Clinical Decision Support Aiming to Accelerate Triage and Time to Dextrose-Containing IV Fluids in the ED for Children with Severe Metabolic Conditions

Abstract

Objectives

This study aimed to describe human-centered design of clinical decision support (CDS) for children with metabolic diseases at high risk of rapid decompensation, assess the influence of CDS on care processes and patient outcomes, and share insights from the implementation.

Methods

A CDS was designed in collaboration with pediatric genetics experts to provide accelerated triage and recommend dextrose-containing fluids for patients metabolic conditions. Formative usability testing was conducted with emergency department (ED) nurses and providers. Pre- and post-intervention data on triage, alert acceptance, and order set usage, as well as clinical outcomes such as time to dextrose fluids, intensive care unit (ICU) admission rates, and length of stay, were compared.

Results

Provider alert acceptance was at 39%. Following CDS implementation, nurse triage at Emergency Severity Index (ESI) <3 (ESI 1 or ESI 2 to escalate patients with metabolic conditions to a higher severity) increased from 84 to 98%. Time to dextrose-containing fluids from patient rooming to administration decreased significantly from 101 to 82 minutes (p = 0.006) for all patients with metabolic conditions, and from 110 to 88 minutes (p = 0.029) for those admitted to the hospital. However, the median time from arrival to fluids administration saw a non-significant reduction from 114 to 102 minutes (p = 0.07). ICU admission rates remained stable pre- and post-intervention (13% vs. 14%; p = 0.60), and there was no significant change in total length of stay.

Conclusion

The CDS, developed through a user-centered design approach, improved appropriateness of triage acuity rates and reduced the time from rooming to administration of dextrose-containing fluids for children with metabolic diseases at risk of rapid decompensation. The study did not demonstrate a significant change in ICU admissions or length of stay, possibly due to increased patient load and external factors. The findings emphasize the importance of usability testing and clinician-centered design for effective CDS integration.

Keywords

clinical decision support - pediatrics - human-centered design - emergency department - pediatrics

Protection of Human and Animal Subjects

This work was done as part of quality improvement in operations and was deemed non-human subjects research (STUDY00000393).

Publication History

Received: 23 January 2025

Accepted: 25 July 2025

Article published online:
11 September 2025

• References

• 1 Ibrahim SY, Vaqar S, Temtem T. Medium-Chain Acyl-CoA Dehydrogenase Deficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025
• 2 MacNeill EC, Walker CP. Inborn errors of metabolism in the emergency department (undiagnosed and management of the known). Emerg Med Clin North Am 2018; 36 (02) 369-385
• 3 Kandaswamy S, Williams H, Thompson SA, Dawson TE, Muthu N, Orenstein EW. Realizing the full potential of clinical decision support: translating usability testing into routine practice in health care operations. Appl Clin Inform 2024; 15 (05) 1039-1048
• 4 Chaparro JD, Beus JM, Dziorny AC. et al. Clinical decision support stewardship: best practices and techniques to monitor and improve interruptive alerts. Appl Clin Inform 2022; 13 (03) 560-568
• 5 Li RC, Wang JK, Sharp C, Chen JH. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. BMJ Qual Saf 2019; 28 (12) 987-996
• 6 Melton BL, Zillich AJ, Russell SA. et al. Reducing prescribing errors through creatinine clearance alert redesign. Am J Med 2015; 128 (10) 1117-1125
• 7 McGreevey III JD. Order sets in electronic health records: principles of good practice. Chest 2013; 143 (01) 228-235
• 8 Kellogg KM, Fairbanks RJ, Ratwani RM. EHR usability: get it right from the start. Biomed Instrum Technol 2017; 51 (03) 197-199