AUCTORES
Globalize your Research
Chat with us
Research Article | DOI: https://doi.org/10.31579/2641-0419/013
1,2,3,4,5 Ichan School of Medicine at Mount Sinai/Mount Sinai Hospital, Department of Emergency Medicine, New York, NY
6 Wayne State University, Department of Emergency Medicine, Detroit, MI
*Corresponding Author: K. Souffront, Ichan School of Medicine at Mount Sinai/Mount Sinai Hospital, Department of Emergency Medicine, New York, USA.
Citation: K. Souffront, L. Rivera , N. Genes, P. L. Richardson, Levy, Integrating a clinical decision support reminder to improve blood pressure reassessment for patients with uncontrolled hypertension, Clinical Cardiology and Cardiovascular Interventions.2(1);DOI: 10.31579/2641-0419/013
Copyright: © 2018 K. Souffront,This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 01 February 2019 | Accepted: 26 February 2019 | Published: 05 March 2019
Keywords: HTN; RCT; common cardiovascular disease; US; CDS; blood pressure reassessment
Background: Emergency department clinicians often overlook asymptomatic hypertension (HTN). Clinical decision support can help improve adherence to the emergency nursing and emergency medicine clinical policy for asymptomatic HTN. While the policy indicates referral for all adults with two or more elevated blood pressures, less than 10% of patients are referred. We sought to determine the efficacy of an electronic health record clinical reminder on nursing (RN) reassessment of blood pressure (BP) for hypertensive patients.
Methods: We conducted a 2-arm, pilot RCT, at an academic medical center in New York City. 107 RNs were randomized to the control group or to the intervention of a 'Best Practice Alert' (BPA) reminding him/her to recheck the BP in adult patients with an initial BP reading ≥140/90 mmHg. Descriptive statistics that included univariate and bivariate analyses were used to obtain adjusted measures of association between the intervention and control group.
Results: RNs were more likely to repeat BP after receiving a BPA alert (56%) compared to RNs who did not receive an alert (44%) (OR=2.3, CI 2.1-2.5; p<.001). Patients who received BP reassessment were more likely to be triaged category 4 (OR 2.88, CI 1.81-4.59, p=.0001); age>75 years (OR 1.47; CI 1.07-2.03; p=.02); had Stage II HTN (OR 3.48; CI 2.63-4.59, p=.0001) and an ED length of stay of 3-4 hours (OR 5.85; CI 4.43-7.73; p=.0001).
Conclusion: The BPA alert was effective in increasing BP reassessment by ED nurses. The findings of this study will help us translate this evidence ED practices.
Hypertension is the most common cardiovascular disease (CVD) in the United States (U.S.), and as such, a frequently encountered condition among patients who visit the emergency department (ED).1 Professional emergency nursing (ENA) and emergency medicine (ACEP) organizations have endorsed efforts to better screen for HTN and help link those with uncontrolled BP to primary care.1 They recommend referral for all adults in which their BP is persistently elevated (two or more BP readings ≥ 140/90 mm Hg). Unfortunately, despite clear recommendations from their professional societies, less than 10% of patients are referred.1 The Centers for Medicaid and Medicare Services (CMS) recently adopted a measure (#317), which imposes a financial penalty for not referring patients with elevated BP to primary care, underscoring the importance of this issue.2 Improved vigilance identifying high-risk patients with HTN may be achieved by implementing novel, multi-disciplinary, streamlined interventions.
Operationally, improving BP management in the ED requires three steps: 1) nursing BP assessment and reassessment, 2) provider referral for patients who have persistent HTN, and 3) successful linking of patients to outpatient management. Appropriate follow-up after BP measurement is a pivotal component in preventing the progression of HTN and the development of heart disease. A recent retrospective analysis conducted by the first and last author demonstrated our BP reassessment rate after an initial abnormal reading was significantly low (49%).2 We sought to improve nurse BP reassessment, using a clinical decision support (CDS) alert integrated into an existing electronic health record (EHR) platform (EPIC®), serving as the first and vital step for improving BP management in the ED. Real-time CDS algorithms may help improve adherence to the ENA-endorsed and ACEP Policy. CDS interventions have been
shown to be effective in a variety of settings, including the ED.1 However, no CDS tool to improve adherence to the ACEP Policy for asymptomatic HTN has been studied.
After a series of discussions with informatics experts and theoretical discussions about the barriers/facilitators to implementation with ED nurses and meaningful use, we pilot tested a randomized controlled trial (RCT) with ED nurses to improve BP reassessment. The purpose of our study was to determine the efficacy of an EHR clinical reminder on nursing BP reassessment for patients who were found to be hypertensive on initial ED triage vital signs.
Study Design. This was a 2-arm (intervention/control); randomized controlled pilot trial to determine the acceptability and efficacy of a CDS tool in the form of a clinical reminder to nurses, on BP reassessment.
Study Setting. Our study took place in the ED of a 1,174-bed tertiary care academic referral center located in the upper east side of New York City, which sees over 100,000 visits per year and serves a diverse population that is 35% Latino, 29% Black, 19% White, 17% Asian & other. The ED uses a single electronic health record (EPIC®).
Study Sample. We included all RNs (n=107) (Full-Time, Part-Time, Per-diem). We included patient’s ≥ 18 year old who had an initial systolic BP ≥ 140 mmHg or an initial diastolic BP ≥ 90 mmHg. The initial systolic/diastolic BP mean and standard deviation for the study sample was
162 (±22.1)/84 (±13.4).
Study Protocol. RNs were randomized to the intervention (n=54) or control group (n=53). Random assignment was performed by a computer generated random number list using Excel
2007 (Microsoft, Redmond, WA, USA), where nurses were allocated to either intervention or control groups. Nurses remained in their assigned group for the entire study period. Patients with initial BP ≥ 140/90 mm Hg triggered the CDS electronic reminder to repeat BP. This CDS tool integrated into the EHR was in the form of a “Best Practice Alert” (BPA) that displayed a message that 1) reminded the RN of the ACEP/ENA-endorsed clinical policy, and 2) prompted the RN to document BP reassessment; a link directly into the vital signs flow sheet where the BP is entered was provided. This alert was shown each time the Registered Nurse went into the chart until a second BP was documented. At 12 weeks, we performed our analysis to evaluate our main outcome, BP reassessment.
Data collection. We electronically extracted data for BP reassessment, which was defined as any repeat BP (yes/no). In 2010, there were approximately 21,000 discharges from our ED, of patients with a BP reading ≥ 140/90 mmHg, translating to ~5200 patient encounters over the three-month data collection period. Using a basal rate of BP reassessment = 50% would yield sufficient power to conduct our study with rigor across a range of projected effect sizes.
Data Analysis. First, we described independent variables (provider and patient) in percentages (%) or means (M) and standard deviations (SD) and compare the percentage of patients with BP reassessment between the intervention group and control group. Next, bivariate analyses were conducted using chi-square tests to test for significant relationships between provider and patient demographics and BP reassessment. Next, a multiple logistic regression analysis was performed. The best-fit model predictive of BP reassessment was produced and presented in
Implementation of our CDS alert was derived from the 2006 ACEP (and ENA-endorsed) clinical policy, which recommends BP reassessment for an initial abnormal BP reading ≥140/90 mmHg and referral to PCP for persistent asymptomatic HTN.3 While ACEP policies have been
shown to be safe and effective, increasing ED clinician adherence to this policy has been an ongoing challenge.4,5 We sought to improve nurse BP reassessment, using a CDS alert, as an important first step for improving adherence to this clinical policy.
CDS has been integrated into EHRs to enhance nursing decision-making and evidence- based practice.6 In a 2012 AHRQ Evidence Report/Technology Assessment on CDS and knowledge management, Lobach et al. identified 15,176 citations, including 1,407 full text articles. 7 The meta-analysis revealed strong evidence that CDS can improve process outcomes, including increased preventive services with an odds ratio of 1.42 (95% CI = 1.27, 1.58).
Results of our pilot RCT provide preliminary evidence that CDS, in the form of an electronic reminder, may improve nurse BP reassessment among patients who present to the ED with an initial abnormal BP reading. However, future modification of our EHR reminder is necessary to reinforce and sustain BP reassessment.
A systematic review of 70 studies documented features of CDS necessary for successful implementation. 8 Results found four features of CDS to be independent predictors of improved clinical practice. These four features included provision of CDS (1) as part of clinician workflow, (2) with recommendations rather than assessments, (3) at the time and location of decision-making, and (4) that is computer-based. While the majority of these studies reviewed were physician-driven, we believe our nurse focused CDS tool adheres to these features.
In addition to key features, it will mostly likely take more trial and error in order to optimize penetration of our CDS into actual practice. For example, audit-feedback (AF) has been shown to improve adherence to clinical policies and thus, a mechanism to track BP reassessment after receiving an alert and provide individual feedback at the individual level may be considered as part of future interventions.9 A meta-analysis of AF and impact on
effectiveness of care quality found that AF has a significant impact on quality outcomes (d=0.40,
95% CI = +/- 0.20); providing specific suggestions for improvement, written, and more frequent feedback strengthened this effect. This was attenuated when AF was in the form of graphical or verbal display.9
While AF is one proven way to accelerate uptake of CDS, several authors have cited “alert fatigue”, “integrated systems (being) too distractive”, or the “systems being user hostile in some other way”, as reasons why CDS may have a negative impact. AHRQ describes “alert fatigue” occurs when clinicians become desensitized to alerts (because of the sheer volume), and as a result ignore or fail to respond to the alert/reminder.
Although we found that BP reassessment improved for our nurses who received the alert, we also found that ED LOS had a significant impact on BP reassessment in our final regression model, whether or not the ED nurse received a CDS alert. Clinical theory supports these findings, such that the longer a patient is in the ED the more likely they are to have their BP reassessed at some time-point during the ED stay. ED mean LOS per patient measured from the patient's arrival to departure has been promoted as a surrogate indicator of crowding in the absence of a standard or universal definition. It is also frequently considered a key process indicator for performance improvement and clinical and operational efficiency. Future study is
In our 2-arm RCT, we found that a CDS, in the form of a clinical reminder, might improve BP reassessment among nurses. This study is the first of its kind and will move the field forward. This study serves as an important first step to promote adherence to clinical policy and patient care, especially, for a patient population that is disproportionately affected by uncontrolled HTN, ultimately helping to close the gap in health disparities related to HTN
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
