Impact of Human Factor Design on the Use of Order Sets in the Treatment of Congestive Heart Failure

BACKGROUND: Although standardized physician order sets are often part of quality improvement projects, the specific design elements contributing to increased adoption and compliance with use often are not considered. OBJECTIVES: To evaluate the impact of human factor design elements on congestive heart failure (CHF) order set utilization, and compliance with recommended CHF clinical practice guidelines (CPG). METHODS: This was a descriptive retrospective medical record review of adult patients who were admitted from our emergency department with the primary diagnosis of CHF. We collected data on acuity and CPG parameters before and after the introduction of a new CHF order set. The new orders were succinct and visually well organized, with narrative information to encourage use of CPG. RESULTS: Eighty-seven patients were studied before, and 84 after, the introduction of new orders. There were no differences in the use of the order sets based on patient acuity before or after the intervention. Order set use significantly increased by the first postintervention interval (POST) and reached 72% (95% confidence interval [CI] = 52% to 86%) during the third POST, compared with a baseline utilization of 9% (95% CI = 5% to 17%; p < 0.001). Compliance with CPG for angiotensin-converting enzyme reached significance in the second POST and was maintained in the third at 83% (95% CI = 61% to 94%), compared with a baseline value of 25% (95% CI = 7% to 59%; p = 0.008). Intravenous nitroglycerin also increased significantly from the first POST and reached 78% (95% CI = 55% to 91%) in the third POST, compared with baseline of 12% (95% CI = 2% to 47%; p < 0.003). Furosemide dosing, systolic blood pressure reduction, and urine output did not significantly change. CONCLUSIONS: Introduction of an order set for CHF with attention to human factor design elements significantly improved utilization of the orders and compliance with CPG.