View source for Impact of computerized physician order entry on clinical practice in a newborn intensive care unit

Values that [[CPOE|Computerized Physician Order Entry CPOE)]] can provide include mechanisms to decrease ancillary service response time and improving efficiency and safe medication ordering practices. The greater value is seen in reducing the medication dosing errors where the potential for adverse drug events is higher, especially among neonates, which is higher than the older pediatric patients. Implementing a CPOE integrated with multidisciplinary pediatric clinical-decision support systems to aid in drug-dose calculation, speed up medication administration (by eliminating the intermediate steps), and significantly decrease the turn-around time for procedure where timelines are critical, been proven by a study done by a group of researcher at the Medical Center NICU of the Ohio State University.

This retrospective study was done on 111 very-low-birth-weight (VLBW birth weight <= 1500 g) infants who were born within 6 months before the implementation of the CPOE and 100 (VLBW) infants born within 6 months post implementation. The study compared (pre-and-post CPOE implementation) medication error rates (dose calculation), pharmacy order time intervals (initiation to completion), and radiology procedures turn-around times (order to image display).  

The study includes administration of two medications, Caffeine-citrate (from the main decentralized pharmacy, routinely administered with a loading dose, and used for pharmacy orders time intervals analysis) and Gentamicin (stored at the NICU itself, administered at time of admission and later at the time of a suspected late onset sepsis, and used for medication error rates analysis). Performing the first chest and abdominal X-ray (used for radiology procedures turn-around times analysis). Pre-CPOE data were obtained retrospectively from medical records, while post-CPOE data were obtained electronically from the computerized lifetime patient record.

The new CPOE system allows the NICU physician enters orders directly into a computer available at the bedside that generates an immediate printout at the pharmacy. Similarly, for radiology orders are immediately relayed through an interface to the radiology computer system.

Pre-CPOE with manual hand written orders and manual dose calculations, from the 95% (105/111) of VLBW infants who received Gentamicin on admission to the NICU 13% (14) encountered prescription dosage errors (prescribed dose > 10% deviation from recommended dose), 1/3 of them with over dosed and 2/3 under dosed). Errors were due to dose calculations and dose rounding calculations. In the post-CPOE period providing recommended dose and frequency defaults, automated dose calculation, and maximum dose check, no instances of medication errors in 89% (89/100) of VLBW infants.

Automation of Caffien orders from the central pharmacy by CPOE reduced the time between the order initiation to the drug administration from 10.5±9.8 hours (in 41 VLBW infants pre-CPOE) to 2.8±3.3 hours (in 48 of them post-CPOE), the default acceptable time set by the NICU is 2 to 3 hours. Also the number of VLBW infants who received the Caffien within the 2 to 3 hours window increased from 10 (35%) pre-CPOE to 12 (62%) for post-CPOE.

Radiology orders to perform X-ray time-window from physician order to completion was reduced by the automatic CPOE order arrival at radiology, with 42±12 (pre) to 32±16 minutes (post). This reduction was due to the shortening of the time window between order start and technician arrival with portable X-ray machine at the NICU (mean 28±13 to17±12 minutes).


== Comments ==

The study shows that implementation of CPOE integrated with clinical-decision support applications (homegrown or vendor ready) can help in increase the quality of medical care to pediatric patients, especially the ones with high morbidity and mortality rates when time and decision accuracy can be critical for their survival, presented of those of very-low-birth-weight infants at the NICU. The study attributed the success of the CPOE implementation not only to the technical abilities provided by the software applications that improve physician prescribing practices, but also to the adopted changes in the clinical work flow that accompanies the introduction of the CPOE to optimize its usage. It empathized on the importance of implementing good clinical practices and guidelines prior to introducing a change or automation to their clinical process. This was represented in a devoted clinical pharmacist at the NICU, specific training to NICU staff and physicians, and incorporating various stakeholders in the process of setting and implementing clinical guidelines and the implementation of the CPOE system.




Values that CPOE (Computerized Physician Order Entry) can provide include mechanisms to decrease ancillary service response time and improving efficiency and safe medication ordering practices. The greater value is seen in reducing the medication dosing errors where the potential for adverse drug events is higher, especially among neonates, which is higher than the older pediatric patients. Implementing a CPOE integrated with multidisciplinary pediatric clinical-decision support systems to aid in drug-dose calculation, speed up medication administration (by eliminating the intermediate steps), and significantly decrease the turn-around time for procedure where timelines are critical, been proven by a study done by a group of researcher at the Medical Center NICU of the Ohio State University.

This retrospective study was done on 111 very-low-birth-weight (VLBW birth weight <= 1500 g) infants who were born within 6 months before the implementation of the CPOE and 100 (VLBW) infants born within 6 months post implementation. The study compared (pre-and-post CPOE implementation) medication error rates (dose calculation), pharmacy order time intervals (initiation to completion), and radiology procedures turn-around times (order to image display).  

The study includes administration of two medications, Caffeine-citrate (from the main decentralized pharmacy, routinely administered with a loading dose, and used for pharmacy orders time intervals analysis) and Gentamicin (stored at the NICU itself, administered at time of admission and later at the time of a suspected late onset sepsis, and used for medication error rates analysis). Performing the first chest and abdominal X-ray (used for radiology procedures turn-around times analysis). Pre-CPOE data were obtained retrospectively from medical records, while post-CPOE data were obtained electronically from the computerized lifetime patient record.

The new CPOE system allows the NICU physician enters orders directly into a computer available at the bedside that generates an immediate printout at the pharmacy. Similarly, for radiology orders are immediately relayed through an interface to the radiology computer system.

Pre-CPOE with manual hand written orders and manual dose calculations, from the 95% (105/111) of VLBW infants who received Gentamicin on admission to the NICU 13% (14) encountered prescription dosage errors (prescribed dose > 10% deviation from recommended dose), 1/3 of them with over dosed and 2/3 under dosed). Errors were due to dose calculations and dose rounding calculations. In the post-CPOE period providing recommended dose and frequency defaults, automated dose calculation, and maximum dose check, no instances of medication errors in 89% (89/100) of VLBW infants.

Automation of Caffien orders from the central pharmacy by CPOE reduced the time between the order initiation to the drug administration from 10.5±9.8 hours (in 41 VLBW infants pre-CPOE) to 2.8±3.3 hours (in 48 of them post-CPOE), the default acceptable time set by the NICU is 2 to 3 hours. Also the number of VLBW infants who received the Caffien within the 2 to 3 hours window increased from 10 (35%) pre-CPOE to 12 (62%) for post-CPOE.

Radiology orders to perform X-ray time-window from physician order to completion was reduced by the automatic CPOE order arrival at radiology, with 42±12 (pre) to 32±16 minutes (post). This reduction was due to the shortening of the time window between order start and technician arrival with portable X-ray machine at the NICU (mean 28±13 to17±12 minutes).


Comments: The study shows that implementation of CPOE integrated with clinical-decision support applications (homegrown or vendor ready) can help in increase the quality of medical care to pediatric patients, especially the ones with high morbidity and mortality rates when time and decision accuracy can be critical for their survival, presented of those of very-low-birth-weight infants at the NICU. The study attributed the success of the CPOE implementation not only to the technical abilities provided by the software applications that improve physician prescribing practices, but also to the adopted changes in the clinical work flow that accompanies the introduction of the CPOE to optimize its usage. It empathized on the importance of implementing good clinical practices and guidelines prior to introducing a change or automation to their clinical process. This was represented in a devoted clinical pharmacist at the NICU, specific training to NICU staff and physicians, and incorporating various stakeholders in the process of setting and implementing clinical guidelines and the implementation of the CPOE system.



[[Category:OHSU-SP-06]]
[[Category:Reviews]]