• D L Schriger, L J Baraff, W H Rogers, and S Cretin.
• UCLA Emergency Medicine Center, University of California, Los Angeles, School of Medicine, USA. schriger@ucla.edu
• JAMA. 1997 Nov 19;278(19):1585-90.

ContextWhile clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care.ObjectiveTo determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines.DesignProspective off-on-off, interrupted time series with intent-to-treat analysis.SettingUniversity hospital emergency department.SubjectsPatients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study.InterventionsImplementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines.Main Outcome MeasuresQuality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities.ResultsMean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase; 95% confidence interval [CI], 34%-49%) and 11 items in aftercare instruction increased from 31 % at baseline to 93% during the intervention phase (62% increase; 95% CI, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% CI, 9%-31 %) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% CI, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase; 95% CI, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively.ConclusionsUse of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.

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