice advisory (BPA) using both a computer prompt and an automated page to alert clinicians to the history of recent BMT. The primary outcome was time to antibiotics, and secondary outcomes included time to vital signs, blood cultures, and transfer. A one-sided Wilcoxon rank-sum test was used to compare before-after intervention times, and the Chi-squared test was used for comparisons of proportions. Statistical tests were assessed for significance at the 5% level.

Results:  Sixty-three patients were included in the study, and most had blood cultures drawn and antibiotics started empirically (87% and 86%, respectively). Median time to antibiotics was lower after BPA implementation (79 vs. 114 min, p<0.01). Despite earlier antibiotic administration, the rate of blood cultures (85% after vs. 92% before, p=0.67) and antibiotics (87% vs. 83%, p=0.96) did not change. No differences were observed in time to vital signs, blood culture, or ED disposition did not change. Conclusion:  Computerized triage support was associated with decreased time to antibiotics, without increased health care utilization. Further studies designed to better understand the role of enhanced triage tools and EMR screening protocols are critical to standardizing care and identifying patients at high risk of clinical deterioration.   Table 1. Comparison of Pre and Post Intervention Times

	Pre			Post
Time To:	n	Median	IQR	n	Median	IQR	P-value
Vitals	24	4	2-11	39	5	3-9	0.32
Blood Culture	22	38	30-60	33	41	25-66	0.45
Antibiotics	20	114	93-168	34	79	61-135	<0.01
Transfer to Unit	24	211	181-257	39	174	152-320	0.28

 

Figure 1. BPA to alert clinicians to BMT history and the need for immediate assessment. The BPA also sends pages to ED LIPs, Charge Nurse and the BMT team.   © 2014 Epic Systems Corporation. Used with permission.