Implementation effort: Reducing the ordering of inappropriate echocardiograms through a point-of-care decision support tool.

Study objective: Reduce inappropriate transthoracic echocardiograms (TTEs) using a series of Plan-Do-Study-Act (PDSA) quality improvement cycles. Design: Three PDSA cycles were designed with the first integrating a previously published decision support tool (DST) into the electronic TTE order, the second tailoring the DST to reflect the most common inappropriately ordered TTEs at our institution, and the third integrating direct clinician education. Setting: Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, USA. Participants: Consecutive patients were studied using the database of all TTEs performed at our institution without regard for specific patient characteristics. Interventions: Three PDSA Cycles as described above. Main outcome measure: Reduction in inappropriate TTEs at our institution. Results: After implementing our DST during the first cycle, no difference in inappropriate TTEs was observed (relative risk [RR] 0.71, p = 0.12, 95 % confidence interval [CI] 0.46-1.09). After the second cycle, we observed a reduction in the proportion of inappropriate TTEs (RR = 0.69, p = 0.014, 95 % CI 0.5-0.94), however two of the four inappropriate TTEs targeted by the DST increased. Feedback gathered from clinicians in the third cycle showed significant knowledge gaps regarding appropriate use criteria for TTE. Conclusions: At our facility, implementation of a DST failed to substantially reduce inappropriate TTEs, even when adapted to facility-specific ordering patterns. Gaps in clinician knowledge about TTEs may have contributed to the inefficacy of our DST.