Impact of Order Set Design on Pediatric Intravenous Fluid Guideline Adherence: A National Study

OBJECTIVES: We sought to describe order set designs implemented by hospitals participating in the national Standardization of Fluids in Inpatient Settings (SOFI) trial and drivers of design decisions. We explored associations between order set design and the SOFI primary outcome of guideline-concordant exclusive isotonic intravenous fluid (IVF) use. PATIENTS AND METHODS: We surveyed site leaders to characterize order set modifications and understand drivers. We used applied thematic analysis to analyze qualitative data. We combined quantitative survey data with SOFI data to evaluate associations between order set changes and guideline adherence using linear mixed-effects regression models. RESULTS: One hundred site leaders were surveyed twice during the SOFI trial (92% response rate). Order set modifications were predominantly made to admission order sets and included listing isotonic IVF first with no preselected order (44%), removing hypotonic fluid options (61%), and preselecting isotonic IVF by default (39%). Drivers of order set design included facilitating personalized care, navigating information technology limitations, preserving clinician autonomy, managing order set ownership, and seeking consensus. Order sets listing isotonic IVF first but without preselecting this option were associated with an additional increase of 3.5% (95% CI 1.1%-5.9%; P = .005) in exclusive isotonic IVF use above the aggregate SOFI intervention effect. CONCLUSIONS: We identified drivers of order set design and found that listing guideline-concordant orders first in order sets was associated with increased guideline adherence. Future quality improvement efforts may benefit from this approach, which increases clinician efficiency, maintains autonomy, and promotes order set applicability to multiple patient populations.