Addressing Alert Fatigue by Replacing a Burdensome Interruptive Alert with Passive Clinical Decision Support

Background: Recognizing that alert fatigue poses risks to patient safety and clinician wellness, there is a growing emphasis on evaluation and governance of electronic health record clinical decision support (CDS). This is particularly critical for interruptive alerts to ensure they achieve desired clinical outcomes while minimizing the burden on clinicians. This study describes an improvement effort to address a problematic interruptive alert intended to notify clinicians about patients needing Coronavirus disease 2019 (COVID) precautions and how we collaborated with operational leaders to develop an alternative passive CDS system in acute care areas. Objectives: Our dual aim was to reduce the alert burden by re-designing the CDS to adhere to best practices for decision support while also improving the percent of admitted patients with symptoms of possible COVID who had appropriate and timely infection precautions orders. Methods: Iterative changes to CDS design included adjustment to alert triggers and acknowledgment reasons and development of a non-interruptive rule-based order panel for acute care areas. Data on alert burden and appropriate precautions orders on symptomatic admitted patients were followed over time on run and attribute (p) and individuals-moving range (X-mR) control charts.. Results: At baseline, the COVID alert fired on average 8206 times per week with an alert per encounter rate of 0.36. After our interventions, the alerts per week decreased to 1449 and alerts per encounter to 0.07 equating to an 80% reduction for both metrics. Concurrently, the percentage of symptomatic admitted patients with COVID precautions ordered increased from 23% to 61% with a reduction in the mean time between COVID test and precautions orders from 19.7 to -1.3 minutes. Conclusion: CDS governance, partnering with operational stakeholders, and iterative design led to successful replacement of a frequently firing interruptive alert with less burdensome passive CDS that improved timely ordering of COVID precautions.