NUR 307 Module 5 Clinical Decision Support Short Paper Example

Dismissed Twenty Times a Shift: Evaluating and Redesigning an Early Mobility Prompt in the Electronic Health Record

[Student Name]

Southern New Hampshire University

NUR 307: Exploring Information Technology for Professional Practice

Module Five Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Dismissed Twenty Times a Shift: Evaluating and Redesigning an Early Mobility Prompt in the Electronic Health Record

Clinical decision support is meant to put the right information in front of clinicians when it will change what they do. When it works, nurses barely notice it. When it fails, it becomes one more box to close. This paper evaluates a composite nurse-facing alert on a medical unit that prompts nurses about patient mobility, a goal almost everyone agrees with. It argues that the alert is failing not because nurses disagree with its goal but because it fires at the wrong moment, repeats itself and asks the wrong person to act, and that a redesign guided by the five rights of decision support can keep the goal while removing most of the interruptions.

The Alert

On 6 North, a composite 28-bed medical unit, nurses document mobility every shift using an eight-level scale ranging from lying in bed to walking 250 feet or more. Eight months ago, the hospital added an interruptive alert that appears when a nurse opens the medication administration screen for a patient whose mobility score is missing or has been 4 or lower for 24 hours. The alert reads that the patient is at risk of functional decline and should be mobilized, and it requires the nurse to select a reason to dismiss it. A two-week review by the unit's informatics nurse found that the alert fired an average of 21 times per nurse per 12-hour shift, and that 94% of firings were dismissed, most often with the reason patient refuses or already addressed. These figures are composites for this example.

Why the Goal Matters

The goal behind the alert is sound. Brown et al. (2009) used activity monitoring to show that older adults in the hospital are in bed for the great majority of the day and upright only briefly, a pattern they described as an underrecognized epidemic of low mobility linked to functional decline. Hoyer et al. (2016) reported a quality improvement project on two general medicine units that used the same eight-level mobility scale. Comparing the early and later phases of the project, the share of patients reaching walking status rose from 43% to 70%, and the project was associated with a shorter adjusted median length of stay, without an increase in injurious falls. Mobility is worth prompting. The question is how.

Evaluation Against the Five Rights

Osheroff et al. (2012) set out five conditions that good decision support has to meet, usually called the five rights. It must carry useful information, reach the clinician who can act on it, take a form suited to the task, arrive by a suitable route and appear at a point in the workflow when acting is possible. Measured against them, the mobility alert fails on four. The information is generic; it tells the nurse something the nurse already knows and says nothing about what is limiting this patient. The person is often wrong: on 6 North, many patients are walked by mobility technicians and physical therapists, not the medication nurse. The format is an interruptive pop-up, the most disruptive option available. The time is wrong, since the alert fires during medication administration, when a nurse is focused on the five rights of medication safety and cannot stop to walk a patient. Only the channel, the electronic record, is reasonable.

Why Nurses Override It

The dismissal rate is predictable from research on alert fatigue. Ancker et al. (2017) analyzed alerts and reminders received by 112 primary care clinicians over three and a half years. Roughly one reminder in three had already fired for that patient earlier in the year, and the likelihood of accepting a reminder fell by 30% for each additional reminder received per encounter and by 10% for each five-point rise in the proportion of repeated reminders. The study was done in primary care, not inpatient nursing, but its mechanism fits 6 North closely: the mobility alert repeats every time a nurse opens the medication screen for the same patient, and nurses learn quickly that most firings contain nothing new. High override rates here are not carelessness; they are a rational response to low-value interruptions.

A Redesign

The redesign keeps the goal and changes the delivery. First, remove the interruptive alert from the medication screen. Second, replace it with a passive column on the unit's patient list showing each patient's current mobility score, target score and hours since last walked, visible to nurses, mobility technicians and physical therapists. Third, route a single daily task, not a pop-up, to the mobility technician for patients below target, and bring the list to the morning safety huddle so the team can decide who needs a therapy consult. Fourth, when a patient cannot move, let the nurse document the barrier once, such as pain, orthostatic hypotension or an order for bed rest, and suppress further prompts until the barrier changes. Each change maps to a right: better information, the right person, a less disruptive format and a moment in the workflow meant for planning.

Measuring the Redesign

The redesign should be judged by outcomes, not only by fewer clicks. Measures should include the share of patients reaching their mobility target each day, the share of patients reaching walking status during the stay, falls with injury, nurse-reported interruptions and the time mobility technicians spend walking patients. If mobility falls after the alert is removed, the passive display is not working and needs to be revisited. Nurses should sit on the design team, because they are the ones who know when in the shift a mobility decision can actually be made.

Conclusion

The mobility alert on 6 North pursues a goal supported by evidence and fails because of design. Evaluated against the five rights, it gives generic information to the wrong person in a disruptive format at a bad moment, and research on repeated alerts explains why nurses dismiss it. A passive display, a routed task, a huddle and a documented barrier that suppresses repeats would keep patients moving without asking nurses to close the same box twenty times a shift.

References

Ancker, J. S., Edwards, A., Nosal, S., Hauser, D., Mauer, E., Kaushal, R., & HITEC Investigators. (2017). Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Medical Informatics and Decision Making, 17, Article 36. https://doi.org/10.1186/s12911-017-0430-8

Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660-1665. https://doi.org/10.1111/j.1532-5415.2009.02393.x

Hoyer, E. H., Friedman, M., Lavezza, A., Wagner-Kosmakos, K., Lewis-Cherry, R., Skolnik, J. L., Byers, S. P., Atanelov, L., Colantuoni, E., Brotman, D. J., & Needham, D. M. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project. Journal of Hospital Medicine, 11(5), 341-347. https://doi.org/10.1002/jhm.2546

Osheroff, J. A., Teich, J. M., Levick, D., Saldana, L., Velasco, F. T., Sittig, D. F., Rogers, K. M., & Jenders, R. A. (2012). Improving outcomes with clinical decision support: An implementer's guide (2nd ed.). HIMSS.