Using An Electronic Clinical Decision Support System to Reduce the Risk of Epidural Hematoma. Am J Ther. 2012;Epub ahead of print. [PMID: 22878410 DOI: 10.1097/mjt.0b013e31825a3631]

Interventions designed to improve the safety and quality of therapeutic anticoagulation in an inpatient electronic medical record

IMPORTANCE

Anticoagulants are high-risk medications with the potential to cause significant patient harm or death. Digital transformation is occurring in hospital practice and it is essential to implement effective, evidence-based strategies for these medications in an electronic medical record (EMR).

OBJECTIVE

To systematically appraise the literature to determine which EMR interventions have improved the safety and quality of therapeutic anticoagulation in an inpatient hospital setting.

METHODS

PubMed, Embase, CINAHL, and the International Pharmaceutical Database were searched for suitable publications. Articles that met eligibility criteria up to September 2018 were included. The review was registered with PROSPERO (CRD42018104899). The web-based software platform Covidence® was used for screening and data extraction. Studies were grouped according to the type of intervention and the outcomes measured. Where relevant, a bias assessment was performed.

RESULTS

We found 2624 candidate articles and 27 met inclusion criteria. They included 3 randomised controlled trials, 4 cohort studies and 20 pre/post observational studies. There were four major interventions; computerised physician order entry (CPOE) (n = 4 studies), clinical decision support system (CDSS) methods (n = 21), dashboard utilisation (n = 1) and EMR implementation in general (n = 1). Seven outcomes were used to summarise the study results. Most research focused on prescribing or documentation compliance (n = 18). The remaining study outcome measures were: medication errors (n = 9), adverse drug events (n = 5), patient outcomes (morbidity/mortality/length of hospital stay/re-hospitalisation) (n = 5), quality use of anticoagulant (n = 4), end-user acceptance (n = 4), cost effectiveness (n = 1).

CONCLUSION

Despite the research cited, limited benefits have been demonstrated to date. It appears healthcare organisations are yet to determine optimal, evidence-based-methods to improve EMR utilisation. Further evaluation, collaboration and work are necessary to measure and leverage the potential benefits of digital health systems. Most research evaluating therapeutic anticoagulation management within an EMR focused on prescribing or documentation compliance, with less focus on clinical impact to the patient or cost effectiveness. Evidence suggests that CPOE in conjunction with CDSS is needed to effectively manage therapeutic anticoagulation. Targets for robust research include the integration of 'stealth' alerts, nomograms into digital systems and the use of dashboards within clinical practice.

The Role of Computerized Clinical Decision Support in Reducing Inappropriate Medication Administration During Epidural Therapy

Background: The use of epidural anesthesia has been shown to improve outcomes in the postoperative setting. To minimize risk of complications, avoiding certain medications with epidural anesthesia is advised. Objective: This study sought to determine the role of a computerized clinical decision support module implemented into the computerized physician order entry (CPOE) system on the incidence of administration of medications known to increase complications with epidural anesthesia. Methods: This study was a retrospective cohort chart review in adult patients receiving epidural anesthesia for at least 1 day. Patients were identified retrospectively and divided into 2 cohorts, those receiving an epidural 3 months prior to initiation of the module and those receiving an epidural 3 months following implementation. The primary end point was incidence of inappropriate medication administration before and after implementation. Complications of therapy were collected as secondary end points. Results: There was a reduction in the incidence of inappropriate medication administration in the postimplementation group versus the preimplementation group (6.3% vs 12.8%) although statistical significance was not achieved. In addition, the incidence of enoxaparin administration was significantly lower postimplementation than the preimplementation (0% vs 3.9%). There were no significant differences in other complications of therapy. Conclusions: This study demonstrated that application of decision support for this high-risk procedural population was able to eliminate the incidence of the most common inappropriate medication for epidural analgesia, enoxaparin. A reduction in incidence of other inappropriate medications was also observed; however, statistical significance was not reached. The use of computerized clinical decision support can be a powerful tool in reducing or ameliorating medication errors, and further study will be required to determine the most appropriate and effective implementation strategies.

Improving Adherence to Practice Guidelines for Anticoagulation in Patients Receiving Neuraxial Anesthesia Using an Electronic Order Entry Alert System

OBJECTIVES

Epidural analgesia is frequently used to alleviate postoperative pain. Though rare, epidural hematoma continues to be a feared complication of neuraxial analgesia. The risk of epidural hematoma is likely increased when certain regimens are used for prophylaxis/treatment of venous thromboembolism. To help decrease the risk, we developed an alert in our electronic medical record to assist providers with adherence to published guidelines addressing neuraxial analgesia and anticoagulation.

METHODS

Patient data were collected retrospectively 3 months before and 3 months after the initiation of the computerized alert to assess the effectiveness of the alert. Patients were included if they had a procedure code associated with epidural analgesia. Pregnant patients and children were excluded. Type and frequency of antithrombotic medications were recorded for comparison to published practice guidelines.

RESULTS

Using Poisson regression to describe the data, patients with epidurals after the best practice alert observed a 61% decrease in the expected number of days of exposure to inappropriate doses of anticoagulation versus patients treated before implementation of the alert.

CONCLUSION

Unapproved antithrombotic administration was significantly reduced after initiation of the alert system. This simple electronic alert was found to have a protective effect for patients receiving both anticoagulation and epidural analgesia.

Computerized decision support in adult and pediatric critical care

Computerized decision support (CDS) is the most advanced form of clinical decision support available and has evolved with innovative technologies to provide meaningful assistance to medical professionals. Critical care clinicians are in unique environments where vast amounts of data are collected on individual patients, and where expedient and accurate decisions are paramount to the delivery of quality healthcare. Many CDS tools are in use today among adult and pediatric intensive care units as diagnostic aides, safety alerts, computerized protocols, and automated recommendations for management. Some CDS use have significantly decreased adverse events and improved costs when carefully implemented and properly operated. CDS tools integrated into electronic health records are also valuable to researchers providing rapid identification of eligible patients, streamlining data-gathering and analysis, and providing cohorts for study of rare and chronic diseases through data-warehousing. Although the need for human judgment in the daily care of critically ill patients has limited the study and realization of meaningful improvements in overall patient outcomes, CDS tools continue to evolve and integrate into the daily workflow of clinicians, and will likely provide advancements over time. Through novel technologies, CDS tools have vast potential for progression and will significantly impact the field of critical care and clinical research in the future.