Abstract
Background
Individuals hospitalized with severe ulcerative colitis represent a complex group of patients. Variation exists in the quality of care of admitted patients with inflammatory bowel disease. We hypothesized that implementation of a standardized admission order set could result in improved adherence to current best practice guidelines (Toronto Consensus Statements) for the management of this patient population.
Methods
A retrospective cohort study of patients admitted with severe ulcerative colitis to a Montreal tertiary center was conducted. Two cohorts were defined based on pre- and post-implementation of a standardized order set. Adherence to 11 quality indicators was assessed before and after implementation of the intervention. These included: Clostridioides difficile and stool cultures testing, ordering an abdominal X-ray and CRP, organizing a flexible sigmoidoscopy, documenting latent tuberculosis, initiating thromboprophylaxis, use of intravenous steroids, prescribing infliximab if refractory to steroids, limiting narcotics, and surgical consultation if refractory to medical therapy.
Results
Adherence to 6 of the 11 quality indicators was improved in the post-intervention cohort. Significant increases were noted in adherence to C difficile testing (75.5% versus 91.9%, P < 0.05), CRP testing (71.4% versus 94.6%, P < 0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P < 0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P < 0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P < 0.01).
Conclusions
Implementation of a standardized order set, focused on pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements.
BACKGROUND
Individuals hospitalized with severe ulcerative colitis (UC) represent a complex group of patients. Since they are often cared for by clinicians from multiple disciplines and specialties including nursing, emergency medicine, family medicine, general internal medicine, and gastroenterology, a coordinated approach to care is paramount to effective and safe inpatient management. Canadian Guidelines titled ‘Treatment of hospitalized adult patients with severe Ulcerative Colitis - Toronto Consensus Statements’ address the inpatient clinical management of patients with severe UC flare (1). Despite these available guidelines describing a standardized approach to this patient population, variation exists in the quality of care and prevention of complications of admitted patients with inflammatory bowel disease (IBD) (2). For example, in a recent multicenter Canadian study of patients admitted for IBD-related problems, there were significant variations in inpatient quality indicators such as venous thromboembolism prophylaxis (VTE) and Clostridioides difficile testing across centers and admitting services (3). Jackson et al. showed that overall adherence to international guidelines for IBD management of admitted patients was 71%, whereas Law et al. revealed that variations exist even among gastroenterologist subspecialities (4,5).
Since efforts to promote adoption of guidelines through multimodal educational interventions alone may not result in improved adherence to standard of care (6), additional measures may be warranted to ensure adherence to the Toronto Consensus Statements. Computerized physician order entry systems can reduce the incidence of preventable adverse events and medication errors and optimize patient safety and efficiency outcomes (7,8). At our institution, order sets have previously been used in the emergency room to streamline medical care and avoid medical errors. The use of standardized protocols permits easier teaching of residents, adoption of approaches by staff, as well as auditing (9). In multiple studies, they have been shown to increase the adherence to standards of care including ordering of appropriate tests, improving consistency of management, and increasing prompt management (10,11). However, there are limited data on their use of patients hospitalized with IBD. We developed a quality improvement initiative which involved the implementation of a standardized order set for patients hospitalized with a severe UC flare and conducted a retrospective study assessing adherence to guidelines before and after the intervention. We hypothesized that implementation of the standardized admission order set could result in improved adherence to current best practice guidelines in the management of this patient population.
METHODS
Study Design and Setting
Adult patients presenting to the emergency department of an urban adult tertiary care university-affiliated teaching center in Montreal, Canada and admitted with a diagnosis of severe UC flare were identified for this retrospective cohort study. Two cohorts were established based on implementation of a standardized order set, which became available in March 2017. The pre-intervention cohort comprised of patients hospitalized between April 1, 2014 and October 31, 2016, and the post-intervention cohort participants were admitted between July 1, 2017, and June 30, 2018. The intervention consisted of a standardized patient order set accessible to the attending emergency medicine physician that could be used when admitting a patient with a severe UC flare to the short stay wards. These wards are run by family medicine physicians and emergency medicine physicians, as gastroenterology does not admit at our institution. A minority of patients were admitted to the internal medicine wards. The order set was developed by all co-authors in collaboration with the administrative team of the hospital. Sections included admission information, consults, diagnostic tests, diet and nutrition, activity level, vital signs, monitoring of bowel movements, laboratory tests, glucose management, intravenous therapy, antibiotic therapy, corticosteroid therapy, nausea management, pain/fever management, and VTE prophylaxis. Additional orders could be entered. Suggested orders were already selected upon opening of the order set, and included stool cultures, C difficile stool testing, methylprednisolone 20 mg intravenous every 8 hours for 72 hours, non-opioid pain control with acetaminophen, and weight-appropriate thromboprophylaxis using low-molecular-weight-heparin, with instructions that these should be considered for all patients admitted with a severe UC flare unless contraindicated. In addition, a gastroenterology consultation to assess the patient for sigmoidoscopy and co-management of the patient, and infectious diseases consultation for the evaluation of latent tuberculosis status were encouraged. The final version of the standardized order set can be found in the Supplementary Material.
Eligibility Criteria
Charts of patients presenting with a principal diagnosis of ‘Colitis’, ‘Ulcerative Colitis’, ‘Acute Abdomen’, and ‘Peritonitis’ on the Canadian Emergency Department Diagnosis Shortlist were manually reviewed for inclusion by three investigators (12). Validation of an admitting diagnosis of severe UC flare required the patient to carry a diagnosis of UC prior to admission or to be suspected of having UC at presentation with the diagnosis being confirmed during the admission. Severe UC flare was defined as per the criteria put forth by Truelove and Witts (13).
Study Variables
Information on baseline characteristics of the study population was collected from patient medical records via a retrospective chart review and included age, sex, known UC diagnosis, number of hospitalizations in the past year, hemodynamic instability at presentation, gastrointestinal bleeding, and biomarker levels (erythrocyte sedimentation rate , C-reactive protein [CRP], and hemoglobin). Quality indicators (QIs) evaluated for adherence to best practice guidelines included diagnostic testing, and both pharmacological and non-pharmacological interventions based on those described in the Toronto Consensus Statements (1). Laboratory, microbiology, and imaging investigations including C difficile toxin testing, stool culture, abdominal X-ray, flexible sigmoidoscopy within 72 hours of presentation, CRP within 24 hours of presentation, testing for latent tuberculosis (by interferon-gamma release assay or tuberculin skin test) were recorded. We also evaluated the administration of thromboprophylaxis within 24 hours of presentation, corticosteroids total daily dose-equivalent to 60 mg of methylprednisolone, and intravenous infliximab given after 5 days of corticosteroids at an appropriate dosage. Moreover, avoidance of narcotics and the request for a surgery consultation after 5 to 7 days of therapy in non-respondents were also recorded. The proportions of admissions with adherence to individual components of the quality indicators (QI) were measured.
Outcome
Our primary outcome was defined as the difference in adherence to each of the 11 individual quality indicators in the pre-intervention group compared to the post-intervention group. Adherence was defined as the proportion of the quality indicator that was completed for each cohort.
Sample Size Calculation
Thromboprophylaxis was selected as a proxy for the other quality indicators to be used to complete a sample size estimate. Described adherence rates to thromboprophylaxis during hospitalization for IBD flare are as low as 37% (14). Considering an adherence rate of 40% for our patient population, our sample size would need to be of 56 patients in total to demonstrate an increase to 80% adherence in the post-intervention cohort, which we thought would represent a clinically relevant improvement for what investigators felt was one of the most important quality indicators.
Statistical Analyses
Individual hospitalization episodes were considered as the unit of analysis. Categorical data were expressed as proportions and continuous data as means ± standard deviations (SD). For comparison of adherence to quality indicators, between-group analysis was performed using Chi-square tests or Fisher exact tests for categorical variables; continuous variables were analyzed using t-tests or non-parametric Wilcoxon signed-rank tests as appropriate. A P-value < 0.05 was considered statistically significant. Missing data were not imputed. All statistical analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, NC, USA).
Ethics
The institutional review board of the Jewish General Hospital gave approval for data collection and analysis.
RESULTS
Baseline Characteristics
An initial search of emergency department electronic medical records yielded 302 and 183 potentially eligible hospitalizations in the pre- and post-intervention cohorts, respectively. After detailed chart reviews, we included a total of 49 and 37 hospitalization episodes in the pre- and post-intervention cohorts, respectively. Excluded hospitalizations were those of patients who did not have a severe UC flare. Overall, participants in both groups were similar (Table 1). However, patients in the post-intervention group were more commonly women, had fewer prior hospitalizations, and had a higher CRP than those in the pre-intervention group (Table 1). The standardized order set was used in 24/37 of admissions in the post-intervention cohort (64.8%).
Table 1.
Baseline characteristics of patient admissions
| Pre-intervention N = 49 |
Post-intervention N = 37 |
|
|---|---|---|
| Age, mean ± SD | 43.9 ± 18.2 | 39.5 ± 16.0 |
| Female, n (%) | 19 (38.8%) | 21 (56.8%) |
| Known for UC, n (%) | 46 (93.9%) | 34 (91.9%) |
| Number of admissions per patient in past year, mean ± SD | 2.7 ± 4.5 | 0.2 ± 0.5 |
| Hemodynamic instability, n (%) | 2 (4.1%) | 3 (8.1%) |
| CRP at presentation (mg/L), mean ± SD | 46.0 ± 61.0 | 87.2 ± 86.9 |
| Hemoglobin (g/L), mean ± SD | 107.5 ± 28.8 | 120.7 ± 23.8 |
| Diarrhea, n (%) | 46 (93.9%) | 37 (100%) |
| Evidence of gastrointestinal bleeding, n (%) | 44 (89.8%) | 33 (89.2%) |
| More than six bowel movements, n (%) | 38 (82.6%) | 35 (100.0%) |
CRP = C-reactive protein; SD = Standard deviation; UC = Ulcerative colitis.
Adherence to Quality Indicators
Adherence to 6 of the 11 quality indicators was improved in the post-intervention cohort. Significant increases after implementation of the standardized order-set were noted in adherence to C difficile testing (75.5% versus 91.9%, P < 0.05), CRP testing (71.4% versus 94.6%, P < 0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P < 0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P < 0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P < 0.01). There were no significant differences in stool cultures performed, flexible sigmoidoscopy within 72 hours, abdominal X-ray, or use of infliximab as a rescue therapy. Appropriate surgical consultation after inadequate response to 5 to 7 days of medical therapy was identical in both groups (Table 2).
Table 2.
Comparison of adherence to quality indicators in the pre- and post-intervention cohorts
| Quality indicator | Adherence pre-intervention N = 49 | Adherence post-intervention N = 37 | P-value |
|---|---|---|---|
| Clostridioides difficile toxin testing | 37 (75.5%) | 34 (91.9%) | <0.05 |
| Stool culture performed | 37 (75.5%) | 31 (83.8%) | 0.35 |
| Abdominal X-ray performed | 19 (38.8%) | 15 (42.9%) | 0.71 |
| Flexible sigmoidoscopy within 72 h of presentation | 16 (32.7%) | 13 (35.1%) | 0.81 |
| C-reactive protein performed within 24 h of presentation | 35 (71.4%) | 35 (94.6%) | <0.01 |
| Testing for latent tuberculosis performed or previously documented | 16 (38.1%) | 22 (84.6%) | <0.01 |
| Venous thromboembolism prophylaxis initiated within 24 h of presentation | 14 (28.6%) | 32 (86.5%) | <0.01 |
| Intravenous steroids at a dose-equivalent of 60 mg of solumedrol in total | 35 (72.9%) | 35 (94.6%) | <0.01 |
| Infliximab given after 5 days of corticosteroids, intravenous route, with proper dosage | 5/15 (33.3%) | 5/14 (35.7%) | 1.00 |
| Narcotics prescribed | 33 (68.8%) | 14 (38.9%) | <0.01 |
| Surgery consultation after 5–7 days of therapy | 3/3 (100.0%) | 3/3 (100.0%) | 1.00 |
DISCUSSION
In this study, we assessed adherence to the Toronto Consensus Statement guidelines on the management of patients hospitalized with severe UC by examining the quality indicators achieved per patient admission after implementing a standardized order set and comparing the pre- and post-intervention cohorts. We demonstrated a clinically and statistically meaningful difference in hospital admissions to 6 of the 11 quality indicators in the post intervention cohort, including C difficile toxin testing, CRP measurement performed within 24 hours of presentation, testing for latent tuberculosis performed or previously documented, VTE prophylaxis initiated within 24 hours of presentation, intravenous steroids administration at a dose-equivalent of 60 mg of solumedrol in total, and avoidance of narcotics prescribing. Consistent with previous studies (15), VTE prophylaxis initiation within 24 hours of presentation showed the greatest improvement in adherence following the implementation of the order set. In a post-hoc analysis, the power was calculated to be 100% for this outcome assuming an alpha of 0.05. The power was lower for the other outcomes.
Previous studies have shown the benefits of implementing standardized templates in the care of patients with IBD. A health maintenance template in the electronic medical record system of an outpatient gastroenterology clinic serving the Veteran’s Affairs IBD population increased the recommendations for preventative care measures such as vaccinations, tuberculosis screening, osteoporosis screening, smoking cessation, and colorectal cancer surveillance by 22.5% to 86.3% (16). Similar improvements in adherence to influenza and pneumococcal immunization as well as tobacco cessation in the outpatient IBD population have been described when incorporating an IBD-specific note template, an order set, and a patient education intervention without any subsequent decrease in documented adherence a year following the intervention (17). Moreover, physician education in addition to a template summarizing IBD quality measures increased adherence to quality measures in both the academic and private practice outpatient settings (18). While the impact of standardized order sets for patients with IBD in the outpatient settings has been well described, the use of standardized order sets for hospitalized patients remains scarce. In one study, an order set for the management of patients presenting with acute severe ulcerative colitis in the ED setting significantly reduced time to C difficile ordering and time to infliximab administration (19). Similarly, an inpatient protocol for patients admitted with UC comprising order sets for gastroenterology consultation, daily gastroenterology progress notes, and standard recommended diagnostic tests and treatments, in addition to an opiate analgesic education and awareness campaign effectively increased the composite outcome of adherence to C difficile testing, thromboprophylaxis initiation, and opiates avoidance (20). Our study is in keeping with these previous findings and demonstrates improved adherence to six individual quality markers with respect to diagnostic tests and management in the hospital setting.
Whether the use of templates and data sets can lead to improved clinical outcomes remains understudied. One quality improvement strategy demonstrated that increased C difficile testing in patients with IBD was associated with shorter hospital stays and fewer admissions (21). In addition, the use of structured algorithms in the management of patients with IBD reduced ED visits (22). While it can be inferred that increased adherence to best practices guidelines is likely to improve clinical outcomes, future studies will need to be conducted to assess the effects of standardized order sets on clinical outcomes in IBD including hospitalization duration, venous thromboembolic disease, and surgical complications. We did not observe significant differences in appropriate infliximab use after a course of ineffective appropriate therapy. Indeed, accurate use of infliximab was only used in 33.3% of scenarios in both cohorts, likely driven by delayed initiation. This suggests that there may be systemic issues beyond ordering that need to be addressed.
There are several strengths to our study. We report improvement in 6 out of 11 individual quality indicators with an easy-to-use order set that was mostly used by emergency and primary care physicians. This improvement is observed with only 64.8% of post-intervention admissions using the standardized order set. Our study was limited by the proportion of adherence to the intervention, likely due to the new introduction of such order sets and admitting teams not being accustomed to identifying and completing them. Given incomplete adherence to the order set, causality of intervention and improved adherence could not be robustly ascertained. We hypothesize that some of the reasons for not using the order set may have included lack of awareness of the order set, challenge in changing practice, and difficulty accessing the order set (23). Further study would be required to explore why the order set was not used for some cases at our institution, in order to improve its implementation into clinical practice. Moreover, despite our best efforts to alert and inform admitting physician, there was no reminder system or trigger to prompt them to use the order set. Thus, adherence score may be improved with additional interventions including physician education and increased familiarity with the order set. While we cast a broad net by screening participants using all diagnoses of emergency department presentation that may have applied, including ‘colitis’, ‘ulcerative colitis’, ‘Acute abdomen’, or ‘peritonitis’, patients who did not carry one of the pre-defined principal diagnoses may have been misclassified as not having a severe UC flare. However, misclassification of cases with severe UC flare were unlikely to have differentially affected the pre- and post-intervention cohorts, and as such this possibility is unlikely to have affected the internal validity of our study. The pre- and post-intervention analysis inherently may not account for changes in clinical practice independent of our intervention or for any possible Hawthorne effect. Furthermore, as the pre- and post-intervention cohorts were not randomized due to the study design, there were slight differences in baseline characteristics, possibly due to low sample size. There were 2.7 ± 4.5 admissions per patient in the past year in the pre-intervention cohort compared to 0.2 ± 0.5 admissions in the post-intervention cohort. Each hospitalization was considered independently to best evaluate the adherence of clinicians for each admission however some quality indicator orders may not be pertinent for recent repeat admissions, thereby lowering the reported adherence to the individual quality indicator. Indeed, while disease severity was not formally assessed, the higher CRP at presentation and greater number of patients with >6 stools per day suggest a possibly more severe group in the post-intervention cohort. Our study was limited to 1 year of use of the order set. Further studies would be warranted to evaluate whether improvement was sustained, and to evaluate long term outcomes following use of the order set. Given the single-center study design, additional studies would be required at other centers to assess generalizability of our findings. Finally, it is important to consider that treating the Toronto Consensus Statements as quality indicators ignores the intricacies of the Grade approach to creating guidelines and is considered a limitation of the study. However, all 11 statements examined were based on graded levels of evidence that yielded a strong recommendation by the experts and should therefore be considered as valuable proxies for quality indicators (1).
Conclusions
Implementation of a standardized order set, focused on specific pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements. Further studies are warranted addressing similar admission order sets that target the management of patients admitted for other gastrointestinal conditions.
Supplementary Material
Contributor Information
Steven Li Fraine, Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada; Division of Gastroenterology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
Isabelle Malhamé, Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada.
Teresa Cafaro, Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
Camille Simard, Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
Elizabeth MacNamara, Department of Medical Biochemistry, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
Myriam Martel, Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada.
Alan Barkun, Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada.
Jonathan M Wyse, Division of Gastroenterology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
FUNDING
Research bursary to Isabelle Malhamé from the McGill University General Internal Medicine Program’s Scholarly Activity Enrichment Fund
CONFLICT OF INTEREST
None declared.
DATA AVAILABILITY
The data underlying this article will be shared on request to the corresponding author.
REFERENCES
- 1. Bitton A, Buie D, Enns R, et al. ; Canadian Association of Gastroenterology Severe Ulcerative Colitis Consensus Group. Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements. Am J Gastroenterol. 2012;107(2):179–94; author reply 195. [DOI] [PubMed] [Google Scholar]
- 2. Kappelman MD, Palmer L, Boyle BM, Rubin DT.. Quality of care in inflammatory bowel disease: A review and discussion. Inflamm Bowel Dis 2010;16(1):125–33. [DOI] [PubMed] [Google Scholar]
- 3. Nguyen GC, Murthy SK, Bressler B, et al. ; CINERGI group. Quality of care and outcomes among hospitalized inflammatory bowel disease patients: A multicenter retrospective study. Inflamm Bowel Dis 2017;23(5):695–701. [DOI] [PubMed] [Google Scholar]
- 4. Jackson BD, Con D, Liew D, De Cruz P.. Clinicians’ adherence to international guidelines in the clinical care of adults with inflammatory bowel disease. Scand J Gastroenterol 2017;52(5):536–42. [DOI] [PubMed] [Google Scholar]
- 5. Law CC, Sasidharan S, Rodrigues R, et al. Impact of specialized inpatient IBD care on outcomes of IBD hospitalizations: A cohort study. Inflamm Bowel Dis 2016;22(9):2149–57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Barkun AN, Bhat M, Armstrong D, et al. Effectiveness of disseminating consensus management recommendations for ulcer bleeding: A cluster randomized trial. Can Med Assoc J 2013;185(3):E156–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: A systematic review and meta-analysis. Syst Rev 2014;3:56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Jones SS, Rudin RS, Perry T, Shekelle PG.. Health information technology: An updated systematic review with a focus on meaningful use. Ann Intern Med 2014;160(1):48–54. [DOI] [PubMed] [Google Scholar]
- 9. Hut-Mossel L, Welker G, Ahaus K, Gans R.. Understanding how and why audits work: Protocol for a realist review of audit programmes to improve hospital care. BMJ Open 2017;7(6):e015121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Gatewood MO, Wemple M, Greco S, Kritek PA, Durvasula R.. A quality improvement project to improve early sepsis care in the emergency department. BMJ Qual Saf 2015;24(12):787–95. [DOI] [PubMed] [Google Scholar]
- 11. Seoane L, Winterbottom F, Nash T, et al. Using quality improvement principles to improve the care of patients with severe sepsis and septic shock. Ochsner J 2013;13(3):359–66. [PMC free article] [PubMed] [Google Scholar]
- 12. Unger B, Afilalo M, Boivin JF, et al. Development of the Canadian Emergency Department Diagnosis Shortlist. CJEM 2010;12(4):311–9. [DOI] [PubMed] [Google Scholar]
- 13. Truelove SC, Witts LJ.. Cortisone in ulcerative colitis; preliminary report on a therapeutic trial. Br Med J 1954;2(4884):375–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Pleet JL, Vaughn BP, Morris JA, Moss AC, Cheifetz AS.. The use of pharmacological prophylaxis against venous thromboembolism in hospitalised patients with severe active ulcerative colitis. Aliment Pharmacol Ther 2014;39(9):940–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Ra G, Thanabalan R, Ratneswaran S, Nguyen GC.. Predictors and safety of venous thromboembolism prophylaxis among hospitalized inflammatory bowel disease patients. J Crohns Colitis 2013;7(10):e479–85. [DOI] [PubMed] [Google Scholar]
- 16. Valluru N, Kang L, Gaidos JKJ.. Health maintenance documentation improves for veterans with IBD using a template in the computerized patient record system. Dig Dis Sci 2018;63(7):1782–6. [DOI] [PubMed] [Google Scholar]
- 17. Bensinger A, Wilson F, Green P, Bloomfeld R, Dharod A.. Sustained improvement in inflammatory bowel disease quality measures using an electronic health record intervention. Appl Clin Inform 2019;10(5):918–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Feuerstein JD, Papamichael K, Popejoy S, et al. Targeted physician education and standardizing documentation improves documented reporting with inflammatory bowel disease quality measures in a large academic and private practice. Dig Dis Sci 2018;63(1):36–45. [DOI] [PubMed] [Google Scholar]
- 19. Snyder C, Berk W, Genes N, Shah BJ, Dubinsky MC.. Standardizing the care of acute severe ulcerative colitis inpatients at an inflammatory bowel disease referral hospital. Gastroenterology 2019;157(1):e32. [Google Scholar]
- 20. Lewin SM, McConnell RA, Patel R, Sharpton SR, Velayos F, Mahadevan U.. Improving the quality of inpatient ulcerative colitis management: Promoting evidence-based practice and reducing care variation with an inpatient protocol. Inflamm Bowel Dis 2019;25(11):1822–7. [DOI] [PubMed] [Google Scholar]
- 21. Axelrad JE, Shah BJ.. Clostridium difficile infection in inflammatory bowel disease: A nursing-based quality improvement strategy. J Healthc Qual 2016;38(5):283–9. [DOI] [PubMed] [Google Scholar]
- 22. Lytvyak E, Sutton RT, Dieleman LA, et al. Management of inflammatory bowel disease patients with clinical care pathways reduces emergency department utilization. Crohn’s & Colitis 360 2020;2(4):1–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Bobb AM, Payne TH, Gross PA.. Viewpoint: controversies surrounding use of order sets for clinical decision support in computerized provider order entry. J Am Med Inform Assoc 2007;14(1):41–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article will be shared on request to the corresponding author.