Using ‘nudge’ principles for order set design: a before and after evaluation of an electronic prescribing template in critical care

Objective Computerised order sets have the potential to reduce clinical variation and improve patient safety but the effect is variable. We sought to evaluate the impact of changes to the design of an order set on the delivery of chlorhexidine mouthwash and hydroxyethyl starch (HES) to patients in the intensive care unit. Methods The study was conducted at University Hospitals Bristol NHS Foundation Trust, UK. Our intensive care unit uses a clinical information system (CIS). All drugs and fluids are prescribed with the CIS and drug and fluid charts are stored within a database. Chlorhexidine mouthwash was added as a default prescription to the prescribing template in January 2010. HES was removed from the prescribing template in April 2009. Both interventions were available to prescribe manually throughout the study period. We conducted a database review of all patients eligible for each intervention before and after changes to the configuration of choices within the prescribing system. Results 2231 ventilated patients were identified as appropriate for treatment with chlorhexidine, 591 before the intervention and 1640 after. 55.3% were prescribed chlorhexidine before the change and 90.4% after (p