Use of a Computerized Forcing Function Improves Performance in Ordering Restraints

Study objective: We evaluate the effect of a computerized order entry system forcing function on improving timely renewal of restraint orders. Methods: In this prospective study of 2 successive interventions, physicians received computerized reminders to renew or discontinue restraint orders before their expiration. The initial intervention allowed acknowledgement of this reminder without further consequence, changing at 6 months to deny computer access until addressed. We performed chart review on emergency department visits with restraint orders in 3 consecutive 6-month periods (A, B, C) separated by these 2 interventions, determining time to order renewal, number of restraint orders, renewal orders per hour in restraints, and time in restraints and evaluating variability in these values across study intervals. Statistical analysis for our primary outcome used the Mann-Whitney and variance ratio tests. Results: Median time to order renewal decreased in periods B and C versus A by 64 and 56 minutes, respectively, with variability in this measure decreasing across all periods. Mean number of restraint orders in periods B and C significantly increased versus those in A (1.46 to 1.89 to 2.34), with corresponding increases in variability. Mean renewal orders per hour in restraint significantly increased in period C versus A and B, from 0.08 to 0.23 to 0.89, with increasing variability across all periods. Decreases in median time spent in restraints observed in periods B and C versus A of 45 and 105 minutes, respectively, trended toward but did not achieve significance, with significantly decreasing variability compared with baseline. Conclusion: The forcing function improved restraint reordering and variability in practice and may have contributed to nonsignificant reductions observed in time in restraint.