Implementing guideline recommendations into an electronic health record notes template can improve guideline adherence in patients undergoing esophagogastroduodenoscopy for upper gastrointestinal bleeding, according to a recent single-center, prospective study.

Appropriate post–upper EGD care in patients with upper gastrointestinal bleeding (UGIB) can improve patient outcomes and reduce cost, but not all recommendations are consistently followed. Researchers at the University of Colorado School of Medicine Anschutz Medical Campus, in Aurora, attempted to improve guideline adherence by adding a notes template to EHRs to prompt appropriate documentation and follow-up care. The notes templates were tailored to the etiology and severity of the UGIB based on the 2007 American Association for the Study of Liver Diseases guidelines on variceal UGIB, the 2019 International Consensus Group guidelines on nonvariceal UGIB and established 2015 quality measures from the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy.

All adults who underwent inpatient EGD for GI bleeding or anemia between June 2019 and July 2021 were included in the study. The researchers compared 199 participants enrolled pre-implementation and 459 were enrolled post-implementation. Outcomes included “process metrics,” which evaluated completeness of the various sections of the notes template (e.g., patient disposition, diet, medication, bleeding outcomes and follow-up care recommendations), and “clinical care metrics,” which evaluated implementation of guideline recommendations on medication regimens and follow-up EGD.

Notable differences between patients in the post- and pre-implementation groups include the proportion with advanced American Society of Anesthesiologists physical status classification (82.6% vs. 58.3%; P<0.001), higher risk lesions (33.3% vs. 22.7%; P=0.007) and concurrent lesions (73.2% vs. 63.3%; P=0.011). In addition, overall endoscopy center procedural volume was lower in the post-implementation group compared with the pre-implementation group (41.3 vs. 51.5 procedures per day; P<0.001).

Overall, the notes template was used for 82.6% of procedures for which it was available. After implementation of the notes template, endoscopists spend an average of two minutes less on the EGD. The completion of a Minimally Standard Report (defined as an EGD report with patient disposition, diet and etiology-specific medication recommendation completed in the notes template) increased to 42.5% after implementation from 28.6% before (P<0.001). This was largely driven by post-implementation increases in completion of recommendations related to diet and disposition because completion of those related to proton pump inhibitor, antibiotics and octreotide completion did not change after implementation.

With regard to the clinical care metrics, compliance with inpatient (77.9% vs. 53.4%; P<0.001) and discharge (61.0% vs. 31.3%; P<0.001) PPI prescriptions among those with non-portal hypertensive bleeding improved after implementation. In addition, among those with variceal bleeding, compliance with inpatient octreotide orders improved after implementation (93.6% vs. 75.0%; P=0.002). Lastly, appropriate coordination of repeat EGD improved post-implementation (87.1% vs. 61.3%; P<0.001). However, there were no significant changes in compliance with antibiotics recommendations or bleeding cessation between the two groups.

Several aspects of their interventions stand out to the researchers as important to its success, including that the templates integrated relatively seamlessly with the current EGD workflow, were easy to learn how to use and reduced miscommunication between various inpatient and outpatient specialists involved in the care of EGD patients.

The researchers noted that they hope to use their findings to make adjustments in the template to further improve care quality and seek to create new templates for other endoscopic procedures.

—Natasha Albaneze, MPH