Special Issue on CDS Failures: Finding the Right Level of Interruption to Improve Suicide Screening Compliance in the Emergency Department.

Abstract

Background: The use of real-time Clinical Decision Support (CDS), such as Our Practice Advisory (OPAs), augments clinical decisions while helping to reduce errors and ensuring compliance with organizational best practices1. In complex large health systems, processes for standardization and adherence to emergency department (ED) based suicide screening practices are challenging and may benefit from the use of CDS-based tools adhering to the five rights of CDS2.

Objectives: To improve suicide screening compliance for the ED to 95% by implementing a contextually appropriate CDS-based tool within the electronic health record (EHR).

Methods: A multidisciplinary group of Quality and ED nursing leadership aimed to develop a chief complaint driven OPA that improved adherence to and completion of suicide screening in the ED. Using an iterative design process over 3 months, a series of two distinct suicide screening OPAs were developed with varying levels of interruption, but both relied on rule-based logic to identify if an ED patient met one of the 57 pre-defined "Reasons for Visit" or chief complaints requiring suicide screening. Use of chief complaint driving CDS removed the need for manually remembering complex criteria while contributing to meeting regulatory and organizational standards.

Results: The ED suicide screening compliance improved from 64.96% to 77.66% with the initial implementation of the non-interruptive OPA. Subsequently, an interruptive OPA (pop-up window based on a defined trigger that stops the clinician and requires a response), was introduced which further increased screenings being completed to 91.69%. The use of CDS interruptive OPAs significantly improved compliance with suicide screening by including the Columbia Suicide Severity Rating Scale (C-SSRS) tool directly in the OPA.

Conclusion: Use of contextually relevant information, such as reason for visit or chief complaint, and interruptive CDS tools embedded into EHR workflows may improve ED based suicide screening.