Association of delay to first intervention with return of spontaneous circulation in a swine model of cardiac arrest

OBJECTIVE: No single drug improves survival after cardiac arrest, despite success in animal studies. We sought to determine the duration of circulatory arrest after which maximal drug treatment and a rescue shock would fail to achieve return of spontaneous circulation (ROSC). DESIGN/SUBJECTS: Retrospective analysis of 271 swine (20-30 kg) resuscitation attempts during ventricular fibrillation. Protocols were divided into five categories: immediate countershock, cardiopulmonary resuscitation (CPR) with standard-dose drugs, CPR alone, CPR and high-dose epinephrine (CPR+HDE) (0.1 mg/kg), and CPR with a drug cocktail (CPR+DC) of propanolol (1 mg), epinephrine (adrenaline) (0.1 mg/kg) and vasopressin (40IU). Time to first CPR, time to first drug administration, time to first shock, and protocol were examined as predictors of ROSC using logistic regression with Hosmer-Lemeshow test of fit. Probability of ROSC was calculated from logistic curves. MAIN RESULTS: ROSC occurred in 119 of the 271 swine (44%). Time to first drug and the CPR+DC group were predictors of ROSC. Time to first CPR, the CPR+DC group, and the CPR+HDE group were also predictors of ROSC. Time to first rescue shock, the CPR+DC group, and the CPR+HDE groups were predictors of ROSC. In the CPR+DC group, 50% ROSC occurred at a first CPR time of 13.4 min, first drug time of 14.1 min and first rescue shock time of 17.5 min. CONCLUSIONS: Pre-shock delivery of CPR+DC increases the likelihood of ROSC, and reaches 50% with a time of drug delivery of 14.1 min. ROSC rates of 50% may be achievable using an optimized resuscitation in experimental CPR.     

Medication errors in patients with severe chronic kidney disease and acute coronary syndrome: the impact of computer-assisted decision support

OBJECTIVETo evaluate the impact of computerized physician order entry (CPOE) with decision support on the frequency of antithrombotic medication errors in patients with chronic kidney disease (CKD) admitted with acute coronary syndrome (ACS) and to measure what effect it would have on in-hospital bleeding.PATIENTS AND METHODSWe evaluated 80 patients with CKD who were admitted with ACS between January 1, 2009, and December 31, 2010, using either a standardized order set or CPOE with decision support to assess the frequency of medication errors and in-hospital bleeding.RESULTSOf the 80 patients, 47 were admitted with standard orders vs 33 with CPOE. In-hospital bleeding occurred in 13 patients: 10 in the standard orders group vs 3 in the CPOE group (P=.12). In-hospital bleeding occurred in 5 (63%) of 8 patients receiving a contraindicated antithrombotic medication compared with 8 (11%) of 72 patients receiving appropriate medications (P=.002); the corresponding length of stay was 12.0 days compared with 6.8 days (P=.10). Contraindicated medications were given to no patients in the CPOE group vs 8 patients (17%) in the standard orders group (P=.01).CONCLUSIONMedication errors occur frequently in patients with CKD admitted with ACS and result in a high risk of in-hospital bleeding. Use of CPOE with decision support is feasible in the ACS setting and may lead to improved patient safety.     

Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation: Analysis and Mitigation Strategies

Objective

Computerized provider/physician order entry (CPOE) with clinical decision support (CDS) is designed to improve patient safety. However, a number of unintended consequences which include duplicate ordering have been reported. The objective of this time-series study was to characterize duplicate orders and devise strategies to minimize them.

Methods

Time series design with systematic weekly sampling for 84 weeks. Each week we queried the CPOE database, downloaded all active orders onto a spreadsheet, and highlighted duplicate orders. We noted the following details for each duplicate order: time, order details (e.g. drug, dose, route and frequency), ordering prescriber, including position and role, and whether the orders originated from a single order or from an order set (and the name of the order set). This analysis led to a number of interventions, including changes in: order sets, workflow, prescriber training, pharmacy procedures, and duplicate alerts.

Results

Duplicates were more likely to originate from different prescribers than from same prescribers; and from order sets than from single orders. After interventions, there was an 84.8% decrease in the duplication rate from weeks 1 to 84 and a 94.6% decrease from the highest (1) to the lowest week (75). Currently, we have negligible duplicate orders.

Conclusions

Duplicate orders can be a significant unintended consequence of CPOE. By analyzing these orders, we were able to devise and implement generalizable strategies that significantly reduced them. The incidence of duplicate orders before CPOE implementation is unknown, and our data originate from a weekly snapshot of active orders, which serves as a sample of total active orders. Thus, it should be noted that this methodology likely under-reports duplicate orders.     

Computerized physician order entry in the critical care and general inpatient setting: a narrative review

Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering clinician orders, especially for medications and laboratory and diagnostic tests. Studies in hospitalized patients, including critically ill patients, have demonstrated that CPOE, especially with decision support, improves several outcomes. These improved outcomes include clinical measures such as reductions in serious medication errors and enhanced antimicrobial management of critically ill patients resulting in reduced length of stay. Additionally, several process outcomes have improved with CPOE such as increased compliance with evidence-based practices, reductions in unnecessary laboratory tests and cost savings in pharmacotherapeutics. Future studies are needed to demonstrate the benefits of more patient specific decision support interventions and the seamless integration of CPOE into a wireless, computerized medication administration system.     

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients

BACKGROUND: Critically ill patients require rapid care, yet they are also at risk for morbidity from the potential complications of that care. Computerized physician order entry (CPOE) is advocated as a tool to reduce medical errors, improve the efficiency of healthcare delivery, and improve outcomes. Little is known regarding the essential attributes of CPOE in the intensive care unit (ICU). OBJECTIVE: To assess the effect of CPOE on ICU patient care. DESIGN: Retrospective before and after cohort study. SETTING: An academic ICU. PATIENTS: Patients admitted to the ICU during use of the initial CPOE application and those admitted after its modification. INTERVENTIONS: Comprehensive order interface redesign improving clarity, specificity, and efficiency. MEASUREMENTS: Orders for complex ICU care were compared between the two groups. In addition, the use of higher-efficiency CPOE order paths was tracked. RESULTS: Patients treated with both the initial and modified CPOE system were similar for all measured characteristics. With the modified CPOE system, there were significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management. There was also a significant increase in orders executed through ICU-specific order sets after system modifications. LIMITATIONS: This retrospective study cannot assess issues related to learner expertise and is meant to only suggest the importance of developing CPOE systems that are appropriate for specialty care environments. CONCLUSION: Appropriate CPOE applications can improve the efficiency of care for critically ill patients. The workflow requirements of individual units must be analyzed before technologies like CPOE can be properly developed and implemented.     

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry

Background

Treatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED.

Methods

We prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication.

Results

Six hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001).

Conclusion

The use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.     

Response to Medication Dosing Alerts for Pediatric Inpatients Using a Computerized Provider Order Entry System

Objective

Medication dosing errors are of particular concern in hospitalized children. Avoidance of such errors is essential to quality improvement and patient safety. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) have the potential to reduce medication errors. The objective of this study was to evaluate provider response to the dosing alerts in a CPOE system with CDS for pediatric inpatients and to identify differences in provider response based on clinician specialty.

Patients and methods

We conducted a retrospective analysis of all medication dosing alerts over a 1-year period (January 1 through December 31, 2008) for all pediatric inpatients at Hospital for Special Surgery. Alerts were analyzed with respect to medication dosing, prescriber, and action taken by the prescriber after the alert was triggered (i.e., accepted suggested change, ignored recommendation/overrode, or cancelled the order).

Results

During the study period, 18,163 medication orders were placed and 1,024 dosing alerts were fired. Overdosing of medications accounted for 91% of the alerts and underdosing 9%. The pediatric-trained providers ignored more alerts and cancelled fewer orders than the non-pediatric-trained providers (p<0.001). Both groups changed the order similarly based on CDS recommendations.

Conclusions

Differences in response to CDS were found between pediatric-trained and non-pediatric-trained providers caring for pediatric patients; however, both groups changed orders based on CDS similarly. CPOE with built-in CDS may be of particular value when providers with different specialties and types of training are caring for pediatric patients.     

Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.     

The Effect of Computerized Provider Order Entry on Medical Students’ Ability to Write Orders

Background: Computerized provider order entry (CPOE) is being implemented at increasing numbers of U.S. hospitals, yet the effects of CPOE on medical student education are largely unstudied. Purpose: The objective is to investigate the effects of CPOE on medical students’ ability to write orders for patients. Methods: One hundred forty-three medical students who began their Basic Medicine clerkship between March 2003 and April 2004 were asked to write mock admission orders for a patient with pneumonia after the 1st month of their clerkship. Students had spent the month at 1 of 3 hospitals: 1 using CPOE, 1 paper orders, and 1 that began using CPOE midway through this study. Admission orders were scored for the presence of specific orders and features. Results: One hundred twenty students attempted to write admission orders. Students who trained at hospitals using CPOE and those who trained at hospitals using paper orders included expected basic, lifesaving, and higher level orders at similar rates. No significant differences in order clarity or inclusion of unnecessary orders were found for the 2 groups. No significant differences were found when controlling for school year and 4 modifiable rotation features. Conclusions: When admission order completeness and quality for medical students who trained at hospitals using CPOE were compared to those who trained using handwritten orders, no important differences were found.     

Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest

AIM OF THE STUDY: To evaluate quality of cardiopulmonary resuscitation (CPR) performed during transport after out-of-hospital cardiac arrest. MATERIALS AND METHODS: Retrospective, observational study of all non-traumatic cardiac arrest patients older than 18 years who received CPR both before and during transport between May 2003 and December 2006 from the community run EMS system in Oslo. Chest compressions and ventilations were detected from impedance changes in routinely collected ECG signals, and hands-off ratio calculated as time without chest compressions divided by total CPR time. RESULTS: Seventy-five of 787 consecutive out-of-hospital cardiac arrest patients met the inclusion criteria. Quality data were available from 36 of 66 patients receiving manual CPR and 7 of 9 receiving mechanical CPR. CPR was performed for mean 21+/-11 min before and 12+/-8 min during transport. With manual CPR hands-off ratio increased from 0.19+/-0.09 on-scene to 0.27+/-0.15 (p=0.002) during transport. Compression and ventilation rates were unchanged causing a reduction in compressions per minute from 94+/-14 min(-1) to 82+/-19 min(-1) (p=0.001). Quality was significantly better with mechanical than manual CPR. Four patients (5%) survived to hospital discharge; two with manual CPR (Cerebral performance categories (CPC) 1 and 2), and two with mechanical CPR (CPC scores 3 and 4). No discharged patients had any spontaneous circulation during transport. CONCLUSIONS: The fraction of time without chest compressions increased during transport of out-of-hospital cardiac arrest patients. Every effort should therefore be made to stabilise patients on-scene before transport to hospital, but all transport with ongoing CPR is not futile.     

Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics

What is known and Objective: Second‐generation antipsychotics (SGAs) play an important role in the pharmacologic management of various psychiatric conditions. Use of these medications has been associated with metabolic complications. Adherence to guideline‐recommended monitoring is suboptimal. We evaluated the effect of a computerized physician order entry (CPOE) pop‐up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs on a University Hospital inpatient psychiatry unit. Methods: A single‐centre, retrospective chart review was performed in which patient demographics and SGA drug and laboratory data were extracted from the CPOE database. We assessed the number of orders for appropriate metabolic monitoring data for patients admitted within a 6‐month period before or after the alert implementation. Results and Discussion: Pre‐alert (n = 171) and post‐alert (n = 157) groups were similar with respect to age, length of stay, sex, race and comorbidities. Following alert implementation, significant increases in monitoring both random (92·4% vs. 100%) and fasting (46·8% vs. 70%) glucose levels as well as random (28·7% vs. 74·5%) and fasting (18·7% vs. 59·9%) lipid panels (all P ≤ 0·001) were observed. The number of patients with both a fasting glucose level and fasting lipid panel available for monitoring increased from 12·9% to 47·8% (P < 0·0001). Significantly more post‐alert laboratory orders were submitted at the same time as the SGA drug order (P < 0·0001), suggesting that the alert itself had a direct influence on the ordering of metabolic monitoring labs. What is new and Conclusions: Implementation and use of an electronic pop‐up alert in an inpatient psychiatric unit significantly improved rates of ordering fasting blood glucose and lipid levels for inpatients treated with SGAs. Overall rates remain suboptimal, suggesting a need for additional strategies to further improve metabolic monitoring.     

Reverse CPR: a pilot study of CPR in the prone position

BACKGROUND: Cardiopulmonary resuscitation (CPR), as described in 1960, remains the cornerstone of therapy for cardiopulmonary arrest. Recent case reports have described CPR in the prone position. We hypothesized rhythmic back pressure on a patient in the prone position with sternal counter-pressure (termed reverse CPR here) would increase intra-thoracic pressure and in turn systolic blood pressure (SBP) during cardiac arrest versus standard CPR. METHODS AND RESULTS: Six patients from Columbia Presbyterian Medical Center's Cardiac and Medical Intensive Care Units (CICU and MICU) were enrolled. Eligible patients had suffered circulatory arrest and failed standard CPR for at least 30 min. After enrollment the patients received 15 additional min of standard CPR and then reverse CPR for 15 min. The study's primary endpoint, mean SBP, significantly improved from 48 mmHg during standard CPR to 72 mmHg during reverse CPR (mean improvement=23+/-14 mmHg). Mean calculated mean arterial pressure (MAP) was also improved significantly from 32 mmHg during standard CPR to 46 mmHg during reverse CPR (mean improvement=14+/-11 mmHg). The mean diastolic blood pressure (DBP) improved from 24 mmHg during standard to 34 mmHg during reverse CPR (mean improvement=10+/-12 mmHg). This difference did not meet statistical significance. No patients had return of spontaneous circulation. CONCLUSIONS: Reverse CPR generates higher mean SBP and higher mean MAP during circulatory arrest than standard CPR. These novel findings justify further research into this technique.     

Assessment of education and computerized decision support interventions for improving transfusion practice

BACKGROUND: Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success. STUDY DESIGN AND METHODS: This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. RESULTS: The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). CONCLUSIONS: Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.     

Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest

OBJECTIVE: Epinephrine (adrenaline) is widely used as a primary adjuvant for improving perfusion pressure and resuscitation rates during cardiopulmonary resuscitation (CPR). Epinephrine is also associated with significant myocardial dysfunction in the post-resuscitation period. We tested the hypothesis that the cardiac effects of epinephrine vary according to the duration of cardiac arrest. METHODS AND MATERIALS: Cardiac arrest (CA) was induced in Sprague-Dawley rats with an IV bolus of KCl (40 microg/g). Three series of experiments were performed with CPR begun after 2, 4, or 6 min of cardiac arrest. Epinephrine (0.01 mg/kg) IV or placebo was given immediately in the 2 and 4 min CA groups. In the 6 min group, CPR was started after 6 min CA and epinephrine was given at 15 min if no return of spontaneous circulation (ROSC) occurred. Time to ROSC was recorded in all groups. Cardiac function was determined with trans-thoracic echocardiography at baseline, 5, 30 and 60 min after ROSC. RESULTS: After 2 min CA, 8/8 (100%) placebo animals and 8/8 (100%) epinephrine animals attained ROSC. Cardiac index was significantly increased during the first 60 min in the epinephrine group compared with the placebo group (p<0.01). After 4 min of cardiac arrest, 14/29 (48%) placebo animals and 14/16 (88%) epinephrine animals attained ROSC (p<0.01). Cardiac index after ROSC returned to baseline in both groups, although tended to be lower in the epinephrine group. After 6 min CA, 10/31 (32%) animals attained ROSC without epinephrine and 17/21 (81%) animals with epinephrine (p<0.01). Post-ROSC depression of cardiac index was greatest in the epinephrine group (p<0.05). CONCLUSIONS: As the duration of cardiac arrest increases, a paradoxical myocardial epinephrine response develops, in which epinephrine becomes increasingly more important to attain ROSC, but is increasingly associated with post-ROSC myocardial depression.     

A comparison of cardiopulmonary resuscitation with cardiopulmonary bypass after prolonged cardiac arrest in dogs. Reperfusion pressures and neurologic recovery.

Resuscitability and outcome after prolonged cardiac arrest were compared in dogs with standard external cardiopulmonary resuscitation (CPR) vs. closed-chest emergency cardiopulmonary bypass (CPB). Ventricular fibrillation (VF) was with no blood flow from VF 0 min to VF 10 min. Subsequent CPR basic life support (BLS) was from 10 min to VF 15 min. Then, group I (n = 13) received CPR advanced life support (ALS) from VF 15 min until restoration of spontaneous circulation to occur not later than VF 40 min. Group II (n = 14) received CPR-ALS from VF 15 min to VF 20 min without defibrillation, and then total CPB to defibrillation attempts started at VF 20 min, followed by assisted CPB to 2 h. Total ischemia time (no-flow time plus CPR time of MAP less than 50 mmHg) was unexpectedly shorter in group I (14.3 +/- 2.5 min) than in group II (18.6 +/- 2.3 min) (P less than 0.01). During CPR-BLS, coronary perfusion pressures were 25 +/- 9 mmHg in group I and 18 +/- 8 mmHg in group II (NS). Epinephrine during CPR-ALS, before countershock, raised coronary perfusion pressure to 40 +/- 10 mmHg in group I and 27 +/- 10 mmHg in group II (NS). In group II, coronary perfusion pressure increased during total CPB to 58 +/- 16 mmHg (P less than 0.01 vs. group I). Spontaneous normotension was restored in 11/13 dogs of group I and all 14 dogs of group II (NS). Ten dogs in each group followed protocol and survived to 96 h. Five of ten in group I and six of ten in group II were neurologically normal (NS). We conclude that: (1) Reperfusion with CPB yields higher coronary perfusion pressures than reperfusion with CPR-ALS; and (2) even after no blood flow for 10 min, optimized CPR can result in cardiovascular resuscitability and neurologic recovery, similar to those achieved by CPB.