Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study
Authors: Shah Surbhi , Switzer Sean , Shippee Nathan D , Wogensen Pamela , Kosednar Kathryn , Jones Emma , Pestka Deborah L , Badlani Sameer , Butler Mary , Wagner Brittin , White Katie , Rhein Joshua , Benson Bradley , Reding Mark , Usher Michael , Melton Genevieve B , Tignanelli Christopher James 
Published: September 2021

Background
Studies evaluating strategies for the rapid development, implementation, and evaluation of clinical decision support (CDS) systems supporting guidelines for diseases with a poor knowledge base, such as COVID-19, are limited.

Objective
We developed an anticoagulation clinical practice guideline (CPG) for COVID-19, which was delivered and scaled via CDS across a 12-hospital Midwest health care system. This study represents a preplanned 6-month postimplementation evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.

Methods
The implementation outcomes evaluated were reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission with clinical outcomes was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to intensive care unit (ICU) admission. The models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir treatment, tocilizumab treatment, steroid treatment, BMI, Elixhauser comorbidity index, oxygen saturation/fraction of inspired oxygen ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients who had laboratory values (D-dimer, C-reactive protein, creatinine, and absolute neutrophil to absolute lymphocyte ratio) present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission.

Results
A total of 2503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was the highest at hospitals that were specifically transformed to only provide care to patients with COVID-19 (COVID-19 cohorted hospitals; 74%-82%) and the lowest in academic settings (47%-55%). CPG delivery via the CDS system was associated with improved adherence (odds ratio [OR] 1.43, 95% CI 1.2-1.7; P<.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU admission within 48 hours (OR 0.39, 95% CI 0.30-0.51; P<.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients who received adherent versus nonadherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours; log-rank test P<.001).

Conclusions
Our institutional experience demonstrated that adherence with the institutional CPG delivered via the CDS system resulted in improved clinical outcomes for patients with COVID-19. CDS systems are an effective means to rapidly scale a CPG across a heterogeneous health care system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units.