For many years physicians have created and used various standardized order forms for patient hospital admissions. The increasing popularity of electronic medical records and forms has led to the use of computerized physician order entry (CPOE) as a means of reducing medication errors.13 Crowley et al.,4 Stucky,5 and Garg et al.,6 along with various committees, have recommended standardized order sets and CPOE as a strategy for reducing medication errors. However, implementation of CPOE systems is expensive and not available in most hospitals. According to a recent survey of hospitals in the US, CPOE was only available to physicians at 16% of the participating institutions.7 Until CPOE becomes widespread, standardized preprinted formatted order sets may serve as an inexpensive alternative.

There is anecdotal evidence that standardized admission order forms may improve quality of care and efficiency, and decrease provider variation.8 However, few rigorous studies exist in the pediatric research literature regarding their ability to actually improve patient care.

In 2005, our institution, a large tertiary‐care academic teaching hospital, developed a standardized preprinted pediatric admission order set (PAOS). We did so for 3 reasons. First, there was a desire to improve completeness of orders. Handwritten orders often missed important elements such as weight, allergies, vital sign parameters, activity, etc. Second, there was a need to save time and improve efficiency. Third, it was important to reduce medical errors and the number of clarification requests by decreasing the necessity to decipher physician handwriting. Our PAOS was a convenience order set as opposed to a best practices order set. In other words, our PAOS did not contain evidence‐based management guidelines or protocols for specific admission diagnoses and was created solely to improve the quality and efficiency of workflow.

Documenting improvement in patient outcomes or reduction of medical errors is ultimately needed to establish the effectiveness of a standardized order set. Secondary outcomes, howeverparticularly the perceptions of the staff who are asked to use the order setare equally important, because they may identify real‐life barriers to use that, regardless of effectiveness, could limit dissemination and uptake. With respect to perceptions, 2 groups become paramount: those who write the orders, and those who respond to them. The purpose of the current study was to examine perceived effects of the new PAOS on inpatient care among those who, in our institution, write the ordersresident physicians.

MATERIALS AND METHODS

The PAOS was created in August 2005 at the University of California, Los Angeles (UCLA) Medical Center by a committee comprising pediatric hospitalists, nurses, pharmacists, residents, and clerks. The PAOS consisted mainly of check boxes (Figure 1). The PAOS was uploaded to the hospital website and made available for printing from all computers in the hospital, emergency room, and clinics.

Figure 1

The UCLA Hospital and Medical Center is a nonprofit, 667‐bed tertiary‐care teaching hospital in Los Angeles, California. The pediatric ward has 70 licensed beds with approximately 3,000 admissions per year. The majority of the admissions were done by the pediatric residents. Physicians were free to edit the PAOS to suit a particular patient's needs or to hand‐write orders on a blank order form.

Measures

Fourteen months after the institution of the PAOS, all 97 UCLA pediatric residents (PL‐1, n = 34; PL‐2, n = 33; PL‐3, n = 30) were asked to complete a survey to anonymously evaluate the order set. All residents were US medical school graduates. Resident participation in the research project was voluntary and confidential, and residents were assured that participation would not affect their standing in the pediatric residency program. Each resident completed only 1 survey. Responses were collected October 2006 to June 2007. The residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5‐point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement (Figure 2).

Figure 2

This study was reviewed and approved by the institutional review board at the UCLA Medical Center.

RESULTS

From October 2006 to June 2007, 59 residents (from a total of 97 residents; 61%) responded to the survey. Overall, 89% of respondents approved of the PAOS, 58% reported using it 90% of the time, and all said that they would recommend it to their colleagues (Table 1). Eighty‐four percent thought that the PAOS improved inpatient care, and 75% thought that medical errors were reduced. Eighty‐eight percent reported that the POAS saved time; 93% said it was convenient; and most reported less need for clarification with clerks (81%) and nurses (82%).

In bivariate analyses, each of the 9 dimensions was strongly associated with the overall rating (P < 0.001 for each). In multivariate analyses, however, only perceived improvement in patient care was independently associated with overall rating (OR, 3.9; P = 0.04).

We then examined whether perceived improvement in patient care itself was independently predicted by the other 8 dimensions. Residents who said that the form was comprehensive (OR, 5.6; P = 0.01), reduced medical errors (OR, 4.1; P = 0.01), or required less need for clarification with nurses (OR, 9.6; P = 0.01) were more likely to perceive that the form improved patient care than residents who did not.

DISCUSSION

A standardized admission order set is a simple, low‐cost intervention that may benefit patients by reducing medical errors and expediting high‐quality care. In general, residents rated the PAOS favorably. Just as importantly, the PAOS scored well across all specific dimensions, which suggests few perceived barriers to use among residents.

Some dimensions, however, appeared potentially more important than others. Residents who perceived an improvement in patient care tended to rate the PAOS favorably. Perceived improvement in patient care, in turn, was linked to the order set's comprehensiveness, perceived reductions in medical errors, and less need for clarification with nurses.

Even though this study did not directly query those most responsible for responding to the order set (ie, nurses, pharmacists, and clerks), the order set was created through a collaborative partnership of physicians, nurses, pharmacists, and clerks. It is reasonable to infer that resident‐perceived reduction in the need for clarification of orders with nurses and clerks might indicate a broad‐based, multidisciplinary improvement in clarity and workflow. Moreover, the fact that less need for clarification with nurses was strongly associated with resident‐perceived improvement in patient care underscores the importance of including nurses, pharmacists, and clerks in the development of these order sets.

Our experience using the standard admission orders over the past 2 years is congruent with other authors' findings. Most studies, however, have examined standardized order forms only in adult populations, and mainly for specific medical conditions. Micek et al.9 demonstrated that use of a standardized physician order set among adults with septic shock lowered 28‐day mortality and reduced hospital stay. Among stroke patients, rates of optimal treatment significantly improved after the introduction of standardized stroke orders.10 For patients with acute myocardial infarction, standardized admission orders increased early administration of aspirin and beta blockers.11, 12 With respect to cancer, implementation of a preprinted chemotherapy prescription form improved order completeness, prevented medication errors, and reduced time spent by pharmacists clarifying orders.13 Finally, standardized trauma admission orders developed in a surgical‐trauma intensive care unit reduced admission laboratory charges and improved order completeness.14 We found only a single pediatric study examining standardized order forms. Kozer et al.15 found that the use of a preprinted structured medication order form cut medication errors nearly in half in a pediatric emergency department.

Whether our results would have been similar had we implemented a series of best practices order sets rather than a single convenience order set is unclear. Although best practices order sets would have facilitated application of evidence‐based guidelines for common diagnoses, they would also have introduced potentially unwelcome logistical heterogeneity (with a separate form and protocol needed for each diagnosis) that might have reduced acceptability and uptake. In addition, there is a risk that best practices order sets would have been perceived as unduly limiting physician professional autonomy.

Our study has limitations. First, our study was performed within a single institution and may not be easily generalized. However, we believe that the basic format of the PAOS lends it to easy adaptability. Second, we did not survey residents before the order set was introduced to assess baseline perceptions. Instead, many of the questions in the survey ask about perceived improvements compared with the previous system. Conducting a formal pre‐post data collection and analysis might have yielded different results. Third, improvement in patient care was measured indirectly based on resident opinion.

In conclusion, our study suggests that our standardized admission order set prompting physicians to initiate comprehensive care is well‐liked by residents and is thought to benefit patients by reducing medical errors and expediting high‐quality care. The next step is to confirm that the resident‐perceived improvement in patient care correlates with actual improvement in patient care. If improvements can be confirmed, then PAOS adoption could be broadly recommended to pediatric hospitals. In the future, the PAOS may also help guide computerized physician order entry templates that can be further tailored to specific common diagnoses.

For many years physicians have created and used various standardized order forms for patient hospital admissions. The increasing popularity of electronic medical records and forms has led to the use of computerized physician order entry (CPOE) as a means of reducing medication errors.13 Crowley et al.,4 Stucky,5 and Garg et al.,6 along with various committees, have recommended standardized order sets and CPOE as a strategy for reducing medication errors. However, implementation of CPOE systems is expensive and not available in most hospitals. According to a recent survey of hospitals in the US, CPOE was only available to physicians at 16% of the participating institutions.7 Until CPOE becomes widespread, standardized preprinted formatted order sets may serve as an inexpensive alternative.

There is anecdotal evidence that standardized admission order forms may improve quality of care and efficiency, and decrease provider variation.8 However, few rigorous studies exist in the pediatric research literature regarding their ability to actually improve patient care.

In 2005, our institution, a large tertiary‐care academic teaching hospital, developed a standardized preprinted pediatric admission order set (PAOS). We did so for 3 reasons. First, there was a desire to improve completeness of orders. Handwritten orders often missed important elements such as weight, allergies, vital sign parameters, activity, etc. Second, there was a need to save time and improve efficiency. Third, it was important to reduce medical errors and the number of clarification requests by decreasing the necessity to decipher physician handwriting. Our PAOS was a convenience order set as opposed to a best practices order set. In other words, our PAOS did not contain evidence‐based management guidelines or protocols for specific admission diagnoses and was created solely to improve the quality and efficiency of workflow.

Documenting improvement in patient outcomes or reduction of medical errors is ultimately needed to establish the effectiveness of a standardized order set. Secondary outcomes, howeverparticularly the perceptions of the staff who are asked to use the order setare equally important, because they may identify real‐life barriers to use that, regardless of effectiveness, could limit dissemination and uptake. With respect to perceptions, 2 groups become paramount: those who write the orders, and those who respond to them. The purpose of the current study was to examine perceived effects of the new PAOS on inpatient care among those who, in our institution, write the ordersresident physicians.

MATERIALS AND METHODS

The PAOS was created in August 2005 at the University of California, Los Angeles (UCLA) Medical Center by a committee comprising pediatric hospitalists, nurses, pharmacists, residents, and clerks. The PAOS consisted mainly of check boxes (Figure 1). The PAOS was uploaded to the hospital website and made available for printing from all computers in the hospital, emergency room, and clinics.

Figure 1

The UCLA Hospital and Medical Center is a nonprofit, 667‐bed tertiary‐care teaching hospital in Los Angeles, California. The pediatric ward has 70 licensed beds with approximately 3,000 admissions per year. The majority of the admissions were done by the pediatric residents. Physicians were free to edit the PAOS to suit a particular patient's needs or to hand‐write orders on a blank order form.

Measures

Fourteen months after the institution of the PAOS, all 97 UCLA pediatric residents (PL‐1, n = 34; PL‐2, n = 33; PL‐3, n = 30) were asked to complete a survey to anonymously evaluate the order set. All residents were US medical school graduates. Resident participation in the research project was voluntary and confidential, and residents were assured that participation would not affect their standing in the pediatric residency program. Each resident completed only 1 survey. Responses were collected October 2006 to June 2007. The residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5‐point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement (Figure 2).

Figure 2

This study was reviewed and approved by the institutional review board at the UCLA Medical Center.

RESULTS

From October 2006 to June 2007, 59 residents (from a total of 97 residents; 61%) responded to the survey. Overall, 89% of respondents approved of the PAOS, 58% reported using it 90% of the time, and all said that they would recommend it to their colleagues (Table 1). Eighty‐four percent thought that the PAOS improved inpatient care, and 75% thought that medical errors were reduced. Eighty‐eight percent reported that the POAS saved time; 93% said it was convenient; and most reported less need for clarification with clerks (81%) and nurses (82%).

In bivariate analyses, each of the 9 dimensions was strongly associated with the overall rating (P < 0.001 for each). In multivariate analyses, however, only perceived improvement in patient care was independently associated with overall rating (OR, 3.9; P = 0.04).

We then examined whether perceived improvement in patient care itself was independently predicted by the other 8 dimensions. Residents who said that the form was comprehensive (OR, 5.6; P = 0.01), reduced medical errors (OR, 4.1; P = 0.01), or required less need for clarification with nurses (OR, 9.6; P = 0.01) were more likely to perceive that the form improved patient care than residents who did not.

DISCUSSION

A standardized admission order set is a simple, low‐cost intervention that may benefit patients by reducing medical errors and expediting high‐quality care. In general, residents rated the PAOS favorably. Just as importantly, the PAOS scored well across all specific dimensions, which suggests few perceived barriers to use among residents.

Some dimensions, however, appeared potentially more important than others. Residents who perceived an improvement in patient care tended to rate the PAOS favorably. Perceived improvement in patient care, in turn, was linked to the order set's comprehensiveness, perceived reductions in medical errors, and less need for clarification with nurses.

Even though this study did not directly query those most responsible for responding to the order set (ie, nurses, pharmacists, and clerks), the order set was created through a collaborative partnership of physicians, nurses, pharmacists, and clerks. It is reasonable to infer that resident‐perceived reduction in the need for clarification of orders with nurses and clerks might indicate a broad‐based, multidisciplinary improvement in clarity and workflow. Moreover, the fact that less need for clarification with nurses was strongly associated with resident‐perceived improvement in patient care underscores the importance of including nurses, pharmacists, and clerks in the development of these order sets.

Our experience using the standard admission orders over the past 2 years is congruent with other authors' findings. Most studies, however, have examined standardized order forms only in adult populations, and mainly for specific medical conditions. Micek et al.9 demonstrated that use of a standardized physician order set among adults with septic shock lowered 28‐day mortality and reduced hospital stay. Among stroke patients, rates of optimal treatment significantly improved after the introduction of standardized stroke orders.10 For patients with acute myocardial infarction, standardized admission orders increased early administration of aspirin and beta blockers.11, 12 With respect to cancer, implementation of a preprinted chemotherapy prescription form improved order completeness, prevented medication errors, and reduced time spent by pharmacists clarifying orders.13 Finally, standardized trauma admission orders developed in a surgical‐trauma intensive care unit reduced admission laboratory charges and improved order completeness.14 We found only a single pediatric study examining standardized order forms. Kozer et al.15 found that the use of a preprinted structured medication order form cut medication errors nearly in half in a pediatric emergency department.

Whether our results would have been similar had we implemented a series of best practices order sets rather than a single convenience order set is unclear. Although best practices order sets would have facilitated application of evidence‐based guidelines for common diagnoses, they would also have introduced potentially unwelcome logistical heterogeneity (with a separate form and protocol needed for each diagnosis) that might have reduced acceptability and uptake. In addition, there is a risk that best practices order sets would have been perceived as unduly limiting physician professional autonomy.

Our study has limitations. First, our study was performed within a single institution and may not be easily generalized. However, we believe that the basic format of the PAOS lends it to easy adaptability. Second, we did not survey residents before the order set was introduced to assess baseline perceptions. Instead, many of the questions in the survey ask about perceived improvements compared with the previous system. Conducting a formal pre‐post data collection and analysis might have yielded different results. Third, improvement in patient care was measured indirectly based on resident opinion.

In conclusion, our study suggests that our standardized admission order set prompting physicians to initiate comprehensive care is well‐liked by residents and is thought to benefit patients by reducing medical errors and expediting high‐quality care. The next step is to confirm that the resident‐perceived improvement in patient care correlates with actual improvement in patient care. If improvements can be confirmed, then PAOS adoption could be broadly recommended to pediatric hospitals. In the future, the PAOS may also help guide computerized physician order entry templates that can be further tailored to specific common diagnoses.

For many years physicians have created and used various standardized order forms for patient hospital admissions. The increasing popularity of electronic medical records and forms has led to the use of computerized physician order entry (CPOE) as a means of reducing medication errors.13 Crowley et al.,4 Stucky,5 and Garg et al.,6 along with various committees, have recommended standardized order sets and CPOE as a strategy for reducing medication errors. However, implementation of CPOE systems is expensive and not available in most hospitals. According to a recent survey of hospitals in the US, CPOE was only available to physicians at 16% of the participating institutions.7 Until CPOE becomes widespread, standardized preprinted formatted order sets may serve as an inexpensive alternative.

There is anecdotal evidence that standardized admission order forms may improve quality of care and efficiency, and decrease provider variation.8 However, few rigorous studies exist in the pediatric research literature regarding their ability to actually improve patient care.

In 2005, our institution, a large tertiary‐care academic teaching hospital, developed a standardized preprinted pediatric admission order set (PAOS). We did so for 3 reasons. First, there was a desire to improve completeness of orders. Handwritten orders often missed important elements such as weight, allergies, vital sign parameters, activity, etc. Second, there was a need to save time and improve efficiency. Third, it was important to reduce medical errors and the number of clarification requests by decreasing the necessity to decipher physician handwriting. Our PAOS was a convenience order set as opposed to a best practices order set. In other words, our PAOS did not contain evidence‐based management guidelines or protocols for specific admission diagnoses and was created solely to improve the quality and efficiency of workflow.

Documenting improvement in patient outcomes or reduction of medical errors is ultimately needed to establish the effectiveness of a standardized order set. Secondary outcomes, howeverparticularly the perceptions of the staff who are asked to use the order setare equally important, because they may identify real‐life barriers to use that, regardless of effectiveness, could limit dissemination and uptake. With respect to perceptions, 2 groups become paramount: those who write the orders, and those who respond to them. The purpose of the current study was to examine perceived effects of the new PAOS on inpatient care among those who, in our institution, write the ordersresident physicians.

MATERIALS AND METHODS

The PAOS was created in August 2005 at the University of California, Los Angeles (UCLA) Medical Center by a committee comprising pediatric hospitalists, nurses, pharmacists, residents, and clerks. The PAOS consisted mainly of check boxes (Figure 1). The PAOS was uploaded to the hospital website and made available for printing from all computers in the hospital, emergency room, and clinics.

Figure 1

The UCLA Hospital and Medical Center is a nonprofit, 667‐bed tertiary‐care teaching hospital in Los Angeles, California. The pediatric ward has 70 licensed beds with approximately 3,000 admissions per year. The majority of the admissions were done by the pediatric residents. Physicians were free to edit the PAOS to suit a particular patient's needs or to hand‐write orders on a blank order form.

Measures

Fourteen months after the institution of the PAOS, all 97 UCLA pediatric residents (PL‐1, n = 34; PL‐2, n = 33; PL‐3, n = 30) were asked to complete a survey to anonymously evaluate the order set. All residents were US medical school graduates. Resident participation in the research project was voluntary and confidential, and residents were assured that participation would not affect their standing in the pediatric residency program. Each resident completed only 1 survey. Responses were collected October 2006 to June 2007. The residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5‐point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement (Figure 2).

Figure 2

This study was reviewed and approved by the institutional review board at the UCLA Medical Center.

RESULTS

From October 2006 to June 2007, 59 residents (from a total of 97 residents; 61%) responded to the survey. Overall, 89% of respondents approved of the PAOS, 58% reported using it 90% of the time, and all said that they would recommend it to their colleagues (Table 1). Eighty‐four percent thought that the PAOS improved inpatient care, and 75% thought that medical errors were reduced. Eighty‐eight percent reported that the POAS saved time; 93% said it was convenient; and most reported less need for clarification with clerks (81%) and nurses (82%).

In bivariate analyses, each of the 9 dimensions was strongly associated with the overall rating (P < 0.001 for each). In multivariate analyses, however, only perceived improvement in patient care was independently associated with overall rating (OR, 3.9; P = 0.04).

We then examined whether perceived improvement in patient care itself was independently predicted by the other 8 dimensions. Residents who said that the form was comprehensive (OR, 5.6; P = 0.01), reduced medical errors (OR, 4.1; P = 0.01), or required less need for clarification with nurses (OR, 9.6; P = 0.01) were more likely to perceive that the form improved patient care than residents who did not.

DISCUSSION

A standardized admission order set is a simple, low‐cost intervention that may benefit patients by reducing medical errors and expediting high‐quality care. In general, residents rated the PAOS favorably. Just as importantly, the PAOS scored well across all specific dimensions, which suggests few perceived barriers to use among residents.

Some dimensions, however, appeared potentially more important than others. Residents who perceived an improvement in patient care tended to rate the PAOS favorably. Perceived improvement in patient care, in turn, was linked to the order set's comprehensiveness, perceived reductions in medical errors, and less need for clarification with nurses.

Even though this study did not directly query those most responsible for responding to the order set (ie, nurses, pharmacists, and clerks), the order set was created through a collaborative partnership of physicians, nurses, pharmacists, and clerks. It is reasonable to infer that resident‐perceived reduction in the need for clarification of orders with nurses and clerks might indicate a broad‐based, multidisciplinary improvement in clarity and workflow. Moreover, the fact that less need for clarification with nurses was strongly associated with resident‐perceived improvement in patient care underscores the importance of including nurses, pharmacists, and clerks in the development of these order sets.

Our experience using the standard admission orders over the past 2 years is congruent with other authors' findings. Most studies, however, have examined standardized order forms only in adult populations, and mainly for specific medical conditions. Micek et al.9 demonstrated that use of a standardized physician order set among adults with septic shock lowered 28‐day mortality and reduced hospital stay. Among stroke patients, rates of optimal treatment significantly improved after the introduction of standardized stroke orders.10 For patients with acute myocardial infarction, standardized admission orders increased early administration of aspirin and beta blockers.11, 12 With respect to cancer, implementation of a preprinted chemotherapy prescription form improved order completeness, prevented medication errors, and reduced time spent by pharmacists clarifying orders.13 Finally, standardized trauma admission orders developed in a surgical‐trauma intensive care unit reduced admission laboratory charges and improved order completeness.14 We found only a single pediatric study examining standardized order forms. Kozer et al.15 found that the use of a preprinted structured medication order form cut medication errors nearly in half in a pediatric emergency department.

Whether our results would have been similar had we implemented a series of best practices order sets rather than a single convenience order set is unclear. Although best practices order sets would have facilitated application of evidence‐based guidelines for common diagnoses, they would also have introduced potentially unwelcome logistical heterogeneity (with a separate form and protocol needed for each diagnosis) that might have reduced acceptability and uptake. In addition, there is a risk that best practices order sets would have been perceived as unduly limiting physician professional autonomy.

Our study has limitations. First, our study was performed within a single institution and may not be easily generalized. However, we believe that the basic format of the PAOS lends it to easy adaptability. Second, we did not survey residents before the order set was introduced to assess baseline perceptions. Instead, many of the questions in the survey ask about perceived improvements compared with the previous system. Conducting a formal pre‐post data collection and analysis might have yielded different results. Third, improvement in patient care was measured indirectly based on resident opinion.

In conclusion, our study suggests that our standardized admission order set prompting physicians to initiate comprehensive care is well‐liked by residents and is thought to benefit patients by reducing medical errors and expediting high‐quality care. The next step is to confirm that the resident‐perceived improvement in patient care correlates with actual improvement in patient care. If improvements can be confirmed, then PAOS adoption could be broadly recommended to pediatric hospitals. In the future, the PAOS may also help guide computerized physician order entry templates that can be further tailored to specific common diagnoses.

A 29‐year‐old man developed palpitations and dyspnea while loading boxes into a truck. In the emergency department, telemetry demonstrated a wide‐complex tachycardia at a rate of 204 beats per minute. The patient spontaneously cardioverted to sinus rhythm (Figure 1) before direct current cardioversion was performed.

Figure 1

Wide‐complex tachycardia is usually explained by a supraventricular tachycardia with aberrant ventricular conduction or a ventricular tachycardia. Although algorithms exist to guide the clinician in parsing out those etiologies, often the knowledge of underlying structural cardiac disease is most informative. In patients with a history of myocardial infarction, greater than 95% of wide‐complex tachycardia is ventricular tachycardia. The ventricular ectopy, T‐wave inversion or flattening, and poor R‐wave progression are suggestive of a cardiomyopathy, either acute or chronic. A pressing concern, especially with the Q waves and concave ST morphology in V1 and V2, would be coronary ischemia. His age makes this less likely, but an aberrant coronary circulation or drug use could account for it.

Over the past 2 years, the patient had several episodes of sustained palpitations, which terminated after several minutes. Previously, the patient exercised frequently including playing rugby in college. However, over the past year he experienced difficulty climbing stairs due to shortness of breath, which he attributed to deconditioning and smoking. He had no significant medical history, was not taking any medications, nor did he use recreational stimulants. He drank alcohol occasionally. He had no risk factors for the human immunodeficiency virus (HIV). Both of the patient's parents were alive and well. There was no family history of sudden cardiac death.

The duration of symptoms suggests that this is a chronic cardiomyopathy rather than acute myocarditis or acute ischemia, acknowledging that either one could be superimposed. The absence of family history lowers the likelihood of heritable causes of arrhythmia that may accompany a structurally normal (eg, long QT syndrome) or abnormal (eg, hypertrophic cardiomyopathy) heart, although penetrance can be variable. What might account for a cardiomyopathy in a young person? Most cases are probably idiopathic, but etiologies that diverge from the usual suspects of coronary artery disease, hypertension, and valvular disease, which affect an older population, include antecedent viral myocarditis, substance abuse, HIV, or infiltrative disorders such as sarcoidosis.

The patient's pulse was 92 beats per minute and regular and the blood pressure was 96/52 mm Hg. The jugular venous pressure was elevated with prominent v‐waves, the point of maximal impulse was diffuse, there were no extra heart sounds or murmurs, and an enlarged liver was detected. An echocardiogram demonstrated left ventricular dysfunction with an ejection fraction of 30%, severe enlargement of the right atrium and right ventricle, and moderate tricuspid regurgitation. Cardiac catheterization revealed normal coronary arteries without evidence of pulmonary hypertension or intracardiac shunt.

The physical examination and echocardiographic findings of right‐sided failure are unusual given the absence of pulmonary hypertension or intracardiac shunt, and could prompt repeat of the hemodynamic measurements and/or investigations for pulmonary disease that may account for right‐sided pressure overload (in addition to that caused by left ventricular failure). An alternative explanation would be a cardiomyopathic process that preferentially involves the right side of the heart, such as arrhythmogenic right ventricular dysplasia (ARVD), but that would not satisfactorily explain the significant decline in left ventricular function. An acute right ventricular infarction could cause his acute symptoms and his examination and echocardiographic findings, but not the underlying chronic illness. It is common to see patients with long‐standing biventricular failure who present with prominent signs of right‐sided failure (elevated neck veins, hepatomegaly, and edema) but limited or no signs of left‐sided failure (rales) to match their degree of volume overload or dyspnea.

Cardiac magnetic resonance imaging (MRI) revealed a dilated right ventricle with extensive hyperenhancement, a right ventricular ejection fraction of 9%, and moderate left ventricular dysfunction (Figure 2). Electrophysiology testing induced both nonsustained polymorphic and monomorphic ventricular tachycardia. Late potentials were detected on a signal‐averaged electrocardiogram. A single‐chamber cardioverter defibrillator was implanted and the patient was discharged on carvedilol, lisinopril, and spironolactone. An HIV‐1 antibody was negative and a thyroid‐stimulating hormone concentration was within normal limits.

Figure 2

Assuming that accurate evaluation of the pulmonary circulation has been undertaken to exclude pulmonary hypertension, the enlarged and hyperenhanced right ventricle on MRI suggests a process that preferentially infiltrates the right ventricular myocardium, and may secondarily affect the left ventricle either by further infiltration or as a consequence of altered mechanics from the highly dysfunctional right ventricle. ARVD affects the right ventricle, but it is possible that another infiltrative cardiomyopathy, such as sarcoid or an antecedent viral infection, could be restricted in its distribution. Late‐potentials identified on signal average electrocardiograms indicate areas of abnormal conduction that may serve as substrate for reentrant ventricular arrhythmias. They are, however, nonspecific, as they are seen in a variety of myocardial diseases.

The patient continued to have progressive dyspnea and was readmitted after receiving an appropriate implantable cardioverter defibrillator shock for ventricular tachycardia. Recurrent slow ventricular tachycardia (Figure 3) was treated with supplemental beta‐blockade and amiodarone (10 g total). Repeat echocardiography demonstrated severe left ventricular dysfunction with an ejection fraction of less than 15%. There were no recurrences of ventricular arrhythmias and the patient was discharged and referred for cardiac transplant evaluation for ARVD.

Figure 3

This degree of left ventricular dysfunction is unlikely to be accounted for by altered mechanics and interactions from a failing right ventricle alone and frames this as a biventricular cardiomyopathy, which has an extensive differential diagnosis and requires information from the general medical evaluation.

On routine laboratory testing 6 months later, a serum aspartate aminotransferase of 79 units/L and a serum alanine aminotransferase of 118 units/L were found. Bilirubin, albumin, and alkaline phosphatase were normal. The transaminase levels had been normal on initial evaluation. The patient reported that 2 paternal uncles had end‐stage nonalcoholic cirrhosis. Transjugular liver biopsy was consistent with mild lobular hepatitis with mild portal fibrosis with a few lobular collections of mononuclear cells. There was no evidence of iron overload. The hepatic venogram and transhepatic pressure gradient (2 mm Hg) were normal.

The elevated transaminase levels could be due to amiodarone‐associated hepatotoxicity, hepatic congestion, or a primary liver disease. It is important to consider combined cardiohepatic syndromes such as hemochromatosis, sarcoidosis, or amyloidosis. The relatively normal liver histology and normal hepatic hemodynamics do not suggest a significant primary intrinsic liver disease. The 2 uncles with cirrhosis could suggest a heritable liver disease, although cirrhosis in multiple family members is frequently accounted for by shared habits such as alcohol consumption or excessive caloric intake. Liver disorders with a genetic component, such as hemochromatosis, Wilson's disease, and alpha‐1‐antitrypsin deficiency are mostly autosomal recessive, which would make this pattern of transmission unusual. Furthermore, aside from hemochromatosis, these genetic hepatic disorders have few cardiac manifestations. Right‐sided congestion and amiodarone appear to be the most likely explanations of his liver abnormalities.

Pulmonary function testing revealed normal lung volumes without obstruction, but the diffusing capacity for carbon monoxide was substantially reduced. Computed tomography of the chest identified scattered ground‐glass opacities as well as small nodules with an upper lobe distribution (Figure 4). Although not reported on the initial interpretation, review of a chest x‐ray taken 6 months previously also demonstrated small nodules in the upper lobe distribution. Bronchoscopic examination was normal. Bronchioalveolar lavage fluid stains and cultures for bacteria, mycobacteria, Pneumocystis, and fungus were negative. Transbronchial biopsies of the right middle lobe had no evidence of infection, malignancy, or granulomatous inflammation. The patient continued to have progressive New York Heart Association Class IV heart failure symptoms. Repeat right heart catheterization was notable for a cardiac index of 1.4 L/minute/m². The mean pulmonary artery pressure was 20 mm Hg. An intraaortic balloon pump was placed for refractory cardiogenic shock.

Figure 4

The reduced diffusion capacity and ground‐glass opacities suggest an interstitial process, which may have been missed on transbronchial biopsy because of sampling error. His pulmonary disease is likely another manifestation of his infiltrative cardiac disease. The constellation of cardiac, pulmonary, and hepatic involvement in the context of progressive dyspnea over 2 years is suggestive of sarcoidosis although the absence of hilar lymphadenopathy and 2 biopsy specimens without granulomas argue against the diagnosis, and the effects of amiodarone on the latter 2 organs cannot be ignored. On the limited menu of pharmacologic treatments that may treat this severe and progressive cardiomyopathy are steroids, which makes a diligent search for a steroid‐responsive syndrome important. Therefore, despite the negative studies, sarcoidosis must be investigated to the fullest extent with either an endomyocardial biopsy or surgical lung biopsy.

The patient underwent cardiac transplantation. The native heart was found to have right ventricular thinning, which was most notable at the right ventricular outflow tract. Microscopic examination revealed extensive fibrosis and granulomatous inflammation (Figure 5) with scarring typical of cardiac sarcoidosis. Six months after cardiac transplantation, the patient is doing well on prednisone, tacrolimus, and mycophenolate mofetil. Follow‐up chest x‐rays show resolution of the pulmonary nodules.

Figure 5

COMMENTARY

Cardiomyopathy in a young person is a relatively uncommon clinical event that prompts consideration of a broad differential diagnosis that is notably different from the most common etiologies of cardiomyopathy in older adults. This case highlights the challenges of arriving at a diagnosis in the absence of a gold standard, and the greater challenges of modifying initial diagnostic impressions as new clinical data become available.

After encountering ventricular tachycardia and right ventricular dysfunction in a young patient, the clinicians arrived at the diagnosis of ARVD. This rare and progressive disorder is associated with up to 20% of ventricular arrhythmias and sudden death in the young,1, 2 but can be challenging to diagnose. Despite common referrals for cardiac MRI to exclude ARVD, cardiac MRI is not the gold standard for diagnosis and is the most common method of misdiagnosis of ARVD.3 A diagnosis of ARVD requires the presence of 2 major, 1 major and 2 minor, or 4 minor International Task Force criteria (Table 1).4, 5 While the diagnostic criteria provide standardization across populations (eg, in clinical studies), additional considerations are needed in the management of individual patients. Scoring systems serve as a tool, but the final diagnosis requires balancing such criteria with competing hypotheses. This dilemma is familiar to clinicians considering other less common conditions such as amyotrophic lateral sclerosis (World Neurology Foundation), rheumatic fever (Jones criteria), or systemic lupus erythematosus (American College of Rheumatology). This patient's cardiac MRI findings, precordial T‐wave inversions, frequent ventricular ectopy, and late potentials on a signal‐averaged electrocardiogram fulfilled the International Task Force criteria for a diagnosis of ARVD. Discordant information included the right bundle branch pattern of the ventricular tachycardia, which suggested left ventricular origin, as opposed to the more common left bundle branch pattern observed in ARVD, and the absence of a family history. In addition, in U.S. populations only 25% of cases present with heart failure and fewer than 5% develop biventricular failure.6 Nonetheless, this patient's imaging evidence of right ventricular structural abnormalities and dysfunction and electrocardiographic abnormalities coupled with the absence of obvious systemic disease made ARVD the logical working diagnosis.

When more widespread manifestations developed, namely hepatic and pulmonary abnormalities, each was investigated with imaging and biopsy. Once a multisystem illness became apparent, the discussant reframed the patient's illness to include other diagnostic possibilities. In practice it is difficult to reverse a working diagnosis despite contradictory evidence because of the common pitfall of anchoring bias. Tversky and Kahneman7 were the first to describe the cognitive processes behind probability assessment and decision making in time‐sensitive situations. Under these conditions, decision makers tend to focus on the first symptom, striking feature, or diagnosis and anchor subsequent probabilities to that initial presentation. Once a decision or diagnosis has been reached, clinicians tend to interpret subsequent findings in the context of the original diagnosis rather than reevaluating their initial impression. In the setting of a known diagnosis of ARVD, 3 separate diagnoses (ARVD, amiodarone‐associated lung injury, and amiodarone‐induced hepatic dysfunction) were considered by the treating physicians. The initial diagnosis of ARVD followed by the sequential rather than simultaneous manifestations of sarcoidosis made arriving at the revised diagnosis even more challenging.

Cardiac sarcoidosis is a mimic of ARVD and should be considered when evaluating a patient for right ventricular dysplasia.8, 9 The differential diagnosis of ARVD includes idiopathic ventricular tachycardia, myocarditis, idiopathic cardiomyopathy, and sarcoidosis. Cardiac sarcoidosis can present as ventricular ectopy, sustained ventricular arrhythmias, asymptomatic ventricular dysfunction, heart failure, or sudden death.10 Although 25% of patients with sarcoidosis have evidence of cardiac involvement at autopsy, only 5% have clinical manifestations.11 Those patients with clinical evidence of cardiac sarcoidosis have a wide range of clinical findings (Table 2). While the patient's cardiomyopathy was advanced, it is possible that earlier administration of corticosteroid therapy may have arrested his progressive biventricular failure. As clinicians, we should always remember to force ourselves to broaden our differential diagnosis when new findings become available, especially those that point to a systemicrather than an organ‐specificdisorder. In this case, while the original diagnostic findings were accurate and strongly suggested ARVD, a change of heart was needed to arrive at the ultimate diagnosis.

KEY POINTS FOR HOSPITALISTS

• 1

  Cardiomyopathy in a young person requires consideration of a broad differential diagnosis that is notably different from the most common etiologies of cardiomyopathy in the elderly.

• 2

  Anchoring bias is a common pitfall in clinical decision making. When new or contradictory findings are uncovered, clinicians should reevaluate their initial impression to ensure it remains the most likely diagnosis.

• 3

  Cardiac sarcoidosis is a mimic of ARVD and should be considered when evaluating a patient for right ventricular cardiomyopathy. The differential diagnosis of ARVD includes idiopathic ventricular tachycardia, right ventricular outflow tract tachycardia, myocarditis, idiopathic dilated cardiomyopathy, and sarcoidosis.

A 29‐year‐old man developed palpitations and dyspnea while loading boxes into a truck. In the emergency department, telemetry demonstrated a wide‐complex tachycardia at a rate of 204 beats per minute. The patient spontaneously cardioverted to sinus rhythm (Figure 1) before direct current cardioversion was performed.

Figure 1

Wide‐complex tachycardia is usually explained by a supraventricular tachycardia with aberrant ventricular conduction or a ventricular tachycardia. Although algorithms exist to guide the clinician in parsing out those etiologies, often the knowledge of underlying structural cardiac disease is most informative. In patients with a history of myocardial infarction, greater than 95% of wide‐complex tachycardia is ventricular tachycardia. The ventricular ectopy, T‐wave inversion or flattening, and poor R‐wave progression are suggestive of a cardiomyopathy, either acute or chronic. A pressing concern, especially with the Q waves and concave ST morphology in V1 and V2, would be coronary ischemia. His age makes this less likely, but an aberrant coronary circulation or drug use could account for it.

Over the past 2 years, the patient had several episodes of sustained palpitations, which terminated after several minutes. Previously, the patient exercised frequently including playing rugby in college. However, over the past year he experienced difficulty climbing stairs due to shortness of breath, which he attributed to deconditioning and smoking. He had no significant medical history, was not taking any medications, nor did he use recreational stimulants. He drank alcohol occasionally. He had no risk factors for the human immunodeficiency virus (HIV). Both of the patient's parents were alive and well. There was no family history of sudden cardiac death.

The duration of symptoms suggests that this is a chronic cardiomyopathy rather than acute myocarditis or acute ischemia, acknowledging that either one could be superimposed. The absence of family history lowers the likelihood of heritable causes of arrhythmia that may accompany a structurally normal (eg, long QT syndrome) or abnormal (eg, hypertrophic cardiomyopathy) heart, although penetrance can be variable. What might account for a cardiomyopathy in a young person? Most cases are probably idiopathic, but etiologies that diverge from the usual suspects of coronary artery disease, hypertension, and valvular disease, which affect an older population, include antecedent viral myocarditis, substance abuse, HIV, or infiltrative disorders such as sarcoidosis.

The patient's pulse was 92 beats per minute and regular and the blood pressure was 96/52 mm Hg. The jugular venous pressure was elevated with prominent v‐waves, the point of maximal impulse was diffuse, there were no extra heart sounds or murmurs, and an enlarged liver was detected. An echocardiogram demonstrated left ventricular dysfunction with an ejection fraction of 30%, severe enlargement of the right atrium and right ventricle, and moderate tricuspid regurgitation. Cardiac catheterization revealed normal coronary arteries without evidence of pulmonary hypertension or intracardiac shunt.

The physical examination and echocardiographic findings of right‐sided failure are unusual given the absence of pulmonary hypertension or intracardiac shunt, and could prompt repeat of the hemodynamic measurements and/or investigations for pulmonary disease that may account for right‐sided pressure overload (in addition to that caused by left ventricular failure). An alternative explanation would be a cardiomyopathic process that preferentially involves the right side of the heart, such as arrhythmogenic right ventricular dysplasia (ARVD), but that would not satisfactorily explain the significant decline in left ventricular function. An acute right ventricular infarction could cause his acute symptoms and his examination and echocardiographic findings, but not the underlying chronic illness. It is common to see patients with long‐standing biventricular failure who present with prominent signs of right‐sided failure (elevated neck veins, hepatomegaly, and edema) but limited or no signs of left‐sided failure (rales) to match their degree of volume overload or dyspnea.

Cardiac magnetic resonance imaging (MRI) revealed a dilated right ventricle with extensive hyperenhancement, a right ventricular ejection fraction of 9%, and moderate left ventricular dysfunction (Figure 2). Electrophysiology testing induced both nonsustained polymorphic and monomorphic ventricular tachycardia. Late potentials were detected on a signal‐averaged electrocardiogram. A single‐chamber cardioverter defibrillator was implanted and the patient was discharged on carvedilol, lisinopril, and spironolactone. An HIV‐1 antibody was negative and a thyroid‐stimulating hormone concentration was within normal limits.

Figure 2

Assuming that accurate evaluation of the pulmonary circulation has been undertaken to exclude pulmonary hypertension, the enlarged and hyperenhanced right ventricle on MRI suggests a process that preferentially infiltrates the right ventricular myocardium, and may secondarily affect the left ventricle either by further infiltration or as a consequence of altered mechanics from the highly dysfunctional right ventricle. ARVD affects the right ventricle, but it is possible that another infiltrative cardiomyopathy, such as sarcoid or an antecedent viral infection, could be restricted in its distribution. Late‐potentials identified on signal average electrocardiograms indicate areas of abnormal conduction that may serve as substrate for reentrant ventricular arrhythmias. They are, however, nonspecific, as they are seen in a variety of myocardial diseases.

The patient continued to have progressive dyspnea and was readmitted after receiving an appropriate implantable cardioverter defibrillator shock for ventricular tachycardia. Recurrent slow ventricular tachycardia (Figure 3) was treated with supplemental beta‐blockade and amiodarone (10 g total). Repeat echocardiography demonstrated severe left ventricular dysfunction with an ejection fraction of less than 15%. There were no recurrences of ventricular arrhythmias and the patient was discharged and referred for cardiac transplant evaluation for ARVD.

Figure 3

This degree of left ventricular dysfunction is unlikely to be accounted for by altered mechanics and interactions from a failing right ventricle alone and frames this as a biventricular cardiomyopathy, which has an extensive differential diagnosis and requires information from the general medical evaluation.

On routine laboratory testing 6 months later, a serum aspartate aminotransferase of 79 units/L and a serum alanine aminotransferase of 118 units/L were found. Bilirubin, albumin, and alkaline phosphatase were normal. The transaminase levels had been normal on initial evaluation. The patient reported that 2 paternal uncles had end‐stage nonalcoholic cirrhosis. Transjugular liver biopsy was consistent with mild lobular hepatitis with mild portal fibrosis with a few lobular collections of mononuclear cells. There was no evidence of iron overload. The hepatic venogram and transhepatic pressure gradient (2 mm Hg) were normal.

The elevated transaminase levels could be due to amiodarone‐associated hepatotoxicity, hepatic congestion, or a primary liver disease. It is important to consider combined cardiohepatic syndromes such as hemochromatosis, sarcoidosis, or amyloidosis. The relatively normal liver histology and normal hepatic hemodynamics do not suggest a significant primary intrinsic liver disease. The 2 uncles with cirrhosis could suggest a heritable liver disease, although cirrhosis in multiple family members is frequently accounted for by shared habits such as alcohol consumption or excessive caloric intake. Liver disorders with a genetic component, such as hemochromatosis, Wilson's disease, and alpha‐1‐antitrypsin deficiency are mostly autosomal recessive, which would make this pattern of transmission unusual. Furthermore, aside from hemochromatosis, these genetic hepatic disorders have few cardiac manifestations. Right‐sided congestion and amiodarone appear to be the most likely explanations of his liver abnormalities.

Pulmonary function testing revealed normal lung volumes without obstruction, but the diffusing capacity for carbon monoxide was substantially reduced. Computed tomography of the chest identified scattered ground‐glass opacities as well as small nodules with an upper lobe distribution (Figure 4). Although not reported on the initial interpretation, review of a chest x‐ray taken 6 months previously also demonstrated small nodules in the upper lobe distribution. Bronchoscopic examination was normal. Bronchioalveolar lavage fluid stains and cultures for bacteria, mycobacteria, Pneumocystis, and fungus were negative. Transbronchial biopsies of the right middle lobe had no evidence of infection, malignancy, or granulomatous inflammation. The patient continued to have progressive New York Heart Association Class IV heart failure symptoms. Repeat right heart catheterization was notable for a cardiac index of 1.4 L/minute/m². The mean pulmonary artery pressure was 20 mm Hg. An intraaortic balloon pump was placed for refractory cardiogenic shock.

Figure 4

The reduced diffusion capacity and ground‐glass opacities suggest an interstitial process, which may have been missed on transbronchial biopsy because of sampling error. His pulmonary disease is likely another manifestation of his infiltrative cardiac disease. The constellation of cardiac, pulmonary, and hepatic involvement in the context of progressive dyspnea over 2 years is suggestive of sarcoidosis although the absence of hilar lymphadenopathy and 2 biopsy specimens without granulomas argue against the diagnosis, and the effects of amiodarone on the latter 2 organs cannot be ignored. On the limited menu of pharmacologic treatments that may treat this severe and progressive cardiomyopathy are steroids, which makes a diligent search for a steroid‐responsive syndrome important. Therefore, despite the negative studies, sarcoidosis must be investigated to the fullest extent with either an endomyocardial biopsy or surgical lung biopsy.

The patient underwent cardiac transplantation. The native heart was found to have right ventricular thinning, which was most notable at the right ventricular outflow tract. Microscopic examination revealed extensive fibrosis and granulomatous inflammation (Figure 5) with scarring typical of cardiac sarcoidosis. Six months after cardiac transplantation, the patient is doing well on prednisone, tacrolimus, and mycophenolate mofetil. Follow‐up chest x‐rays show resolution of the pulmonary nodules.

Figure 5

COMMENTARY

Cardiomyopathy in a young person is a relatively uncommon clinical event that prompts consideration of a broad differential diagnosis that is notably different from the most common etiologies of cardiomyopathy in older adults. This case highlights the challenges of arriving at a diagnosis in the absence of a gold standard, and the greater challenges of modifying initial diagnostic impressions as new clinical data become available.

After encountering ventricular tachycardia and right ventricular dysfunction in a young patient, the clinicians arrived at the diagnosis of ARVD. This rare and progressive disorder is associated with up to 20% of ventricular arrhythmias and sudden death in the young,1, 2 but can be challenging to diagnose. Despite common referrals for cardiac MRI to exclude ARVD, cardiac MRI is not the gold standard for diagnosis and is the most common method of misdiagnosis of ARVD.3 A diagnosis of ARVD requires the presence of 2 major, 1 major and 2 minor, or 4 minor International Task Force criteria (Table 1).4, 5 While the diagnostic criteria provide standardization across populations (eg, in clinical studies), additional considerations are needed in the management of individual patients. Scoring systems serve as a tool, but the final diagnosis requires balancing such criteria with competing hypotheses. This dilemma is familiar to clinicians considering other less common conditions such as amyotrophic lateral sclerosis (World Neurology Foundation), rheumatic fever (Jones criteria), or systemic lupus erythematosus (American College of Rheumatology). This patient's cardiac MRI findings, precordial T‐wave inversions, frequent ventricular ectopy, and late potentials on a signal‐averaged electrocardiogram fulfilled the International Task Force criteria for a diagnosis of ARVD. Discordant information included the right bundle branch pattern of the ventricular tachycardia, which suggested left ventricular origin, as opposed to the more common left bundle branch pattern observed in ARVD, and the absence of a family history. In addition, in U.S. populations only 25% of cases present with heart failure and fewer than 5% develop biventricular failure.6 Nonetheless, this patient's imaging evidence of right ventricular structural abnormalities and dysfunction and electrocardiographic abnormalities coupled with the absence of obvious systemic disease made ARVD the logical working diagnosis.

When more widespread manifestations developed, namely hepatic and pulmonary abnormalities, each was investigated with imaging and biopsy. Once a multisystem illness became apparent, the discussant reframed the patient's illness to include other diagnostic possibilities. In practice it is difficult to reverse a working diagnosis despite contradictory evidence because of the common pitfall of anchoring bias. Tversky and Kahneman7 were the first to describe the cognitive processes behind probability assessment and decision making in time‐sensitive situations. Under these conditions, decision makers tend to focus on the first symptom, striking feature, or diagnosis and anchor subsequent probabilities to that initial presentation. Once a decision or diagnosis has been reached, clinicians tend to interpret subsequent findings in the context of the original diagnosis rather than reevaluating their initial impression. In the setting of a known diagnosis of ARVD, 3 separate diagnoses (ARVD, amiodarone‐associated lung injury, and amiodarone‐induced hepatic dysfunction) were considered by the treating physicians. The initial diagnosis of ARVD followed by the sequential rather than simultaneous manifestations of sarcoidosis made arriving at the revised diagnosis even more challenging.

Cardiac sarcoidosis is a mimic of ARVD and should be considered when evaluating a patient for right ventricular dysplasia.8, 9 The differential diagnosis of ARVD includes idiopathic ventricular tachycardia, myocarditis, idiopathic cardiomyopathy, and sarcoidosis. Cardiac sarcoidosis can present as ventricular ectopy, sustained ventricular arrhythmias, asymptomatic ventricular dysfunction, heart failure, or sudden death.10 Although 25% of patients with sarcoidosis have evidence of cardiac involvement at autopsy, only 5% have clinical manifestations.11 Those patients with clinical evidence of cardiac sarcoidosis have a wide range of clinical findings (Table 2). While the patient's cardiomyopathy was advanced, it is possible that earlier administration of corticosteroid therapy may have arrested his progressive biventricular failure. As clinicians, we should always remember to force ourselves to broaden our differential diagnosis when new findings become available, especially those that point to a systemicrather than an organ‐specificdisorder. In this case, while the original diagnostic findings were accurate and strongly suggested ARVD, a change of heart was needed to arrive at the ultimate diagnosis.

KEY POINTS FOR HOSPITALISTS

• 1

  Cardiomyopathy in a young person requires consideration of a broad differential diagnosis that is notably different from the most common etiologies of cardiomyopathy in the elderly.

• 2

  Anchoring bias is a common pitfall in clinical decision making. When new or contradictory findings are uncovered, clinicians should reevaluate their initial impression to ensure it remains the most likely diagnosis.

• 3

  Cardiac sarcoidosis is a mimic of ARVD and should be considered when evaluating a patient for right ventricular cardiomyopathy. The differential diagnosis of ARVD includes idiopathic ventricular tachycardia, right ventricular outflow tract tachycardia, myocarditis, idiopathic dilated cardiomyopathy, and sarcoidosis.

A 29‐year‐old man developed palpitations and dyspnea while loading boxes into a truck. In the emergency department, telemetry demonstrated a wide‐complex tachycardia at a rate of 204 beats per minute. The patient spontaneously cardioverted to sinus rhythm (Figure 1) before direct current cardioversion was performed.

Figure 1

Wide‐complex tachycardia is usually explained by a supraventricular tachycardia with aberrant ventricular conduction or a ventricular tachycardia. Although algorithms exist to guide the clinician in parsing out those etiologies, often the knowledge of underlying structural cardiac disease is most informative. In patients with a history of myocardial infarction, greater than 95% of wide‐complex tachycardia is ventricular tachycardia. The ventricular ectopy, T‐wave inversion or flattening, and poor R‐wave progression are suggestive of a cardiomyopathy, either acute or chronic. A pressing concern, especially with the Q waves and concave ST morphology in V1 and V2, would be coronary ischemia. His age makes this less likely, but an aberrant coronary circulation or drug use could account for it.

Over the past 2 years, the patient had several episodes of sustained palpitations, which terminated after several minutes. Previously, the patient exercised frequently including playing rugby in college. However, over the past year he experienced difficulty climbing stairs due to shortness of breath, which he attributed to deconditioning and smoking. He had no significant medical history, was not taking any medications, nor did he use recreational stimulants. He drank alcohol occasionally. He had no risk factors for the human immunodeficiency virus (HIV). Both of the patient's parents were alive and well. There was no family history of sudden cardiac death.

The duration of symptoms suggests that this is a chronic cardiomyopathy rather than acute myocarditis or acute ischemia, acknowledging that either one could be superimposed. The absence of family history lowers the likelihood of heritable causes of arrhythmia that may accompany a structurally normal (eg, long QT syndrome) or abnormal (eg, hypertrophic cardiomyopathy) heart, although penetrance can be variable. What might account for a cardiomyopathy in a young person? Most cases are probably idiopathic, but etiologies that diverge from the usual suspects of coronary artery disease, hypertension, and valvular disease, which affect an older population, include antecedent viral myocarditis, substance abuse, HIV, or infiltrative disorders such as sarcoidosis.

The patient's pulse was 92 beats per minute and regular and the blood pressure was 96/52 mm Hg. The jugular venous pressure was elevated with prominent v‐waves, the point of maximal impulse was diffuse, there were no extra heart sounds or murmurs, and an enlarged liver was detected. An echocardiogram demonstrated left ventricular dysfunction with an ejection fraction of 30%, severe enlargement of the right atrium and right ventricle, and moderate tricuspid regurgitation. Cardiac catheterization revealed normal coronary arteries without evidence of pulmonary hypertension or intracardiac shunt.

The physical examination and echocardiographic findings of right‐sided failure are unusual given the absence of pulmonary hypertension or intracardiac shunt, and could prompt repeat of the hemodynamic measurements and/or investigations for pulmonary disease that may account for right‐sided pressure overload (in addition to that caused by left ventricular failure). An alternative explanation would be a cardiomyopathic process that preferentially involves the right side of the heart, such as arrhythmogenic right ventricular dysplasia (ARVD), but that would not satisfactorily explain the significant decline in left ventricular function. An acute right ventricular infarction could cause his acute symptoms and his examination and echocardiographic findings, but not the underlying chronic illness. It is common to see patients with long‐standing biventricular failure who present with prominent signs of right‐sided failure (elevated neck veins, hepatomegaly, and edema) but limited or no signs of left‐sided failure (rales) to match their degree of volume overload or dyspnea.

Cardiac magnetic resonance imaging (MRI) revealed a dilated right ventricle with extensive hyperenhancement, a right ventricular ejection fraction of 9%, and moderate left ventricular dysfunction (Figure 2). Electrophysiology testing induced both nonsustained polymorphic and monomorphic ventricular tachycardia. Late potentials were detected on a signal‐averaged electrocardiogram. A single‐chamber cardioverter defibrillator was implanted and the patient was discharged on carvedilol, lisinopril, and spironolactone. An HIV‐1 antibody was negative and a thyroid‐stimulating hormone concentration was within normal limits.

Figure 2

Assuming that accurate evaluation of the pulmonary circulation has been undertaken to exclude pulmonary hypertension, the enlarged and hyperenhanced right ventricle on MRI suggests a process that preferentially infiltrates the right ventricular myocardium, and may secondarily affect the left ventricle either by further infiltration or as a consequence of altered mechanics from the highly dysfunctional right ventricle. ARVD affects the right ventricle, but it is possible that another infiltrative cardiomyopathy, such as sarcoid or an antecedent viral infection, could be restricted in its distribution. Late‐potentials identified on signal average electrocardiograms indicate areas of abnormal conduction that may serve as substrate for reentrant ventricular arrhythmias. They are, however, nonspecific, as they are seen in a variety of myocardial diseases.

The patient continued to have progressive dyspnea and was readmitted after receiving an appropriate implantable cardioverter defibrillator shock for ventricular tachycardia. Recurrent slow ventricular tachycardia (Figure 3) was treated with supplemental beta‐blockade and amiodarone (10 g total). Repeat echocardiography demonstrated severe left ventricular dysfunction with an ejection fraction of less than 15%. There were no recurrences of ventricular arrhythmias and the patient was discharged and referred for cardiac transplant evaluation for ARVD.

Figure 3

This degree of left ventricular dysfunction is unlikely to be accounted for by altered mechanics and interactions from a failing right ventricle alone and frames this as a biventricular cardiomyopathy, which has an extensive differential diagnosis and requires information from the general medical evaluation.

On routine laboratory testing 6 months later, a serum aspartate aminotransferase of 79 units/L and a serum alanine aminotransferase of 118 units/L were found. Bilirubin, albumin, and alkaline phosphatase were normal. The transaminase levels had been normal on initial evaluation. The patient reported that 2 paternal uncles had end‐stage nonalcoholic cirrhosis. Transjugular liver biopsy was consistent with mild lobular hepatitis with mild portal fibrosis with a few lobular collections of mononuclear cells. There was no evidence of iron overload. The hepatic venogram and transhepatic pressure gradient (2 mm Hg) were normal.

The elevated transaminase levels could be due to amiodarone‐associated hepatotoxicity, hepatic congestion, or a primary liver disease. It is important to consider combined cardiohepatic syndromes such as hemochromatosis, sarcoidosis, or amyloidosis. The relatively normal liver histology and normal hepatic hemodynamics do not suggest a significant primary intrinsic liver disease. The 2 uncles with cirrhosis could suggest a heritable liver disease, although cirrhosis in multiple family members is frequently accounted for by shared habits such as alcohol consumption or excessive caloric intake. Liver disorders with a genetic component, such as hemochromatosis, Wilson's disease, and alpha‐1‐antitrypsin deficiency are mostly autosomal recessive, which would make this pattern of transmission unusual. Furthermore, aside from hemochromatosis, these genetic hepatic disorders have few cardiac manifestations. Right‐sided congestion and amiodarone appear to be the most likely explanations of his liver abnormalities.

Pulmonary function testing revealed normal lung volumes without obstruction, but the diffusing capacity for carbon monoxide was substantially reduced. Computed tomography of the chest identified scattered ground‐glass opacities as well as small nodules with an upper lobe distribution (Figure 4). Although not reported on the initial interpretation, review of a chest x‐ray taken 6 months previously also demonstrated small nodules in the upper lobe distribution. Bronchoscopic examination was normal. Bronchioalveolar lavage fluid stains and cultures for bacteria, mycobacteria, Pneumocystis, and fungus were negative. Transbronchial biopsies of the right middle lobe had no evidence of infection, malignancy, or granulomatous inflammation. The patient continued to have progressive New York Heart Association Class IV heart failure symptoms. Repeat right heart catheterization was notable for a cardiac index of 1.4 L/minute/m². The mean pulmonary artery pressure was 20 mm Hg. An intraaortic balloon pump was placed for refractory cardiogenic shock.

Figure 4

The reduced diffusion capacity and ground‐glass opacities suggest an interstitial process, which may have been missed on transbronchial biopsy because of sampling error. His pulmonary disease is likely another manifestation of his infiltrative cardiac disease. The constellation of cardiac, pulmonary, and hepatic involvement in the context of progressive dyspnea over 2 years is suggestive of sarcoidosis although the absence of hilar lymphadenopathy and 2 biopsy specimens without granulomas argue against the diagnosis, and the effects of amiodarone on the latter 2 organs cannot be ignored. On the limited menu of pharmacologic treatments that may treat this severe and progressive cardiomyopathy are steroids, which makes a diligent search for a steroid‐responsive syndrome important. Therefore, despite the negative studies, sarcoidosis must be investigated to the fullest extent with either an endomyocardial biopsy or surgical lung biopsy.

The patient underwent cardiac transplantation. The native heart was found to have right ventricular thinning, which was most notable at the right ventricular outflow tract. Microscopic examination revealed extensive fibrosis and granulomatous inflammation (Figure 5) with scarring typical of cardiac sarcoidosis. Six months after cardiac transplantation, the patient is doing well on prednisone, tacrolimus, and mycophenolate mofetil. Follow‐up chest x‐rays show resolution of the pulmonary nodules.

Figure 5

COMMENTARY

Cardiomyopathy in a young person is a relatively uncommon clinical event that prompts consideration of a broad differential diagnosis that is notably different from the most common etiologies of cardiomyopathy in older adults. This case highlights the challenges of arriving at a diagnosis in the absence of a gold standard, and the greater challenges of modifying initial diagnostic impressions as new clinical data become available.

After encountering ventricular tachycardia and right ventricular dysfunction in a young patient, the clinicians arrived at the diagnosis of ARVD. This rare and progressive disorder is associated with up to 20% of ventricular arrhythmias and sudden death in the young,1, 2 but can be challenging to diagnose. Despite common referrals for cardiac MRI to exclude ARVD, cardiac MRI is not the gold standard for diagnosis and is the most common method of misdiagnosis of ARVD.3 A diagnosis of ARVD requires the presence of 2 major, 1 major and 2 minor, or 4 minor International Task Force criteria (Table 1).4, 5 While the diagnostic criteria provide standardization across populations (eg, in clinical studies), additional considerations are needed in the management of individual patients. Scoring systems serve as a tool, but the final diagnosis requires balancing such criteria with competing hypotheses. This dilemma is familiar to clinicians considering other less common conditions such as amyotrophic lateral sclerosis (World Neurology Foundation), rheumatic fever (Jones criteria), or systemic lupus erythematosus (American College of Rheumatology). This patient's cardiac MRI findings, precordial T‐wave inversions, frequent ventricular ectopy, and late potentials on a signal‐averaged electrocardiogram fulfilled the International Task Force criteria for a diagnosis of ARVD. Discordant information included the right bundle branch pattern of the ventricular tachycardia, which suggested left ventricular origin, as opposed to the more common left bundle branch pattern observed in ARVD, and the absence of a family history. In addition, in U.S. populations only 25% of cases present with heart failure and fewer than 5% develop biventricular failure.6 Nonetheless, this patient's imaging evidence of right ventricular structural abnormalities and dysfunction and electrocardiographic abnormalities coupled with the absence of obvious systemic disease made ARVD the logical working diagnosis.

When more widespread manifestations developed, namely hepatic and pulmonary abnormalities, each was investigated with imaging and biopsy. Once a multisystem illness became apparent, the discussant reframed the patient's illness to include other diagnostic possibilities. In practice it is difficult to reverse a working diagnosis despite contradictory evidence because of the common pitfall of anchoring bias. Tversky and Kahneman7 were the first to describe the cognitive processes behind probability assessment and decision making in time‐sensitive situations. Under these conditions, decision makers tend to focus on the first symptom, striking feature, or diagnosis and anchor subsequent probabilities to that initial presentation. Once a decision or diagnosis has been reached, clinicians tend to interpret subsequent findings in the context of the original diagnosis rather than reevaluating their initial impression. In the setting of a known diagnosis of ARVD, 3 separate diagnoses (ARVD, amiodarone‐associated lung injury, and amiodarone‐induced hepatic dysfunction) were considered by the treating physicians. The initial diagnosis of ARVD followed by the sequential rather than simultaneous manifestations of sarcoidosis made arriving at the revised diagnosis even more challenging.

Cardiac sarcoidosis is a mimic of ARVD and should be considered when evaluating a patient for right ventricular dysplasia.8, 9 The differential diagnosis of ARVD includes idiopathic ventricular tachycardia, myocarditis, idiopathic cardiomyopathy, and sarcoidosis. Cardiac sarcoidosis can present as ventricular ectopy, sustained ventricular arrhythmias, asymptomatic ventricular dysfunction, heart failure, or sudden death.10 Although 25% of patients with sarcoidosis have evidence of cardiac involvement at autopsy, only 5% have clinical manifestations.11 Those patients with clinical evidence of cardiac sarcoidosis have a wide range of clinical findings (Table 2). While the patient's cardiomyopathy was advanced, it is possible that earlier administration of corticosteroid therapy may have arrested his progressive biventricular failure. As clinicians, we should always remember to force ourselves to broaden our differential diagnosis when new findings become available, especially those that point to a systemicrather than an organ‐specificdisorder. In this case, while the original diagnostic findings were accurate and strongly suggested ARVD, a change of heart was needed to arrive at the ultimate diagnosis.

KEY POINTS FOR HOSPITALISTS

• 1

  Cardiomyopathy in a young person requires consideration of a broad differential diagnosis that is notably different from the most common etiologies of cardiomyopathy in the elderly.

• 2

  Anchoring bias is a common pitfall in clinical decision making. When new or contradictory findings are uncovered, clinicians should reevaluate their initial impression to ensure it remains the most likely diagnosis.

• 3

  Cardiac sarcoidosis is a mimic of ARVD and should be considered when evaluating a patient for right ventricular cardiomyopathy. The differential diagnosis of ARVD includes idiopathic ventricular tachycardia, right ventricular outflow tract tachycardia, myocarditis, idiopathic dilated cardiomyopathy, and sarcoidosis.

The use of clinical decision support, despite great promise to improve health care, remains preliminary.1 The broad scope of quality and safety challenges facing clinicians2, 3 requires this situation to change. There is an urgent need to develop decision support tools and strategies that are effective, address many quality issues simultaneously, and are easy to implement in both academic and community settings.

One decision support tool that could help to meet this challenge is the order set. An order set is a group of orders with a common functional purpose that is used directly by a physician to create orders for a specific patient. Order sets can be used with either paper‐based or computerized provider order entry (CPOE) systems. Several studies have investigated the delivery of focused evidence‐based treatments to patients admitted using disease‐specific order sets compared with either historical or concurrent controls and have demonstrated increased use of therapies such as aspirin for acute myocardial infarction admissions,4 systemic corticosteroids, metered‐dose inhalers and pulse oximetry for pediatric asthma admissions,5 and venous thromboembolism prophylaxis for adult emergency department admissions.6 However, the ability of order sets to improve multiple quality measures in a diverse patient population has not been evaluated previously.

This study examined the effect of paper‐based order sets on the quality of admission orders for general medical patients in a community hospital. The primary hypothesis was that order set use would increase the proportion of general medical patients ordered deep venous thrombosis (DVT) prophylaxis. We chose this primary endpoint because DVT prophylaxis continues to be significantly underused in hospitalized patients.7, 8 Secondary hypotheses were that order sets would improve other admission order quality of care measures. We studied paper‐based order sets because the study hospital, along with the vast majority of North American hospitals, uses paper for order entry.9

PATIENTS AND METHODS

RESULTS

As shown in Table 1, there were no clinically important differences in demographic or clinical characteristics of medical patients between the 2 years of the study. There were small but statistically significant increases in patient illness complexity (as reflected in median RIW) (P = 0.003) and length of stay (P = 0.0002).

Clinicians used order sets in 32.3% of admissions during period 2 (AprilDecember 2004, 412 months after order set availability), increasing to 51.6% in period 3 (FebruaryMarch 2005, 1415 months after order set availability). The results of the chart audit assessing the impact of order set use on DVT prophylaxis are shown in Figure 1. Prior to order set introduction, 10.9% of patients received orders for DVT prophylaxis. Subsequently, ordering of DVT prophylaxis in patients admitted with order sets increased (period 2: 35.6%; P < 0.001; RR, 3.27; 95% CI, 1.806.12 and period 3: 44.0%; P < 0.001; RR, 4.04; 95% CI, 2.327.31). In contrast, DVT prophylaxis ordering in the nonorder set group was initially unchanged (period 2: 10.6%; P = 0.93; RR, 0.97; 95% CI, 0.491.95), although later it increased to a smaller extent (period 3: 20.6%; P = 0.049; RR, 1.90; 95% CI, 1.013.65). As a result of this differential increase, patients admitted with order sets were more likely to be ordered DVT prophylaxis in both study periods (period 2: 35.6% versus 10.6%; P < 0.0001; RR, 3.38; 95% CI, 2.035.62 and period 3: 44.0% versus 20.6%; P < 0.0001; RR, 2.13; 95% CI, 1.443.16). The use of therapeutic anticoagulation was similar in patients admitted with and without order sets and did not change between time periods.

Figure 1

The hospital‐wide monthly utilization of heparin for DVT prophylaxis in medical inpatients increased from an average of 12.8% (range, 9.7%16.1%) of patient‐days before order set implementation (AprilNovember 2003) to 18.5% (range, 16.4%20.0%) of patient‐days in the 8 months after order sets were first implemented (DecemberJuly 2004, P < 0.0001 compared to the preorder set time period). After August 2004, when upgraded order sets were introduced, DVT prophylaxis utilization increased further in the last 7 months of the study to 25.8% (range, 22.4%32.2%; P < 0.0001 compared to preorder set time period; Figure 2).

Figure 2

Table 2 shows the impact of order sets on secondary outcomes. Admissions completed with order sets had statistically significant increases in general care orders (ECG and notification of physician for chest pain, allied health consultations and standard hospital diabetic diet, insulin scale, and potassium replacement protocol orders), documentation of allergies and code status, numbering of pages, and use of a standardized arrangement for orders. Ordering of BUN decreased significantly.

Order sets were not associated with changes in diet, activity, or vital sign orders, documentation of admission diagnosis, or the signing and timing of orders. Apart from order timing, these orders were present in >75% of admissions completed without order sets. The only negative effect of order sets was a reduction in the dating of orders (84.0% of order set admissions versus 93.9% of nonorder set admissions, P = 0.007). Finally, order sets had both an intended and unintended effect on nighttime sedation orders. Relative frequency of ordering of zopiclone compared to lorazepam increased (43/55 in the order set group vs. 2/17 in the no order set group [P < 0.0001], the intended effect), and increased overall frequency of ordering of nighttime sedation (55/94 vs. 17/197 [P < 0.0001], an unintended effect).

The additional chart audit in OctoberNovember 2007, just prior to final submission of the manuscript, determined that clinician use of order sets had increased to 92.6% of admitted medical patients, and that ordering of DVT prophylaxis in patients admitted with order sets had been sustained at 43.2% (P = 0.90 compared to period 3) (Figure 1).

DISCUSSION

We found that paper‐based order sets were associated with markedly increased use of DVT prophylaxis and made physician ordering more consistent with hospital consensus guidelines in multiple other areas, including laboratory test utilization and general care, while also increasing completeness of documentation. Given the difficulties and limited resources frequently associated with guideline development, dissemination, and implementation,12 it is worth noting that our improvements were achieved in a community hospital with voluntary physician adoption and no dedicated project funding, care process redesign, or healthcare worker education. The broad impact of order sets combined with minimal organizational resources required for implementation in this study suggests that this clinical decision support tool may have wide applicability.

The study hospital used paper‐based orders rather than CPOE, similar to 90% of U.S. hospitals at the time of the study.9 Order sets can be deployed in either paper‐based or computerized ordering systems. By providing a mechanism for entering large blocks of orders in an efficient manner, paper‐based order sets may be a necessary first step to facilitate the paper to CPOE transition, making them well suited to the current care delivery environment. Successful use of paper‐based order sets may help accelerate adoption of CPOE, which appears to be many years away from full implementation in the majority of U.S. hospitals.13

The most clinically important outcome in our study was a more than 4‐fold increase in ordering of DVT prophylaxis (last study period compared with baseline) in medical patients admitted with order sets, compared to a smaller increase in patients admitted without order sets. Our result is particularly significant as this study was performed in a community hospital, a setting with a lower adherence to DVT prophylaxis guidelines compared to academic centers.8, 14 The increase in DVT prophylaxis in patients admitted without order sets could be the result of a secular trend or a passive educational effect of order sets on physicians who only used order sets intermittently. The study was not publicized and thus was unlikely in itself to contribute to the increased performance.

We did not assess clinical outcomes of DVT or pulmonary embolism, but the clinical efficacy of improving adherence to DVT prophylaxis has been previously established.15 We also did not assess the appropriateness of DVT prophylaxis (or any other order). However, a recent multicenter Canadian observational study, using the American College of Chest Physician's Consensus Guidelines on Antithrombotic Therapy16 as a reference standard, found that 90% of medical patients admitted to hospital meeting study criteria had indications for thromboprophylaxis, but only 16% of eligible patients actually received it.8 In addition, multivariable regression analysis demonstrated even lower utilization in community hospitals compared to academic hospitals. These data suggest that the study hospital is typical of Canadian hospitals, and that the low overall utilization of DVT prophylaxis (13% of hospital patient‐days) prior to the availability of order sets in the study hospital is a significant gap between optimal and actual practice.

In addition, order sets had an impact on many secondary outcomes, such as standardization and completeness of orders (for example documentation of allergies and resuscitation status). While these effects appear to be beneficial in terms of quality of care and patient safety, the relationship of our secondary outcomes to patient‐important outcomes has not been established.

Furthermore, our before‐after design does not exclude the possibility of unknown confounding effects as explanations of improved performance in the order set group. For example, the change could have been driven by a small number of admitting physicians, since it is likely that order sets were adopted more readily by some physicians than others, and this group could have been responsible for a greater proportion of the admissions at different times. Unfortunately, we did not record the identity of the admitting physician. However, data from OctoberNovember 2007 show that >90% of medical patients were admitted using order sets, suggesting that voluntary clinician adoption of order sets has become nearly universal. Nevertheless, there still appear to be a few physicians who rarely or never used orders sets. Motivating these physicians to prescribe appropriate DVT prophylaxis remains a challenge.

Although this study was conducted in 1 center, other hospitals have similarly low rates of thromboprophylaxis,8 and our order set implementation strategy consumed few resources, improving the generalizability of our results. While most changes were beneficial, order set use was associated with decreased dating of orders and with an unintended effect or overall increase ordering of nightime sedation. Although the reasons for this are unclear, it highlights the importance of systematically evaluating the impact of order sets to identify unintended consequences and areas in which the order set may need to be redesigned to address these issues.

The study of order sets is preliminary despite their role as a key enabler for CPOE17 and their suggested usefulness to reduce medical error.18 For example, order sets were not considered in recent analyses of factors predicting success of computerized decision support systems19, 20 and have not been reviewed by the Cochrane Effective Practice and Organisation of Care Group.21 As discussed in the introduction, several studies have demonstrated that disease‐specific order sets can increase the use of evidence‐based treatments.46 Our study extends this work by demonstrating that admission order sets can improve performance hospital‐wide for a broad range of outcomes simultaneously, including DVT prophylaxis. Although most studies have demonstrated increased utilization of evidence‐based therapies, at least 1 study found no increased use of aspirin, heparin, or beta‐blockers in acute coronary syndrome admissions with the introduction of order sets.22 This suggests that the way order sets are structured or introduced is important to ensure that they achieve the desired changes in practice. Finally, our study suggests that improved outcomes using order sets can still be achieved with minimal organizational resources.

Order sets may potentially complement other decision support tools such as alerts and reminders. Alerts are an effective decision support tool12, 23, 24 but risk disrupting clinician workflow. Moreover, excessive alerts can lead to alert fatigue, resulting in many alerts being ignored.25 This phenomenon reduces alert effectiveness and limits the number of issues that alerts can address simultaneously. In contrast, order sets are broad in scope due to integration with clinical workflow, but lack the ability of alerts to apply rules to a specific patient's data. A potentially effective 2‐staged decision support strategy would use order sets as the primary admission decision support tool and selective alerts for remaining issues. This approach may increase the overall scope, physician adoption, and effectiveness of clinical decision support, and should be evaluated.

Our postintervention rate of DVT prophylaxis, while substantially improved from baseline, is still below ideal practice. Order sets were simply made available to clinicians admitting medical patients, who had the option to select DVT prophylaxis. Given limited resources, we did not develop and implement education programs regarding the appropriate use of DVT prophylaxis or make available any DVT risk assessment evaluations (available in Ref.26). Our study methodology thus provides a realistic assessment of improvements attainable in other hospitals with similarly limited resources. Additional increases in DVT prophylaxis rates would likely require a more comprehensive and resource‐intensive multifaceted quality improvement initiative. Detailed guidelines and supporting references for implementing such an initiative are available from the Society of Hospital Medicine.26 As described in their Venous Thromboembolism (VTE) Resource Room,26 such an initiative should include a standardized DVT risk assessment to guide the need for DVT prophylaxis integrated into admission order sets; prompts to order DVT prophylaxis when completing admission orders; and a system to audit adverse events and variations from best practice and return this information to clinicians.26

CONCLUSIONS

This is the largest and most comprehensive evaluation of the effectiveness of order sets as a clinical decision support tool. We found that order sets improved the quality of multiple patient orders and improved hospital‐wide DVT prophylaxis rates. These improvements were achieved in a community hospital with voluntary physician adoption and no dedicated project funding, care process redesign, or healthcare worker education. Although used in a paper‐based format in this study, order sets can also be employed in a computerized ordering environment. By providing a mechanism for entering large blocks of orders in an efficient manner, paper‐based order sets may be a necessary first step to facilitate the paper‐to‐CPOE transition. These attributes make order sets an attractive quality improvement tool in community and academic settings. More research is needed on the optimal design and use of this promising decision support tool.

The use of clinical decision support, despite great promise to improve health care, remains preliminary.1 The broad scope of quality and safety challenges facing clinicians2, 3 requires this situation to change. There is an urgent need to develop decision support tools and strategies that are effective, address many quality issues simultaneously, and are easy to implement in both academic and community settings.

One decision support tool that could help to meet this challenge is the order set. An order set is a group of orders with a common functional purpose that is used directly by a physician to create orders for a specific patient. Order sets can be used with either paper‐based or computerized provider order entry (CPOE) systems. Several studies have investigated the delivery of focused evidence‐based treatments to patients admitted using disease‐specific order sets compared with either historical or concurrent controls and have demonstrated increased use of therapies such as aspirin for acute myocardial infarction admissions,4 systemic corticosteroids, metered‐dose inhalers and pulse oximetry for pediatric asthma admissions,5 and venous thromboembolism prophylaxis for adult emergency department admissions.6 However, the ability of order sets to improve multiple quality measures in a diverse patient population has not been evaluated previously.

This study examined the effect of paper‐based order sets on the quality of admission orders for general medical patients in a community hospital. The primary hypothesis was that order set use would increase the proportion of general medical patients ordered deep venous thrombosis (DVT) prophylaxis. We chose this primary endpoint because DVT prophylaxis continues to be significantly underused in hospitalized patients.7, 8 Secondary hypotheses were that order sets would improve other admission order quality of care measures. We studied paper‐based order sets because the study hospital, along with the vast majority of North American hospitals, uses paper for order entry.9

PATIENTS AND METHODS

RESULTS

As shown in Table 1, there were no clinically important differences in demographic or clinical characteristics of medical patients between the 2 years of the study. There were small but statistically significant increases in patient illness complexity (as reflected in median RIW) (P = 0.003) and length of stay (P = 0.0002).

Clinicians used order sets in 32.3% of admissions during period 2 (AprilDecember 2004, 412 months after order set availability), increasing to 51.6% in period 3 (FebruaryMarch 2005, 1415 months after order set availability). The results of the chart audit assessing the impact of order set use on DVT prophylaxis are shown in Figure 1. Prior to order set introduction, 10.9% of patients received orders for DVT prophylaxis. Subsequently, ordering of DVT prophylaxis in patients admitted with order sets increased (period 2: 35.6%; P < 0.001; RR, 3.27; 95% CI, 1.806.12 and period 3: 44.0%; P < 0.001; RR, 4.04; 95% CI, 2.327.31). In contrast, DVT prophylaxis ordering in the nonorder set group was initially unchanged (period 2: 10.6%; P = 0.93; RR, 0.97; 95% CI, 0.491.95), although later it increased to a smaller extent (period 3: 20.6%; P = 0.049; RR, 1.90; 95% CI, 1.013.65). As a result of this differential increase, patients admitted with order sets were more likely to be ordered DVT prophylaxis in both study periods (period 2: 35.6% versus 10.6%; P < 0.0001; RR, 3.38; 95% CI, 2.035.62 and period 3: 44.0% versus 20.6%; P < 0.0001; RR, 2.13; 95% CI, 1.443.16). The use of therapeutic anticoagulation was similar in patients admitted with and without order sets and did not change between time periods.

Figure 1

The hospital‐wide monthly utilization of heparin for DVT prophylaxis in medical inpatients increased from an average of 12.8% (range, 9.7%16.1%) of patient‐days before order set implementation (AprilNovember 2003) to 18.5% (range, 16.4%20.0%) of patient‐days in the 8 months after order sets were first implemented (DecemberJuly 2004, P < 0.0001 compared to the preorder set time period). After August 2004, when upgraded order sets were introduced, DVT prophylaxis utilization increased further in the last 7 months of the study to 25.8% (range, 22.4%32.2%; P < 0.0001 compared to preorder set time period; Figure 2).

Figure 2

Table 2 shows the impact of order sets on secondary outcomes. Admissions completed with order sets had statistically significant increases in general care orders (ECG and notification of physician for chest pain, allied health consultations and standard hospital diabetic diet, insulin scale, and potassium replacement protocol orders), documentation of allergies and code status, numbering of pages, and use of a standardized arrangement for orders. Ordering of BUN decreased significantly.

Order sets were not associated with changes in diet, activity, or vital sign orders, documentation of admission diagnosis, or the signing and timing of orders. Apart from order timing, these orders were present in >75% of admissions completed without order sets. The only negative effect of order sets was a reduction in the dating of orders (84.0% of order set admissions versus 93.9% of nonorder set admissions, P = 0.007). Finally, order sets had both an intended and unintended effect on nighttime sedation orders. Relative frequency of ordering of zopiclone compared to lorazepam increased (43/55 in the order set group vs. 2/17 in the no order set group [P < 0.0001], the intended effect), and increased overall frequency of ordering of nighttime sedation (55/94 vs. 17/197 [P < 0.0001], an unintended effect).

The additional chart audit in OctoberNovember 2007, just prior to final submission of the manuscript, determined that clinician use of order sets had increased to 92.6% of admitted medical patients, and that ordering of DVT prophylaxis in patients admitted with order sets had been sustained at 43.2% (P = 0.90 compared to period 3) (Figure 1).

DISCUSSION

We found that paper‐based order sets were associated with markedly increased use of DVT prophylaxis and made physician ordering more consistent with hospital consensus guidelines in multiple other areas, including laboratory test utilization and general care, while also increasing completeness of documentation. Given the difficulties and limited resources frequently associated with guideline development, dissemination, and implementation,12 it is worth noting that our improvements were achieved in a community hospital with voluntary physician adoption and no dedicated project funding, care process redesign, or healthcare worker education. The broad impact of order sets combined with minimal organizational resources required for implementation in this study suggests that this clinical decision support tool may have wide applicability.

The study hospital used paper‐based orders rather than CPOE, similar to 90% of U.S. hospitals at the time of the study.9 Order sets can be deployed in either paper‐based or computerized ordering systems. By providing a mechanism for entering large blocks of orders in an efficient manner, paper‐based order sets may be a necessary first step to facilitate the paper to CPOE transition, making them well suited to the current care delivery environment. Successful use of paper‐based order sets may help accelerate adoption of CPOE, which appears to be many years away from full implementation in the majority of U.S. hospitals.13

The most clinically important outcome in our study was a more than 4‐fold increase in ordering of DVT prophylaxis (last study period compared with baseline) in medical patients admitted with order sets, compared to a smaller increase in patients admitted without order sets. Our result is particularly significant as this study was performed in a community hospital, a setting with a lower adherence to DVT prophylaxis guidelines compared to academic centers.8, 14 The increase in DVT prophylaxis in patients admitted without order sets could be the result of a secular trend or a passive educational effect of order sets on physicians who only used order sets intermittently. The study was not publicized and thus was unlikely in itself to contribute to the increased performance.

We did not assess clinical outcomes of DVT or pulmonary embolism, but the clinical efficacy of improving adherence to DVT prophylaxis has been previously established.15 We also did not assess the appropriateness of DVT prophylaxis (or any other order). However, a recent multicenter Canadian observational study, using the American College of Chest Physician's Consensus Guidelines on Antithrombotic Therapy16 as a reference standard, found that 90% of medical patients admitted to hospital meeting study criteria had indications for thromboprophylaxis, but only 16% of eligible patients actually received it.8 In addition, multivariable regression analysis demonstrated even lower utilization in community hospitals compared to academic hospitals. These data suggest that the study hospital is typical of Canadian hospitals, and that the low overall utilization of DVT prophylaxis (13% of hospital patient‐days) prior to the availability of order sets in the study hospital is a significant gap between optimal and actual practice.

In addition, order sets had an impact on many secondary outcomes, such as standardization and completeness of orders (for example documentation of allergies and resuscitation status). While these effects appear to be beneficial in terms of quality of care and patient safety, the relationship of our secondary outcomes to patient‐important outcomes has not been established.

Furthermore, our before‐after design does not exclude the possibility of unknown confounding effects as explanations of improved performance in the order set group. For example, the change could have been driven by a small number of admitting physicians, since it is likely that order sets were adopted more readily by some physicians than others, and this group could have been responsible for a greater proportion of the admissions at different times. Unfortunately, we did not record the identity of the admitting physician. However, data from OctoberNovember 2007 show that >90% of medical patients were admitted using order sets, suggesting that voluntary clinician adoption of order sets has become nearly universal. Nevertheless, there still appear to be a few physicians who rarely or never used orders sets. Motivating these physicians to prescribe appropriate DVT prophylaxis remains a challenge.

Although this study was conducted in 1 center, other hospitals have similarly low rates of thromboprophylaxis,8 and our order set implementation strategy consumed few resources, improving the generalizability of our results. While most changes were beneficial, order set use was associated with decreased dating of orders and with an unintended effect or overall increase ordering of nightime sedation. Although the reasons for this are unclear, it highlights the importance of systematically evaluating the impact of order sets to identify unintended consequences and areas in which the order set may need to be redesigned to address these issues.

The study of order sets is preliminary despite their role as a key enabler for CPOE17 and their suggested usefulness to reduce medical error.18 For example, order sets were not considered in recent analyses of factors predicting success of computerized decision support systems19, 20 and have not been reviewed by the Cochrane Effective Practice and Organisation of Care Group.21 As discussed in the introduction, several studies have demonstrated that disease‐specific order sets can increase the use of evidence‐based treatments.46 Our study extends this work by demonstrating that admission order sets can improve performance hospital‐wide for a broad range of outcomes simultaneously, including DVT prophylaxis. Although most studies have demonstrated increased utilization of evidence‐based therapies, at least 1 study found no increased use of aspirin, heparin, or beta‐blockers in acute coronary syndrome admissions with the introduction of order sets.22 This suggests that the way order sets are structured or introduced is important to ensure that they achieve the desired changes in practice. Finally, our study suggests that improved outcomes using order sets can still be achieved with minimal organizational resources.

Order sets may potentially complement other decision support tools such as alerts and reminders. Alerts are an effective decision support tool12, 23, 24 but risk disrupting clinician workflow. Moreover, excessive alerts can lead to alert fatigue, resulting in many alerts being ignored.25 This phenomenon reduces alert effectiveness and limits the number of issues that alerts can address simultaneously. In contrast, order sets are broad in scope due to integration with clinical workflow, but lack the ability of alerts to apply rules to a specific patient's data. A potentially effective 2‐staged decision support strategy would use order sets as the primary admission decision support tool and selective alerts for remaining issues. This approach may increase the overall scope, physician adoption, and effectiveness of clinical decision support, and should be evaluated.

Our postintervention rate of DVT prophylaxis, while substantially improved from baseline, is still below ideal practice. Order sets were simply made available to clinicians admitting medical patients, who had the option to select DVT prophylaxis. Given limited resources, we did not develop and implement education programs regarding the appropriate use of DVT prophylaxis or make available any DVT risk assessment evaluations (available in Ref.26). Our study methodology thus provides a realistic assessment of improvements attainable in other hospitals with similarly limited resources. Additional increases in DVT prophylaxis rates would likely require a more comprehensive and resource‐intensive multifaceted quality improvement initiative. Detailed guidelines and supporting references for implementing such an initiative are available from the Society of Hospital Medicine.26 As described in their Venous Thromboembolism (VTE) Resource Room,26 such an initiative should include a standardized DVT risk assessment to guide the need for DVT prophylaxis integrated into admission order sets; prompts to order DVT prophylaxis when completing admission orders; and a system to audit adverse events and variations from best practice and return this information to clinicians.26

CONCLUSIONS

This is the largest and most comprehensive evaluation of the effectiveness of order sets as a clinical decision support tool. We found that order sets improved the quality of multiple patient orders and improved hospital‐wide DVT prophylaxis rates. These improvements were achieved in a community hospital with voluntary physician adoption and no dedicated project funding, care process redesign, or healthcare worker education. Although used in a paper‐based format in this study, order sets can also be employed in a computerized ordering environment. By providing a mechanism for entering large blocks of orders in an efficient manner, paper‐based order sets may be a necessary first step to facilitate the paper‐to‐CPOE transition. These attributes make order sets an attractive quality improvement tool in community and academic settings. More research is needed on the optimal design and use of this promising decision support tool.

The use of clinical decision support, despite great promise to improve health care, remains preliminary.1 The broad scope of quality and safety challenges facing clinicians2, 3 requires this situation to change. There is an urgent need to develop decision support tools and strategies that are effective, address many quality issues simultaneously, and are easy to implement in both academic and community settings.

One decision support tool that could help to meet this challenge is the order set. An order set is a group of orders with a common functional purpose that is used directly by a physician to create orders for a specific patient. Order sets can be used with either paper‐based or computerized provider order entry (CPOE) systems. Several studies have investigated the delivery of focused evidence‐based treatments to patients admitted using disease‐specific order sets compared with either historical or concurrent controls and have demonstrated increased use of therapies such as aspirin for acute myocardial infarction admissions,4 systemic corticosteroids, metered‐dose inhalers and pulse oximetry for pediatric asthma admissions,5 and venous thromboembolism prophylaxis for adult emergency department admissions.6 However, the ability of order sets to improve multiple quality measures in a diverse patient population has not been evaluated previously.

This study examined the effect of paper‐based order sets on the quality of admission orders for general medical patients in a community hospital. The primary hypothesis was that order set use would increase the proportion of general medical patients ordered deep venous thrombosis (DVT) prophylaxis. We chose this primary endpoint because DVT prophylaxis continues to be significantly underused in hospitalized patients.7, 8 Secondary hypotheses were that order sets would improve other admission order quality of care measures. We studied paper‐based order sets because the study hospital, along with the vast majority of North American hospitals, uses paper for order entry.9

PATIENTS AND METHODS

RESULTS

As shown in Table 1, there were no clinically important differences in demographic or clinical characteristics of medical patients between the 2 years of the study. There were small but statistically significant increases in patient illness complexity (as reflected in median RIW) (P = 0.003) and length of stay (P = 0.0002).

Clinicians used order sets in 32.3% of admissions during period 2 (AprilDecember 2004, 412 months after order set availability), increasing to 51.6% in period 3 (FebruaryMarch 2005, 1415 months after order set availability). The results of the chart audit assessing the impact of order set use on DVT prophylaxis are shown in Figure 1. Prior to order set introduction, 10.9% of patients received orders for DVT prophylaxis. Subsequently, ordering of DVT prophylaxis in patients admitted with order sets increased (period 2: 35.6%; P < 0.001; RR, 3.27; 95% CI, 1.806.12 and period 3: 44.0%; P < 0.001; RR, 4.04; 95% CI, 2.327.31). In contrast, DVT prophylaxis ordering in the nonorder set group was initially unchanged (period 2: 10.6%; P = 0.93; RR, 0.97; 95% CI, 0.491.95), although later it increased to a smaller extent (period 3: 20.6%; P = 0.049; RR, 1.90; 95% CI, 1.013.65). As a result of this differential increase, patients admitted with order sets were more likely to be ordered DVT prophylaxis in both study periods (period 2: 35.6% versus 10.6%; P < 0.0001; RR, 3.38; 95% CI, 2.035.62 and period 3: 44.0% versus 20.6%; P < 0.0001; RR, 2.13; 95% CI, 1.443.16). The use of therapeutic anticoagulation was similar in patients admitted with and without order sets and did not change between time periods.

Figure 1

The hospital‐wide monthly utilization of heparin for DVT prophylaxis in medical inpatients increased from an average of 12.8% (range, 9.7%16.1%) of patient‐days before order set implementation (AprilNovember 2003) to 18.5% (range, 16.4%20.0%) of patient‐days in the 8 months after order sets were first implemented (DecemberJuly 2004, P < 0.0001 compared to the preorder set time period). After August 2004, when upgraded order sets were introduced, DVT prophylaxis utilization increased further in the last 7 months of the study to 25.8% (range, 22.4%32.2%; P < 0.0001 compared to preorder set time period; Figure 2).

Figure 2

Table 2 shows the impact of order sets on secondary outcomes. Admissions completed with order sets had statistically significant increases in general care orders (ECG and notification of physician for chest pain, allied health consultations and standard hospital diabetic diet, insulin scale, and potassium replacement protocol orders), documentation of allergies and code status, numbering of pages, and use of a standardized arrangement for orders. Ordering of BUN decreased significantly.

Order sets were not associated with changes in diet, activity, or vital sign orders, documentation of admission diagnosis, or the signing and timing of orders. Apart from order timing, these orders were present in >75% of admissions completed without order sets. The only negative effect of order sets was a reduction in the dating of orders (84.0% of order set admissions versus 93.9% of nonorder set admissions, P = 0.007). Finally, order sets had both an intended and unintended effect on nighttime sedation orders. Relative frequency of ordering of zopiclone compared to lorazepam increased (43/55 in the order set group vs. 2/17 in the no order set group [P < 0.0001], the intended effect), and increased overall frequency of ordering of nighttime sedation (55/94 vs. 17/197 [P < 0.0001], an unintended effect).

The additional chart audit in OctoberNovember 2007, just prior to final submission of the manuscript, determined that clinician use of order sets had increased to 92.6% of admitted medical patients, and that ordering of DVT prophylaxis in patients admitted with order sets had been sustained at 43.2% (P = 0.90 compared to period 3) (Figure 1).

DISCUSSION

We found that paper‐based order sets were associated with markedly increased use of DVT prophylaxis and made physician ordering more consistent with hospital consensus guidelines in multiple other areas, including laboratory test utilization and general care, while also increasing completeness of documentation. Given the difficulties and limited resources frequently associated with guideline development, dissemination, and implementation,12 it is worth noting that our improvements were achieved in a community hospital with voluntary physician adoption and no dedicated project funding, care process redesign, or healthcare worker education. The broad impact of order sets combined with minimal organizational resources required for implementation in this study suggests that this clinical decision support tool may have wide applicability.

The study hospital used paper‐based orders rather than CPOE, similar to 90% of U.S. hospitals at the time of the study.9 Order sets can be deployed in either paper‐based or computerized ordering systems. By providing a mechanism for entering large blocks of orders in an efficient manner, paper‐based order sets may be a necessary first step to facilitate the paper to CPOE transition, making them well suited to the current care delivery environment. Successful use of paper‐based order sets may help accelerate adoption of CPOE, which appears to be many years away from full implementation in the majority of U.S. hospitals.13

The most clinically important outcome in our study was a more than 4‐fold increase in ordering of DVT prophylaxis (last study period compared with baseline) in medical patients admitted with order sets, compared to a smaller increase in patients admitted without order sets. Our result is particularly significant as this study was performed in a community hospital, a setting with a lower adherence to DVT prophylaxis guidelines compared to academic centers.8, 14 The increase in DVT prophylaxis in patients admitted without order sets could be the result of a secular trend or a passive educational effect of order sets on physicians who only used order sets intermittently. The study was not publicized and thus was unlikely in itself to contribute to the increased performance.

We did not assess clinical outcomes of DVT or pulmonary embolism, but the clinical efficacy of improving adherence to DVT prophylaxis has been previously established.15 We also did not assess the appropriateness of DVT prophylaxis (or any other order). However, a recent multicenter Canadian observational study, using the American College of Chest Physician's Consensus Guidelines on Antithrombotic Therapy16 as a reference standard, found that 90% of medical patients admitted to hospital meeting study criteria had indications for thromboprophylaxis, but only 16% of eligible patients actually received it.8 In addition, multivariable regression analysis demonstrated even lower utilization in community hospitals compared to academic hospitals. These data suggest that the study hospital is typical of Canadian hospitals, and that the low overall utilization of DVT prophylaxis (13% of hospital patient‐days) prior to the availability of order sets in the study hospital is a significant gap between optimal and actual practice.

In addition, order sets had an impact on many secondary outcomes, such as standardization and completeness of orders (for example documentation of allergies and resuscitation status). While these effects appear to be beneficial in terms of quality of care and patient safety, the relationship of our secondary outcomes to patient‐important outcomes has not been established.

Furthermore, our before‐after design does not exclude the possibility of unknown confounding effects as explanations of improved performance in the order set group. For example, the change could have been driven by a small number of admitting physicians, since it is likely that order sets were adopted more readily by some physicians than others, and this group could have been responsible for a greater proportion of the admissions at different times. Unfortunately, we did not record the identity of the admitting physician. However, data from OctoberNovember 2007 show that >90% of medical patients were admitted using order sets, suggesting that voluntary clinician adoption of order sets has become nearly universal. Nevertheless, there still appear to be a few physicians who rarely or never used orders sets. Motivating these physicians to prescribe appropriate DVT prophylaxis remains a challenge.

Although this study was conducted in 1 center, other hospitals have similarly low rates of thromboprophylaxis,8 and our order set implementation strategy consumed few resources, improving the generalizability of our results. While most changes were beneficial, order set use was associated with decreased dating of orders and with an unintended effect or overall increase ordering of nightime sedation. Although the reasons for this are unclear, it highlights the importance of systematically evaluating the impact of order sets to identify unintended consequences and areas in which the order set may need to be redesigned to address these issues.

The study of order sets is preliminary despite their role as a key enabler for CPOE17 and their suggested usefulness to reduce medical error.18 For example, order sets were not considered in recent analyses of factors predicting success of computerized decision support systems19, 20 and have not been reviewed by the Cochrane Effective Practice and Organisation of Care Group.21 As discussed in the introduction, several studies have demonstrated that disease‐specific order sets can increase the use of evidence‐based treatments.46 Our study extends this work by demonstrating that admission order sets can improve performance hospital‐wide for a broad range of outcomes simultaneously, including DVT prophylaxis. Although most studies have demonstrated increased utilization of evidence‐based therapies, at least 1 study found no increased use of aspirin, heparin, or beta‐blockers in acute coronary syndrome admissions with the introduction of order sets.22 This suggests that the way order sets are structured or introduced is important to ensure that they achieve the desired changes in practice. Finally, our study suggests that improved outcomes using order sets can still be achieved with minimal organizational resources.

Order sets may potentially complement other decision support tools such as alerts and reminders. Alerts are an effective decision support tool12, 23, 24 but risk disrupting clinician workflow. Moreover, excessive alerts can lead to alert fatigue, resulting in many alerts being ignored.25 This phenomenon reduces alert effectiveness and limits the number of issues that alerts can address simultaneously. In contrast, order sets are broad in scope due to integration with clinical workflow, but lack the ability of alerts to apply rules to a specific patient's data. A potentially effective 2‐staged decision support strategy would use order sets as the primary admission decision support tool and selective alerts for remaining issues. This approach may increase the overall scope, physician adoption, and effectiveness of clinical decision support, and should be evaluated.

Our postintervention rate of DVT prophylaxis, while substantially improved from baseline, is still below ideal practice. Order sets were simply made available to clinicians admitting medical patients, who had the option to select DVT prophylaxis. Given limited resources, we did not develop and implement education programs regarding the appropriate use of DVT prophylaxis or make available any DVT risk assessment evaluations (available in Ref.26). Our study methodology thus provides a realistic assessment of improvements attainable in other hospitals with similarly limited resources. Additional increases in DVT prophylaxis rates would likely require a more comprehensive and resource‐intensive multifaceted quality improvement initiative. Detailed guidelines and supporting references for implementing such an initiative are available from the Society of Hospital Medicine.26 As described in their Venous Thromboembolism (VTE) Resource Room,26 such an initiative should include a standardized DVT risk assessment to guide the need for DVT prophylaxis integrated into admission order sets; prompts to order DVT prophylaxis when completing admission orders; and a system to audit adverse events and variations from best practice and return this information to clinicians.26

CONCLUSIONS

This is the largest and most comprehensive evaluation of the effectiveness of order sets as a clinical decision support tool. We found that order sets improved the quality of multiple patient orders and improved hospital‐wide DVT prophylaxis rates. These improvements were achieved in a community hospital with voluntary physician adoption and no dedicated project funding, care process redesign, or healthcare worker education. Although used in a paper‐based format in this study, order sets can also be employed in a computerized ordering environment. By providing a mechanism for entering large blocks of orders in an efficient manner, paper‐based order sets may be a necessary first step to facilitate the paper‐to‐CPOE transition. These attributes make order sets an attractive quality improvement tool in community and academic settings. More research is needed on the optimal design and use of this promising decision support tool.