Effect of Best Practice Advisories on Sedation Protocol Compliance and Drug-Related Hazardous Condition Mitigation Among Critical Care Patients*

Abstract

To determine whether best practice advisories improved sedation protocol compliance and could mitigate potential propofol-related hazardous conditions. Retrospective observational cohort study. Two adult ICUs at two academic medical centers that share the same sedation protocol. Adults 18 years old or older admitted to the ICU between January 1, 2016, and January 31, 2018, who received a continuous infusion of propofol. Two concurrent best practice advisories built in the electronic health record as a clinical decision support tool to enforce protocol compliance with triglyceride and lipase level monitoring and mitigate propofol-related hazardous conditions. The primary outcomes were baseline and day 3 compliance with triglyceride and lipase laboratory monitoring per protocol and time to discontinuation of propofol in the setting of triglyceride and/or lipase levels exceeding protocol cutoffs. A total of 1,394 patients were included in the study cohort (n = 700 in the pre–best practice advisory group; n = 694 in the post–best practice advisory group). In inverse probability weighted regression analyses, implementing the best practice advisory was associated with a 56.6% (95% CI, 52.6–60.9) absolute increase and a 173% relative increase (risk ratio, 2.73; 95% CI, 2.45–3.04) in baseline laboratory monitoring. The best practice advisory was associated with a 34.0% (95% CI, 20.9–47.1) absolute increase and a 74% (95% CI, 1.39–2.19) relative increase in day 3 laboratory monitoring after inverse probability weighted analyses. Among patients with laboratory values exceeding protocol cutoffs, implementation of the best practice advisory resulted in providers discontinuing propofol an average of 16.6 hours (95% CI, 4.8–28.3) sooner than pre–best practice advisory. Findings from alternate analyses using interrupted time series were consistent with the inverse probability weighted analyses. Best practice advisories can be effectively used in ICUs to improve sedation protocol compliance and may mitigate potential propofol-related hazardous conditions. Best practice advisories should undergo continuous quality assurance and optimizations to maximize clinical utility and minimize alert fatigue.