Clinical utility of a standardized electronic order set for the management of acute upper gastrointestinal hemorrhage in patients with cirrhosis

Background & aims: Recent reductions in mortality after acute upper gastrointestinal hemorrhage among patients with cirrhosis have been attributed to early and aggressive use of guideline-recommended pharmacologic agents, antibiotics, and endoscopic therapy. Studies have shown, however, that adherence to recommended guidelines is low. We investigated whether use of a standardized electronic order set would improve adherence to treatment and timeliness of delivery.

Methods: We performed a prospective observational study, implementing an electronic order set for 123 patients with known or suspected cirrhosis who presented with symptoms/signs of upper gastrointestinal hemorrhage at Parkland Memorial Hospital (in Dallas, TX) from July 2011 through June 2012. The order set included standard nursing orders, laboratory tests, medications, orders for consultative services, and a brief evidence-based review of the benefits of octreotide and antibiotics in patients with cirrhosis. Primary outcomes included overall adherence to the administration of octreotide and antibiotics and the performance of upper endoscopy, as well as time to these interventions.

Results: Administration of antibiotics increased in patients for whom the order set was used (100% vs 89% for whom it was not used; P = .01); the use of the order set significantly reduced the time to administration of antibiotics (3 h 28 min vs 10 h 4 min; P < .001). The time to administration of octreotide also significantly was reduced for patients for whom the order set was used (2 h 16 min vs 6 h 21 min; P < .002). Although all patients underwent endoscopy, there was no significant difference in the time to procedure between patients for whom the order set was used and not used (17 h 54 min vs 18 h 5 min; P = .95).

Conclusions: The use of a standardized electronic order set improved not only overall adherence, but also the timeliness of administration of recommended therapies for patients with known or suspected cirrhosis presenting with upper gastrointestinal hemorrhage.