CPOE in Critical Care
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CPOE in Critical Care CPOE in Critical Care Andy Steele, MD, MPH (Director, Medical Informatics, Denver Health) Ivor Douglas, MD, (Director, MICU, Denver Health) AHRQ Patient Safety Conference June 6th, 2005
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CPOE in Critical Care. Andy Steele, MD, MPH (Director, Medical Informatics, Denver Health) Ivor Douglas, MD, (Director, MICU, Denver Health). AHRQ Patient Safety Conference June 6th, 2005. Outline. WHY CPOE? CPOE in the Critical Care Unit MICU CPOE Lessons Learned Questions. - PowerPoint PPT Presentation
Transcript of CPOE in Critical Care
CPOE in Critical CareCPOE in Critical Care
Andy Steele, MD, MPH(Director, Medical Informatics, Denver Health)
Ivor Douglas, MD, (Director, MICU, Denver Health)
AHRQ Patient Safety ConferenceJune 6th, 2005
Outline
• WHY CPOE?
• CPOE in the Critical Care Unit
• MICU CPOE Lessons Learned
• Questions
Computerized Provider Order Entry (CPOE) - WHY?
• Improved Patient Care– Patient Safety (medication errors)– Improved Efficiency and Quality of Care
• Support of Compliance Efforts
• Support of Provider Billing Activities
• External Forces: Payers-Leapfrog, Legislation
• Marketing Advantage
Critical Care Impact on Health Care Resources
• 15-20% of health care expenditures (1.5% GNP)
• 10-25% of all hospital beds and increasing• Postoperative management accounts for 65%
of all ICU admissions. • ICU’s are usually money-losing operation due
to “outliers” (10% patients account for 67% of costs)
• Large shortage of “skilled” critical care providers
CPOE Benefits in Critical Care
JAMIA. 1999;6:313-3210
109
0
63
0
57
023
0
50
100
150
200
250
300
Baseline Period 1 Period 2 Period 3
Non-ICU (79% reduction)
BWH Experience With CPOEBWH Experience With CPOEMedication Error Rate Medication Error Rate
(#/1,000 patient days)(#/1,000 patient days)
CPOE Benefits in Critical Care
JAMIA. 1999;6:313-321
248
109
71 63
159
5735 23
0
50
100
150
200
250
300
Baseline Period 1 Period 2 Period 3
ICU (86% reduction) Non-ICU (79% reduction)
BWH Experience With CPOEBWH Experience With CPOEMedication Error Rate Medication Error Rate
(#/1,000 patient days)(#/1,000 patient days)
CPOE Benefits in Critical Care
Improved Quality and Efficiency of Care– Lab collection - 77 down to 21.5 min.– Radiology Exams - 96.5 down to 29.5 min.
• Crit Care Med 2004; 32:1306 –1309
– NICU medication turn-around times- 10.5 down to 2.8 hours
– Improved NICU accuracy of gentamicin dosing-12% over/under dosages decreased to 0%
• Journal of Perinatology (2004) 24, 88–93.
Denver Health Clinical Statistics
• 20,000 admissions annually• 75% minority population
• MICU-24 beds (Step-down Unit-8 beds)• 2,000 Admissions annually
• CPOE In Use For 23 months– ~500 providers/users trained
– ~6,000 orders input/week
– ~30 standardized care order sets being used
CPOE/CDSS : Protocol Driven Aggressive Correction Of Diabetic Emergencies
• Diabetic Emergencies– Diabetic Ketoacidosis
– Hyperglycemic hyperosmolar syndrome
– 5-18% of admission to MICU
– Aggressive “tight” blood sugar control in other critical illness (sepsis) reduced mortality
• Principles of management– Multiple differing strategies, very little rigorous prospective evaluation
• Correct metabolic abnormalities
• Correct precipitant
• Aggressive IV fluid resuscitation
• Insulin, Potassium
CPOE Driven DKA/HHS Protocol
Pre CPOE Pre CPOE (N=131)(N=131)
Post CPOEPost CPOE(N=111)(N=111)
PP
Age 39.9±1.16 39.3±1.19 NS
Male (%) 59% 63% NS
Anion Gap (mmol/L) 27.9±0.54 28.2±0.6 NS
Bl Sugar (mg/dL) 565.1±17.5 588.3±23.2 NS
Ketone (1-3U) 2.6±0.06 2.6±0.07 NS
CPOE Driven DKA/HHS Protocol Outcomes
Pre CPOE Pre CPOE (N=131)(N=131)
Post CPOEPost CPOE(N=111)(N=111)
PP
ICU LOS (hrs) 44.3 ± 2.43 34.2 ± 1.74 0.007
Total LOS (hrs) 91.3 ± 6.4 64.3 ± 3.9 0.001
Time to Anion gap clearance (hrs)
15.4 ± 1.16 10.3 ± 0.44 0.001
Time to Ketone clearance (hrs)
56.4 ± 5.45 37.3 ± 3.4 0.003
Hypoglycemic Episodes (BS<55)
15 ± 0.04% 14 ± 0.04 % 0.969
MICU CPOE Lessons Learned
• Organizational/Physician Resistance– Executive staff commitment– Physician champions– Address workflow and policy changes (physician, nursing
participation is critical)
• Cost– Single Vendor (interoperability)– Focus on safety– Measure impact
• Product Immaturity– Establish long-term relationship with vendor– Expect to use resources to “customize” application
MICU CPOE Lessons Learned
• Training– Universal computer literacy– Flexibility to meet house staff needs
• Time efficiency is critical– Sign-on– User acceptance testing
• CPOE can drive critical care performance improvement– Protocolization/guideline implementation with order sets– Integrate Evidence Based Medicine– IS staff need clinical experience
MICU CPOE Lessons Learned
• Appropriate support important– On Site Command post
– 24/7 Tech Support During go-live
• Project Management– Issue escalation process
– Address the technology and integration issue first
• Measuring up to the VA system
CPOE System Requirementsfor Intensive Care Unit Use
• http://www.sccm.org/corporate_resources/coalition_for_critical_care_excellence/Documents/cpoe.pdf
QuestionsQuestions
Andy SteeleAndy Steele
[email protected]@dhha.org
Questions?Questions?
Contact InformationContact InformationAndy Steele, MDAndy Steele, MD
