Background

Children on the ketogenic diet must limit carbohydrate intake to maintain ketosis and reduce seizure burden. Patients on ketogenic diet are vulnerable to harm in the hospital setting where carbohydrate-containing medications are commonly prescribed. We developed clinical decision support to reduce inappropriate prescription of carbohydrate-containing medications in hospitalized children on ketogenic diet.

Methods

A clinical decision support alert was developed through formative and summative usability testing. The alert warned prescribers when they entered an order for a carbohydrate-containing medication in patients on ketogenic diet. The alert was implemented using a quasi-experimental design with sequential crossover from control to intervention at two tertiary care pediatric hospitals within a single health system. The primary outcome was carbohydrate-containing medication orders per patient-day.

Results

During the study period, there were 280 ketogenic diet patient admissions totaling 1219 patient-days. The carbohydrate-containing medication order rate declined from 0.69 to 0.35 orders per patient-day (absolute rate reduction 0.34, 95% confidence interval 0.25-0.43), corresponding to 256 inappropriate orders prevented. The alert fired 398 times and was accepted (i.e., the order was removed) 227 times for an overall acceptance rate of 57%.

Conclusions

Implementation of a clinical decision support alert at order-entry resulted in a sustained reduction in carbohydrate-containing medication orders for hospitalized patients on ketogenic diet without an increase in alert burden. Clinical decision support developed with user-centered design principles can improve patient safety for children on ketogenic diet by influencing prescriber behavior.

中文翻译：

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减少住院儿童的生酮饮食处方错误

背景

使用生酮饮食的儿童必须限制碳水化合物的摄入量以维持酮症并减少癫痫发作负担。生酮饮食的患者在通常开具含碳水化合物药物的医院环境中很容易受到伤害。我们开发了临床决策支持，以减少生酮饮食住院儿童的含碳水化合物药物的不当处方。

方法

临床决策支持警报是通过形成性和总结性可用性测试开发的。当处方者为生酮饮食的患者输入含碳水化合物的药物时，警报警告了他们。该警报是使用准实验设计实施的，在一个卫生系统内的两家三级保健儿科医院中，从控制到干预的顺序交叉。主要结果是每患者日含碳水化合物的药物订单。

结果

在研究期间，共有 280 名生酮饮食患者入院，共计 1219 个患者日。含碳水化合物的药物订单率从每患者日的 0.69 次下降到 0.35 次（绝对率降低 0.34，95% 置信区间 0.25-0.43），对应于 256 次不适当的订单被阻止。警报发出 398 次并被接受（即订单被删除）227 次，总体接受率为 57%。

结论

在订单输入时实施临床决策支持警报导致住院患者接受生酮饮食的含碳水化合物药物订单持续减少，而不会增加警报负担。以用户为中心的设计原则开发的临床决策支持可以通过影响处方者的行为来提高生酮饮食儿童患者的安全性。