Use of a Computerized Forcing Function Improves Performance in Ordering Restraints
Presented as an abstract at the Society for Academic Emergency Medicine annual meeting, May 2006, San Francisco, CA.
Received 3 September 2007; received in revised form 18 February 2008, 18 April 2008 and 8 May 2008; accepted 15 May 2008. published online 21 July 2008.
Refers to article:
Forcing Functions: The Need for Restraint
, 26 August 2008
Ann M. Bisantz, Robert L. Wears
Annals of Emergency Medicine
April 2009 (Vol. 53, Issue 4, Pages 477-479) Full Text |
Full-Text PDF (131 KB)
Study objective
We evaluate the effect of a computerized order entry system forcing function on improving timely renewal of restraint orders.
Methods
In this prospective study of 2 successive interventions, physicians received computerized reminders to renew or discontinue restraint orders before their expiration. The initial intervention allowed acknowledgement of this reminder without further consequence, changing at 6 months to deny computer access until addressed. We performed chart review on emergency department visits with restraint orders in 3 consecutive 6-month periods (A, B, C) separated by these 2 interventions, determining time to order renewal, number of restraint orders, renewal orders per hour in restraints, and time in restraints and evaluating variability in these values across study intervals. Statistical analysis for our primary outcome used the Mann-Whitney and variance ratio tests.
Results
Median time to order renewal decreased in periods B and C versus A by 64 and 56 minutes, respectively, with variability in this measure decreasing across all periods. Mean number of restraint orders in periods B and C significantly increased versus those in A (1.46 to 1.89 to 2.34), with corresponding increases in variability. Mean renewal orders per hour in restraint significantly increased in period C versus A and B, from 0.08 to 0.23 to 0.89, with increasing variability across all periods. Decreases in median time spent in restraints observed in periods B and C versus A of 45 and 105 minutes, respectively, trended toward but did not achieve significance, with significantly decreasing variability compared with baseline.
Conclusion
The forcing function improved restraint reordering and variability in practice and may have contributed to nonsignificant reductions observed in time in restraint.
aDivision of Emergency Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
bDepartment of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Address for correspondence: Richard T. Griffey, MD, MPH, Division of Emergency Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, Box 8072, 660 Euclid Ave, St. Louis, MO 63110-1010; 314-747-4899, fax 314-362-0478
Supervising editor: Robert L. Wears, MD, MS
Author contributions: RTG and NG conceived of and designed the study. RTG, KW, and NG performed data collection. RTG and KW managed the data and oversaw data quality control. ATM provided statistical advice on study design. RTG and ATM analyzed the data. RTG drafted the article and all authors contributed to its revision. RTG takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Publication dates: Available online July 19, 2008.
ABSTRACT