Development of a Web-Based Nonoperative Small Bowel Obstruction Treatment Pathway App

Abstract

Objective An electronic pathway for the management of adhesive small bowel obstruction (SBO) was built and implemented on top of the electronic health record. The aims of this study are to describe the development of the electronic pathway and to report early outcomes.

Methods The electronic SBO pathway was designed and implemented at a single institution. All patients admitted to a surgical service with a diagnosis of adhesive SBO were enrolled. Outcomes were compared across three time periods: (1) patients not placed on either pathway from September 2013 through December 2014, (2) patients enrolled in the paper pathway from January 2017 through January 2018, and (3) patients enrolled in the electronic pathway from March through October 2018. The electronic SBO pathway pulls real-time data from the electronic health record to prepopulate the evidence-based algorithm. Outcomes measured included length of stay (LOS), time to surgery, readmission, surgery, and need for bowel resection. Comparative analyses were completed with Pearson's chi-squared, analysis of variance, and Kruskal–Wallis tests.

Results There were 46 patients enrolled in the electronic pathway compared with 93 patients on the paper pathway, and 101 nonpathway patients. Median LOS was lower in both pathway cohorts compared with those not on either pathway (3 days [range 1–11] vs. 3 days [range 1–27] vs. 4 days [range 1–13], p = 0.04). Rates of readmission, surgery, time to surgery, and bowel resection were not significantly different across the three groups.

Conclusion It is feasible to implement and utilize an electronic, evidence-based clinical pathway for adhesive SBOs. Use of the electronic and paper pathways was associated with decreased hospital LOS for patients with adhesive SBOs.

Keywords

pathways - digital health - Web-based application - EHR - surgery

• References

• 1 Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med 2010; 8: 31
• 2 Zhang Y, Padman R. Data-driven clinical and cost pathways for chronic care delivery. Am J Manag Care 2016; 22 (12) 816-820
• 3 Spiegel TF, Wassermann TB, Neumann N. , et al. A clinical pathway for heart failure reduces admissions from the ED without increasing congestion in the ED. Am J Emerg Med 2018; 36 (07) 1202-1208
• 4 Than MP, Pickering JW, Dryden JM. , et al; ICare-ACS Implementation Group. ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): a study of cross-system implementation of a national clinical pathway. Circulation 2018; 137 (04) 354-363
• 5 Austrian JS, Volpicelli F, Jones S. , et al. The financial and clinical impact of an electronic health record integrated pathway in elective colon surgery. Appl Clin Inform 2020; 11 (01) 95-103
• 6 Rao G, Kirley K, Epner P. , et al. Identifying, analyzing, and visualizing diagnostic paths for patients with nonspecific abdominal pain. Appl Clin Inform 2018; 9 (04) 905-913
• 7 Catena F, Di Saverio S, Coccolini F. , et al. Adhesive small bowel adhesions obstruction: evolutions in diagnosis, management and prevention. World J Gastrointest Surg 2016; 8 (03) 222-231
• 8 Azagury D, Liu RC, Morgan A, Spain DA. Small bowel obstruction: a practical step-by-step evidence-based approach to evaluation, decision making, and management. J Trauma Acute Care Surg 2015; 79 (04) 661-668
• 9 Keenan JE, Turley RS, McCoy CC, Migaly J, Shapiro ML, Scarborough JE. Trials of nonoperative management exceeding 3 days are associated with increased morbidity in patients undergoing surgery for uncomplicated adhesive small bowel obstruction. J Trauma Acute Care Surg 2014; 76 (06) 1367-1372
• 10 Ceresoli M, Coccolini F, Montori G, Sartelli M, Catena F, Ansaloni L. Water-soluble contrast agent in adhesive small bowel obstruction: the game is still on. Surgery 2017; 162 (01) 199-200
• 11 Ceresoli M, Coccolini F, Catena F. , et al. Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value. Am J Surg 2016; 211 (06) 1114-1125
• 12 Assalia A, Schein M, Kopelman D, Hirshberg A, Hashmonai M. Therapeutic effect of oral Gastrografin in adhesive, partial small-bowel obstruction: a prospective randomized trial. Surgery 1994; 115 (04) 433-437
• 13 Abbas S, Bissett IP, Parry BR. Oral water soluble contrast for the management of adhesive small bowel obstruction. Cochrane Database Syst Rev 2007; (03) CD004651
• 14 Zhang Y, Padman R. An interactive platform to visualize data-driven clinical pathways for the management of multiple chronic conditions. Stud Health Technol Inform 2017; 245: 672-676
• 15 Lyu HG, Castillo-Angeles M, Bruno M. , et al. Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction. J Trauma Acute Care Surg 2019; 87 (03) 630-635
• 16 Mandl KD, Kohane ISA. A 21st-century health IT system - creating a real-world information economy. N Engl J Med 2017; 376 (20) 1905-1907
• 17 Trevino CM, VandeWater T, Webb TP. Implementation of an adhesive small bowel obstruction protocol using low-osmolar water soluble contrast and the impact on patient outcomes. Am J Surg 2019; 217 (04) 689-693
• 18 Rodriguez-Loya S, Aziz A, Chatwin C. A service oriented approach for guidelines-based clinical decision support using BPMN. Stud Health Technol Inform 2014; 205: 43-47
• 19 Zhang Y, Padman R, Patel N. Paving the COWpath: learning and visualizing clinical pathways from electronic health record data. J Biomed Inform 2015; 58: 186-197
• 20 Sahota N, Lloyd R, Ramakrishna A. , et al; CCDSS Systematic Review Team. Computerized clinical decision support systems for acute care management: a decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implement Sci 2011; 6 (01) 91-98
• 21 Griffey RT, Lo HG, Burdick E, Keohane C, Bates DW. Guided medication dosing for elderly emergency patients using real-time, computerized decision support. J Am Med Inform Assoc 2012; 19 (01) 86-93
• 22 Hemens BJ, Holbrook A, Tonkin M. , et al; CCDSS Systematic Review Team. Computerized clinical decision support systems for drug prescribing and management: a decision-maker-researcher partnership systematic review. Implement Sci 2011; 6 (01) 89
• 23 Rotter T, Plishka C, Hansia MR. , et al. The development, implementation and evaluation of clinical pathways for chronic obstructive pulmonary disease (COPD) in Saskatchewan: protocol for an interrupted times series evaluation. BMC Health Serv Res 2017; 17 (01) 782
• 24 Horvath KJ, Ecklund AM, Hunt SL, Nelson TF, Toomey TL. Developing Internet-based health interventions: a guide for public health researchers and practitioners. J Med Internet Res 2015; 17 (01) e28
• 25 CDS Hooks [Internet], Ann Arbor & Boston: HL7 & Boston Children's Hospital; 2019. Available at: https://cds-hooks.hl7.org/ . Accessed March 2, 2020