Electronic Ordering System Improves Postoperative Pain Management after Total Knee or Hip Arthroplasty

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  • OBJECTIVE: The authors investigated the impact of computerized provider order entry (CPOE) on the delivery times of analgesia and subsequent patient outcomes. We hypothesized that patients would report less pain and use less pain medications compared with the previous paper-based system.
  • METHODS: Two groups of patients after a total hip (THA) or knee arthroplasty (TKA) were retrospectively compared: one comprising 106 patients when the paper-based ordering system was in effect (conventional group), and one comprising 96 patients after CPOE was installed (electronic group). All patients received a regional anaesthetic at surgery (combined spinal-epidural). TKA patients also received a single-injection femoral nerve block. After transfer to the postoperative anaesthesia care unit (PACU), a patient-controlled epidural analgesia (PCEA) infusion was initiated. The following data was collected from the PACU record: time to initiation of analgesia, visual analog scale (VAS) pain scores at initiation of analgesia and hourly for the first postoperative day (POD), volume of pain medication used, length of stay (LOS) in the PACU and the hospital.
  • RESULTS: The time to initiation of analgesia from arrival in the PACU was significantly lower in the electronic group compared to the conventional group (24.5 ± 28.3 minutes vs. 51.1 ± 26.2 minutes; mean ± SD, p < 0.001), as were VAS pain scores (0.82 ± 1.08 vs. 1.5 ± 1.52, p < 0.001) and the volume of PCEA needed to control pain (27.9 ± 20.2 ml vs. 34.8 ± 20.3 ml, p = 0.001) at 4 hours postoperatively. PACU LOS and hospital LOS did not significantly differ in the two groups.
  • CONCLUSIONS: After implementation of CPOE, patients received their postoperative analgesia faster, had less pain, and required less medication.




Typically patients who receive a total hip arthroplasty(THA) or a total knee arthroplasty(TKA) experience pain which can lead to delayed physical therapy if not treated adequately. Usually opioids are used for treatment, but these drugs cause major side effects. A major goal has been to reduce the use of the drugs for recovery, to do this a move to patient controlled dosages has been made due to the fact that patients will delay the medications until they are actually needed. So the purpose of this study is to examine how CPOEs effect the delivery of patient controlled epidural analgesia (PCEA) in postoperative THA and TKA patients.


In New York City's Hospital for Special Surgery a clinical information system was implemented. The system was well developed with over 250 standardized order sets. It is thought that the CPOE will decrease the time it takes for patient medication turn arounds and improve outcomes. For post and pre operative patients the following were measured: time to pain control, total dose of narcotics, and length of stay. Two groups of patients were studied. Group 1 was 106 patients before the implementation of the CPOE and Group 2 was 96 patients after the implementation of the CPOE. Records were kept for all patients and were retrospectively reviewed for time to imitation of PCEA, amount of pain experienced on first day as measured by VAS, amount of pain medication used, and length of PACU and hospital stay. Statistical methods were then used to analyze the data.


  • Time to Initiation of PCEA:
    • Pre-CPOE: 51.1+/- 26.2 mins
    • Post-CPOE: 24.5+/- 28.3 mins

The post-CPOE rate of administration initiated at a much earlier rate.

  • Amount of Pain Experienced during the First Day:
    • Pre-CPOE: 1.5+/-2.9 VAS score
    • Post-CPOE: 0.9+/-2.0 VAS score

Amount of pain experienced on the first day was less for the post-CPOE patients.

  • Amount of Pain Medication Used:
    • Pre-CPOE: 34.8+/-20.3 mL
    • Post-CPOE: 27.9+/-20.2 mL

Pain medication used by the post-CPOE patients was on average 7mL less than pre-CPOE patients.

  • Length of Stay in PACU and in Hospital:

Length of stay did not differ between the two groups of patients.


The post-CPOE patients received their medication faster and usually before the onset of pain when compared to the pre-CPOE patients. This speed of drug administration allows for a preemptive strike against the pain and reduces the patients need for medication later on. It is clear that post-CPOE initiation showed significant changes in workflow and medication turn around times.


As stated earlier it is important for patient recovery that opioids be reduced, and with the use of the CPOE system it is possible to not only decrease patient medication turn around time but it also decreases patient opioid use and thus their recovery time.


I think that this paper gives us yet again another good reason to be using CPOEs within hospital settings. If this medication reduction occurs in every single patient that goes into a hospital it will not only save the patient money on medications but it will also help with the problem over overprescribing that has become a big issue in the US. It is important that drugs be used as little as possible: Opioids so that addiction doesn't occur, antibiotics so superbugs don't occur, and so on.

Additional Resources

Compare systems[1]

Top-10-hospital-emr-vendors-by-number-of-installed-system [2]


  1. Urban, M. K., Chiu, T., Wolfe, S., & Magid, S. (2015). Electronic Ordering System Improves Postoperative Pain Management after Total Knee or Hip Arthroplasty. Appl Clin Inform, 6(3), 591-599. http://aci.schattauer.de/en/contents/archive/issue/2233/manuscript/24955/show.html