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.     

Computerized physician order entry and decision support improves ED analgesic ordering for renal colic

Objectives

Computerized physician order entry (CPOE) offers the potential for safer, faster patient care, as well as greater use of evidence-based therapy via built-in decision support. However, the effectiveness of CPOE in yielding these benefits has shown mixed results in the emergency department (ED) setting. Our objective was to evaluate the impact of CPOE implementation on analgesic prescribing and dosing practices for renal colic presentations.

Methods

This retrospective pre/post comparative study was conducted in 3 tertiary hospitals that implemented CPOE in 2010. Two patient groups were compared: prior to (pre-CPOE) and after (post-CPOE) CPOE implementation. Each group consisted of 230 randomly selected, high-acuity patients presenting to the ED with renal colic. The primary outcome was the proportion of patients receiving ketorolac in the ED. Secondary outcomes included choice of analgesic and average morphine dose.

Results

The proportion of patients receiving ketorolac significantly increased after CPOE implementation (65.6% pre-CPOE vs 76.5% post-CPOE, P = .015), as did the proportion of patients receiving fentanyl (pre, 9.7%; post, 16.7%; P = .047). Differences in morphine use (pre, 66.0%; post, 69.1%) and average morphine dose (pre, 10.09 mg; post, 12.28 mg) did not reach statistical significance.

Conclusions

The introduction of CPOE is associated with an increase in ketorolac use for ED renal colic visits. This may reflect the inclusion of ketorolac in the renal colic order set. Computerized physician order entry implementation with condition-specific electronic order sets and decision support may improve evidence-based practice.     

Assessing physician utilization of laboratory practice guidelines: Barriers and opportunities for improvement

Objectives

To assess physician utilization of laboratory practice guidelines (LPGs)³ to improve LPG uptake and use.

Design and methods

A statewide survey of 4987 primary care physicians (PCPs) and 75 infectious disease (ID) specialists was conducted in 2005–2006 to correlate guideline source with users' awareness, utilization, and perceived usefulness of LPGs. We compared LPGs developed by the Centers for Disease Control and Prevention (CDC) to LPGs developed by the Washington State Department of Health through its Clinical Laboratory Advisory Council (CLAC).

Results

Physician awareness of LPGs was a major impediment to utilization of CLAC LPGs, and they were perceived as inaccessible, too numerous and unhelpful. However, once aware, respondents tended to use LPGs and there were no important differences in impediments or the ways CDC and CLAC LPGs were used. Of the PCPs who had a computerized physician order entry system (CPOE), a majority (92%) found, or expected that they would find, the integration of guidelines into their system helpful.

Conclusions

For both CDC and CLAC LPGs, the greatest impediments to uptake were awareness and familiarity, which depended upon LPG source, physician specialty, and practice setting. There was no apparent impediment to uptake of CLAC or CDC LPGs based upon their credibility. Because better promotion could increase uptake, CLAC LPGs are now promoted by the Washington State Medical Association. Integration of LPGs into CPOE and smart phone applications could address major impediments to clinician use. The Cabana paradigm would be useful for any organization seeking to improve LPG impact.     

Implementation of a clinical pathway based on a computerized physician order entry system for ischemic stroke attenuates off-hour and weekend effects in the ED

Background

Admission on weekends and off-hours has been associated with poor outcomes and mortality from acute stroke. The purpose of this study was to investigate whether an organized clinical pathway (CP) for ischemic stroke can effectively reduce the time from arrival to evaluation and treatment in the emergency department (ED) and improve outcomes, regardless of the time from arrival in the ED.

Methods

We conducted a retrospective analysis of all consecutive patients included in the prospective registry database in the Brain Salvage through Emergency Stroke Therapy program, which uses the computerized physician order entry (CPOE) system. Patients were classified based on their time of arrival in the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Clinical outcomes were categorized according to 30 days in-hospital mortality, in-hospital mortality, and the modified Rankin score during a single length of stay (LOS).

Results

No time intervals differed significantly among the 4 patient groups who received intravenous administration of tissue plasminogen activator (IV-tPA). Use of IV-tPA (P = .5110) was not affected by arrival in the ED on off-days or weekends. The overall mortality rate was 3.9%, and the median LOS was 7 days (Interquartile range (IQR), 5-10). By Kaplan-Meier analysis, the cumulative probability of mortality and survival did not differ significantly among the 4 groups over 30 days (P = .1557).

Conclusion

An organized CP, based on CPOE, for ischemic stroke can effectively attenuate disparities in the time interval between ED arrival to evaluation and treatment regardless of ED arrival time. This pathway may also help to eliminate off-hour and weekend effects on outcomes from ischemic stroke.     

Impact of Physician Screening in the Emergency Department on Patient Flow

Background

Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

Study Objective

We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients.

Methods

We conducted a 2-year before–after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before–after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables.

Results

The median time to disposition decision decreased by 6 min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16 min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors.

Conclusions

Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.     

Impact of computerized physician order entry on ED patient length of stay

Objectives

We evaluated whether implementation of computerized physician order entry (CPOE) reduces length of stay (LOS) for discharged emergency department (ED) patients.

Methods

Emergency department LOS for discharged and admitted patients were analyzed in a university-affiliated ED before and after introduction of CPOE. Patient demographics and covariates that may affect LOS (mode of arrival, provider staffing, daily census, and admission rate) were measured.

Results

The study included 71?188 patients; 49?175 (69%) were discharged from the ED (28?687 before and 20?488 after CPOE). Length of stay for discharged patients decreased from 198 to 168 minutes (difference of −30; 95% confidence interval [CI], −28 to −33), whereas LOS for admitted patients increased from 405 to 441 minutes (difference of +36; 95% CI, 26-46). After controlling for covariates, CPOE implementation was associated with a 23-minute decrease in LOS for discharged patients (β = −23 [95% CI, −26 to −19]).

Conclusion

Implementation of CPOE was associated with a clinically significant (23-minute) decrease in LOS among patients who were discharged from the ED.     

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.     

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.     

Computerized Physician Order Entry (CPOE) in pediatric and neonatal intensive care: Recommendations how to meet clinical requirements

Objective

To identify and summarize the requirements of an optimized CPOE application for pediatric intensive care.

Methods

We analyzed the medication process and its documentation in the pediatric and neonatal intensive care units (PICU/NICU) of two university hospitals using workflow analysis techniques, with the aim of implementing computer-supported physician order entry (CPOE).

Results

In both PICU/NICU, we identified similar processes that differed considerably from adult medication routine. For example, both PICU/NICU prepare IV pump syringes on the ward, but receive individualized ready-to-use mixed IV bags for each patient from the hospital pharmacy on the basis of a daily order. For drug dose calculation, both PICU/NICU employ electronic calculation tools that are either incorporated within the CPOE system, or are external modules invoked via interface.

Conclusion

On the basis of this analysis, we provide suggestions to optimize CPOE applications for use in the pediatric and neonatal intensive care unit in the form of three catalogues of desiderata for drug order entry support.     

Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Background

The Emergency Department (ED) is an environment at risk for medical errors.

Objective

Our aim was to determine the factors associated with the adverse events resulting from medical errors in the ED among patients who were admitted.

Methods

This was a prospective observational study. For a 1-month period, we included all ED patients who were subsequently admitted to the medical ward. Detection of medical errors was made by the admitting physician and then validated by two experts who reviewed all available data and medical charts pertaining to the patient’s hospital stay, including the first review from the ward physician. Related adverse events resulting from medical errors were then classified by type and severity. Adverse events were defined as medical errors that needed an intervention or caused harm to the patient. Univariate analysis examined relationships between characteristics of both patients and physicians and the risk of adverse events.

Results

From 197 analyzed patients, 130 errors were detected, of these, 34 were categorized as adverse events among 19 patients (10%). Seventy-six percent of these were categorized as proficiency errors. The only factors associated with a lower risk of adverse events were the transition of care involving a handoff within the ED (0% vs. 19%; p = 0.03) and the involvement of a resident (junior doctor) in addition to the senior physician (37% vs. 67%; p < 0.01).

Conclusions

In our study, the involvement of more than one physician was associated with a lower risk of adverse events.     

Using Computerized Provider Order Entry to Enforce Documentation of Tests with Pending Results at Hospital Discharge

Background

Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup.

Objective

Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries.

Methods

We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality.

Results

Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming.

Conclusions

A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.     

Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge

Introduction

Electronic health record systems used in conjunction with clinical decision support (CDS) or computerized provider order entry (CPOE) have shown potential in improving quality of care, yet less is known about the effects of combination use of CDS and CPOE on prescribing rates at discharge.

Objectives

This study investigates the effectiveness of combination use of CDS and CPOE on appropriate drug prescribing rates at discharge for AMI or HF patients.

Methods

Combination use of CDS and CPOE is defined as hospitals self-reporting full implementation across all hospital units of CDS reminders, CDS guidelines, and CPOE. Appropriate prescribing rates of aspirin, ACEI/ARBs, or beta blockers are defined using quality measures from Hospital Compare. Multivariate linear regressions are used to test for differences in mean appropriate prescribing rates between hospitals reporting combination use of CDS and CPOE, compared to those reporting the singular use of one or the other, or the absence of both. Covariates include hospital size, region, and ownership status.

Results

Approximately 10% of the sample reported full implementation of both CDS and CPOE, while 7% and 17% reported full use of only CPOE or only CDS, respectively. Hospitals reporting full use of CDS only reported between 0.2% (95% CI 0.04 – 1.0) and 1.6% (95% CI 0.6 – 2.6) higher appropriate prescribing rates compared to hospitals reporting use of neither system. Rates of prescribing by hospitals reporting full use of both CPOE and CDS did not significantly differ from the control group.

Conclusions

Although associations found between full implementation of CDS and appropriate prescribing rates suggest that clinical decision tools are sufficient compared to basic EHR systems in improving prescribing at discharge, the modest differences raise doubt about the clinical relevance of the findings. Future studies need to continue investigating the causal nature and clinical relevance of these associations.     

Traditional nurse triage vs physician telepresence in a pediatric ED

Objectives

The objective of the study is to compare traditional nurse triage (TNT) in a pediatric emergency department (PED) with physician telepresence (PTP).

Methods

This is a prospective 2 × 2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children's hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied.

Results

Paired samples t tests showed a statistically significant difference in triage time between TNT and PTP (P = .03) but no significant difference in documentation errors (P = .10). Triage scores of TNT were 71% accurate, compared with PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP, and most indicated that they would prefer PTP again at their next PED visit. Physician telepresence diagnostic ordering was comparable with the actual PED physician ordering, showing no statistical differences.

Conclusions

Using PTP technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors, and patient and parent satisfaction.     

ED overcrowding is associated with an increased frequency of medication errors

Objectives

Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.

Methods

We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.

Results

A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's ρ = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.

Conclusions

We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.