1. 16 • CARING FOR THE AGES DECEMBER 2015
Caring Transitions
INTERACT Order Sets Target Avoidable Hospitalizations
By David Robertson and Joseph G. Ouslander, MD,
with James Lett, MD, CMD
This column strives to highlight innovations long-term care, major gaps remain in
in care transitions. This month, we discuss the translation of these resources into
an order set product that will enhance the practice.
INTERACT quality improvement program. To fill these gaps, Think Research
Caring for the Ages does not endorse Corporation collaborated with an
any specific product or products. expert advisory panel convened by
— James Lett, MD, CMD Joseph Ouslander, MD, the creator of
C
INTERACT (Interventions to Reduce
onsiderable attention is now fo- Acute Care Transfers), at Florida Atlantic
cused on preventing avoidable University to develop evidence-based
hospitalizations across a wide and consensus-derived INTERACT
spectrum of health care stakeholders in Compatible Order Sets that target 10 con-
the United States as a key way to improve ditions responsible for the majority of
care, prevent complications, and lower avoidable hospitalizations. Clinician order
system costs. Yet, limited attention is be- sets, a well-established practice in acute
ing paid to, or initiatives being targeted care for improving patient outcomes
at, the practice patterns of clinicians serv- while reducing costs, offer an important
ing skilled nursing facilities most often clinical resource to support reductions
responsible for transferring people to the in avoidable hospital transfers. Think
hospital. Despite significant progress by Research’s order sets were originally
organizations such as AMDA in devel- developed for acute care settings. A simi-
opment of leadership training, practice lar approach was used in the development
guidelines, and tools for clinicians in of the INTERACT compatible order sets.
INTERACT Compatible
Provider Order Sets
INTERACT is a widely adopted quality
improvement program focused on the
management of acute changes in condi-
tion in order to improve care and reduce
avoidable hospitalizations (see https://
interact.fau.edu/ or https://interact2.
net/).INTERACTisdesignedtoimprove
the early identification, assessment, doc-
umentation, and communication about
changes in condition of patients in SNFs.
A review of the INTERACT program is
available in the Journal of the American
Medical Directors Association ( J Am Med
Dir Assoc 2014;15:162–70).
Think Research (formerly
PatientOrderSets) is the market leader
in Canadian acute care development
and deployment of provider order sets.
Founded in 2006 by Chris O’Connor,
MD, a practicing critical care physician,
Think Research has established a unique
collaborative approach to creating and
improving clinical content. To advance
frommemorydrivenhand-writtenorders,
order sets are developed to provide a real-
time structured logic document that
guides a clinician as he or she determines
a patient’s individualized orders and
authorizes treatment. Electronic order
sets act as checklists that contain current
evidence-based, best practice treatment
options in a single document that follows
thecognitiveflowof aclinician.Ordersets
havebeenshowntoimprovepatientsafety
and outcomes (including a reduction in
avoidable30-dayreadmissions)inhospitals
and outpatient clinics in several studies.
Developing and maintaining the high-
est quality clinical content requires a
strong quality control process and input
from a variety of sources, including stan-
dards setting bodies (e.g., the Institute
for Safe Medication Practices), cross-
functional clinical perspectives (e.g.,
physicians, nurses, pharmacists, special-
ists), and subject matter experts includ-
ing clinical specialists and/or clinical
best-practice organizations (e.g., AMDA,
American Geriatrics Society, and more).
More costly traditional publishing
models of content development do not
leverage the existing potential of special-
ist clinical networks, nor do they provide
the data sharing required to enable an
ongoing assessment and renewal cycle
of clinical content.
Expert Advisory Group
Building on the success of Think
Research’s model in Canada, the com-
pany decided to expand into U.S. health
care. Given market conditions in the
United States — with the Affordable
Care Act and increasing attention on
avoidable hospitalizations — long-term
and post-acute care were identified as
benefiting the most, as standardization
and sharing of best practices through
order sets were not currently in place.
Think Research began work on con-
tent in Canada through a federally
funded grant (Canada Health Infoway)
to expand the library of reference order
sets to include long-term care. This led to
a library of more than 50 order sets and
several pilots in Canadian LTC homes,
where initial studies have demonstrated
what is already known from hospital
deployments — a reduction in medical
errors and increased use of best practices.
Because of the focus on avoidable hos-
pitalizations, it made sense to start by
developing order sets for conditions asso-
ciated with these events. Think Research
collaboratedwithDr.Ouslandertodevelop
the highest quality content for post-acute/
long-term care. Input was gathered from
an interdisciplinary expert advisory group
Skilled Nursing Facility
Urinary Tract Infection (UTI) Order Set
ACTION
ReferenceDocumentOnly
©2012PatientOrderSets.comLtd.Allrightsreserved.Unauthorizeduse,reproductionordisclosureisprohibited.
Submitted by: Read Back
ID PRINTED NAME YYYY-MM-DD HH:MM
Practitioner:
ID PRINTED NAME YYYY-MM-DD HH:MM SIGNATURE
08-14 V1 Page 1 of 6
Document allergies on approved form and ensure medication
reconciliation has been reviewed as per organizational process
RESIDENT/PATIENT INFORMATION
Symptoms of UTI may include: dysuria, lower abdominal pain or tenderness, blood in urine, new or worsening urinary
urgency, frequency or incontinence, and malaise or lethargy with no other identified cause
This order set is compatible with INTERACT
TM
Symptoms of Urinary Tract (UTI) Care Path (http://interact.fau.edu)
Clinician = Physician (MD/DO), Nurse Practitioner (NP), or Physician Assistant (PA)
Resident/Patient Risk Factors for Urinary Tract Infection (UTI)
Check/verify with the clinician the risk factors for UTI
Relevant History
UTI Other:
Invasive Device(s)
Urinary Catheter Other:
Lab Investigations
Additional Lab orders may be found in the following sections: Therapeutic Anticoagulation Adjustments and Follow-up
Nursing Management
***if a Urinalysis and Urine C&S are ordered, the results should be reviewed within 48-72 hours. If antibiotic therapy is
ordered, it should be modified or discontinued as indicated by the results***
Lab Investigations
CBC with Differential. STAT or ASAP as per facility Policy Reason:
Basic Metabolic Panel. STAT or ASAP as per facility Policy Reason:
(Electrolytes, Glucose, Creatinine, BUN)
Urinalysis and Urine C+S via clean catch specimen
Notify clinician of results within hours of collection (48-72 hours)
If antibiotics ordered, obtain urine sample before starting antibiotic therapy
Do not attempt to change or insert a catheter in a male resident with known prostate enlargement. Notify clinician
If a male resident/patient is unable to provide an adequate sample, apply a clean condom external collection system
to obtain urine sample
If unable to obtain an adequate sample from a female, perform a sterile in and out catheter for specimen
If indwelling urinary catheter in place, change catheter and send urine sample obtained from new catheter
***not recommended to routinely recheck Urinalysis or Urine C+S post antibiotic therapy***
Other: . STAT or ASAP as per facility Policy Reason:
SMITH, JOHN W
DOB: 1977-06-11 M
Visit #: EN8557957373
829 AVENUE ROAD
Toronto, ON M5X 1G9
416-333-6696
Hydration
PO/Enteral Tube
If not contraindicated, encourage PO fluids
Offer mL of PO fluids q h when awake for days
Encourage PO fluid intake to Liter(s) per 24 hours for days (1 – 2 Liters)
If on enteral nutrition, (increase or decrease) H2O flushes with mL q h
for days
Other:
Free-text order
lines
Optional and
default orders
Standardized
format
Evidence-based /
expert recommended
ordering options
Customized to
facility needs
Visual alerts and
reminders
Order sets are
available for all
INTERACTTM
care paths
From Think Research Corporation, Toronto, Ontario, Canada.

2. CARINGFORTHEAGES.COM CARING FOR THE AGES • 17
in order to refine order sets specifically
focused on the 10 conditions addressed by
INTERACTCarePathsandothertoolsthat
are responsible for documenting patient
care in a majority of avoidable hospital-
izations. This input was obtained during
a 2-day in-person meeting that was pre-
ceded by draft review of the order sets by
the panel. Then, the group provided more
input through an iterative process over the
next several months. The group specifi-
cally focused on 1) using evidence where it
existed;2)highlightingimportantfactorsto
consider related to specific orders; and 3)
structuring the orders in a way that aligns
with how a clinician thinks when writing
orders. The work of Think Research and
the expert advisory group resulted in 10
reference order sets compatible with the
10CarePathsof theINTERACTprogram
(J Am Med Dir Assoc 2015;16:524–6).
Pilot Testing the Order Sets
Practices that implement order sets
require a strong change management
approach and should customize to local
clinical settings to obtain the greatest
impact. Reference order sets are reviewed
by the clinical leadership of a practice
and/or facility to 1) obtain user buy-in
and adoption; 2) ensure alignment to facil-
ity capability and workflow (and confi-
dence in decisions to treat on-site); and
3) align with local formularies to ensure
availability of treatments in preventing
transfers.
In addition to clinical customization,
integration with local information tech-
nology (e.g., a facility and/or provider
electronic health record system) facili-
tates easier adoption by clinicians. To
accommodate the current landscape
of multiple EHR systems both within
and across health care settings, Think
Research has developed an EHR-neutral
technology platform that enables inte-
gration into any IT scenario, including
existing paper-based charting.
INTERACT Compatible Order Sets are
currently being used to support the tele-
medicine program that is being rolled out
in all six of the University of Pittsburgh
Medical Center-owned SNFs under the
leadership of Steven M. Handler, MD,
PhD. The telemedicine service is avail-
able to support the remote evaluation of
residents with acute changes of condi-
tion during evenings and weekends when
providers are generally unavailable. Dr.
Handler was part of the Think Research
U.S. LTC expert advisory group and is
responsible for the local change manage-
ment approach and clinical customization
of the order sets to the UPMC clinical
environment. To maximize the effective-
ness of the order sets, they were refined
based on the clinical capabilities, medica-
tions available in the emergency boxes,
and policies and procedures of the SNFs.
INTERACT Compatible Order Sets
are also being pilot tested as part of a
Centers for Medicare & Medicaid Services
Innovation Award focused on reducing
unnecessary hospitalizations of long-stay
SNF patients (see http://innovation.cms.
gov/initiatives/rahnfr/). This pilot and
evaluation project is underway in several
Nevada SNFs through a partnership with
HealthInsight,aqualityimprovementorga-
nization where Steven Phillips, MD, serves
as medical director for the CMS project.
This work is intended to help refine real-
world workflows, data, and experience
to promote further dissemination of the
order sets. Numerous studies have con-
firmed the positive impact on outcomes
for both patients and payers in a health sys-
temthroughordersetdeployment,andwe
expect the work in Nevada to corroborate
a similar impact in the SNF setting.
Value Proposition
Order sets provide value to health care
delivery in several ways. They have been
shown in early studies to increase the
use of best practices in ordering and
reducing medical errors. There are more
potential cost savings through a reduc-
tion in hospital-acquired complications.
Given current funding models for SNFs,
the most significant financial incentives
result from the impact on census in a
facility — either through a reduction in
lost days to current residents or through
an increase in referrals resulting from a
facility’s improved reputation.
There are many other potential finan-
cial benefits to order sets. Detailed,
order-level data grouped around patients,
clinicians, clinical issues, and organiza-
tions will provide a quality improvement
platform to support examination of prac-
tice variability against a variety of patient
outcomes.
To find out more about order sets,
visit www.thinkresearch.com, or email
info@thinkresearch.com. CfA
Mr. Robertson currently leads the U.S.
launch of Think Research, establishing
a collaborative network for health system
transitions of care tools, including the
development of INTERACT Compatible
Order Sets with Florida Atlantic University.
Dr. Ouslander is a professor and senior
associate dean for geriatric programs; chair,
Department of Integrated Medical Sciences,
Charles E. Schmidt College of Medicine;
and professor (courtesy), Christine E. Lynn
College of Nursing, at FAU. Dr. Ouslander
is also the executive editor of the Journal of
the American Geriatrics Society.
Dr. Lett, a past AMDA president, chaired
the AMDA workgroup that created the
clinical practice guideline “Care Transitions
in the Long-Term Care Continuum”
and currently is chairman of the AMDA
Transitions of Care Committee. Dr. Lett
and his wife, Cheryl Phillips, MD, were
compensated members of the panel assembled
by Dr. Ouslander to assist in the creation of
the order sets discussed in this column.
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