From the 2018 HVPAA National Conference
Daniel Burczak (Rush University Medical Center), Keith Burczak (Chicago College of Osteopathic Medicine), Celine Goetz (Rush University Medical Center)
Many studies have shown that docusate is an ineffective stool softener. However, it is frequently prescribed for the treatment and prevention of constipation. We aimed to decrease docusate prescriptions at an academic hospital through an educational intervention followed by changes to electronic medical record (EMR) order sets.
-Educate internal medicine residents and hospitalists on the inefficacy of docusate sodium in treating constipation.
-Identify areas for intervention in the EMR.
Prescribing patterns of docusate by inpatient providers on the general medical and observation units of Rush University Medical Center (RUMC) were trended over a three-month pre-intervention period and collected as total number of docusate sodium doses per 100 bed days. An aims statement of reducing total docusate doses on the general medicine inpatient units by 33% in three months was established. Key stakeholders were defined and included on the quality improvement initiative, including two physicians from the hospitalist group and one pharmacist.
A cause and effect “fishbone” diagram was used to identify several opportunities for intervention with a primary focus centered on education and EMR changes. The educational initiative utilized one email and two brief didactic sessions directed towards resident and attending physician prescribers. To sustain change created through the educational initiative, docusate sodium was targeted for removal from the top five most frequently used order sets in which it was included.
Results post intervention were reported as total number of docusate doses per 100 bed days, collected weekly over a three-month period, and organized into a run chart. The pre and post intervention medians were calculated and compared for significance.
he educational email was disseminated to all 102 internal medicine residents, and 37 (36%) confirmed they had read the email. Additionally, 33 (32%) of internal medicine residents were in attendance at the noon conference presentation. Fifteen (36%) of the hospitalist group attended the presentation which took place during the monthly hospitalist meeting.
EMR Order sets were highlighted as a possible area for intervention, in addition to adding text to ordering window that stated docusate sodium is an ineffective medication for constipation. A query of RUMC’s EMR Epic revealed docusate sodium to be included in >75 order sets used at rush. Five were specific to internal medicine.
Docusate sodium doses per 100 bed days were decreased by 39% from a median of 4.12 pre-intervention to a median of 2.48 post-intervention (p-value<0.01). The run chart indicates a shift one week prior to the first intervention, and continued through the study period.
Although docusate sodium may seem like a benign drug, its’ common use despite lack of evidence decreases the value of patient care. This medical student driven project was able to achieve its aim, decreasing administration of docusate sodium by more than a third. While it seems that benefits of the educational initiative peaked at one month, areas in the EMR were targeted and strategies are currently being implemented to spawn lasting change.
Implications for the Patient
This quality initiative directly challenged the status quo of constipation management at our institution, and as a result the use of an ineffective medication was decreased.