Development of a Perioperative Medication-Related Clinical Decision Support Tool to Prevent Medication Errors: An Analysis of User Feedback

OBJECTIVES

 Medication use in the perioperative setting presents many patient safety challenges that may be improved with electronic clinical decision support (CDS). The objective of this paper is to describe the development and analysis of user feedback for a robust, real-time medication-related CDS application designed to provide patient-specific dosing information and alerts to warn of medication errors in the operating room (OR).

METHODS

 We designed a novel perioperative medication-related CDS application in four phases: (1) identification of need, (2) alert algorithm development, (3) system design, and (4) user interface design. We conducted group and individual design feedback sessions with front-line clinician leaders and subject matter experts to gather feedback about user requirements for alert content and system usability. Participants were clinicians who provide anesthesia (attending anesthesiologists, nurse anesthetists, and house staff), OR pharmacists, and nurses.

RESULTS

 We performed two group and eight individual design feedback sessions, with a total of 35 participants. We identified 20 feedback themes, corresponding to 19 system changes. Key requirements for user acceptance were: Use hard stops only when necessary; provide as much information as feasible about the rationale behind alerts and patient/clinical context; and allow users to edit fields such as units, time, and baseline values (e.g., baseline blood pressure).

CONCLUSION

 We incorporated user-centered design principles to build a perioperative medication-related CDS application that uses real-time patient data to provide patient-specific dosing information and alerts. Emphasis on early user involvement to elicit user requirements, workflow considerations, and preferences during application development can result in time and money efficiencies and a safer and more usable system.

An Environmental Scan of Anesthesia Information Management Systems in the American and Canadian Marketplace

Anesthesia Information Management Systems are specialized forms of electronic medical records used by anesthesiologists to automatically and reliably collect, store, and present perioperative patient data. There are no recent academic publications that outline the names and features of AIMS in the current American and Canadian marketplace. An environmental scan was performed to first identify existing AIMS in this marketplace, and then describe and compare these AIMS. We found 13 commercially available AIMS but were able to describe in detail the features and functionalities of only 10 of these systems, as three vendors did not participate in the study. While all AIMS have certain key features, other features and functionalities are only offered by some of the AIMS. Features less commonly offered included patient portals for pre-operative questionnaires, clinical decision support systems, and voice-to-text capability for documentation. The findings of this study can inform AIMS procurement efforts by enabling anesthesia departments to compare features across AIMS and find an AIMS whose features best fit their needs and priorities. Future studies are needed to describe the features and functionalities of these AIMS at a more granular level, and also assess the usability and costs of these systems.

National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review

In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies. However, it is unclear whether national and international obstetric societies' PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland, an international multidisciplinary consensus group, and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies' recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.

Documentation and Treatment of Intraoperative Hypotension: Electronic Anesthesia Records versus Paper Anesthesia Records

In this study, we examined anesthetic records before and after the implementation of an electronic anesthetic record documentation (AIMS) in a single surgical population. The purpose of this study was to identify any inconsistencies in anesthetic care based on handwritten documentation (paper) or AIMS. We hypothesized that the type of anesthetic record (paper or AIMS) would lead to differences in the documentation and management of hypotension. Consecutive patients who underwent esophageal surgery between 2009 and 2014 by a single surgeon were eligible for the study. Patients were grouped in to 'paper' or 'AIMS' based on the type of anesthetic record identified in the chart. Pertinent patient identifiers were removed and data collated after collection. Predetermined preoperative and intraoperative data variables were reviewed. Consecutive esophageal surgery patients (N = 189) between 2009 and 2014 were evaluated. 92 patients had an anesthetic record documented on paper and 97 using AIMS. The median number of unique blood pressure recordings was lower in the AIMS group (median (Q1,Q3) AIMS 30.0 (24.0, 39.0) vs. Paper 35.0 (28.5, 43.5), p < 0.01). However, the median number of hypotensive events (HTEs) was higher in the AIMS group (median (Q1,Q3) 8.0 (4.0, 18.0) vs. 4.0 (1.0, 10.5), p < 0.001), and the percentage of HTEs per blood pressure recording was higher in the AIMS group (30.4 ((Q1, Q3) (9.5, 60.9)% vs. 12.5 (2.4, 27.5)%), p < 0.01). Multivariable regression analysis identified independent predictors of HTEs. The incidence of HTEs was found to increase with AIMS (IRR = 1.88, p < 0.01). Preoperative systolic blood pressure, increased blood loss, and phenylephrine. A phenylephrine infusion was negatively associated with hypotensive events (IRR = 0.99, p = 0.03). We noted an increased incidence of HTEs associated with the institution of an AIMS. Despite this increase, no change in medical therapy for hypotension was seen. AIMS did not appear to have an effect on the management of intraoperative hypotension in this patient population.

A systematic review of near real-time and point-of-care clinical decision support in anesthesia information management systems

Anesthesia information management systems (AIMS) are sophisticated hardware and software technology solutions that can provide electronic feedback to anesthesia providers. This feedback can be tailored to provide clinical decision support (CDS) to aid clinicians with patient care processes, documentation compliance, and resource utilization. We conducted a systematic review of peer-reviewed articles on near real-time and point-of-care CDS within AIMS using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Studies were identified by searches of the electronic databases Medline and EMBASE. Two reviewers screened studies based on title, abstract, and full text. Studies that were similar in intervention and desired outcome were grouped into CDS categories. Three reviewers graded the evidence within each category. The final analysis included 25 articles on CDS as implemented within AIMS. CDS categories included perioperative antibiotic prophylaxis, post-operative nausea and vomiting prophylaxis, vital sign monitors and alarms, glucose management, blood pressure management, ventilator management, clinical documentation, and resource utilization. Of these categories, the reviewers graded perioperative antibiotic prophylaxis and clinical documentation as having strong evidence per the peer reviewed literature. There is strong evidence for the inclusion of near real-time and point-of-care CDS in AIMS to enhance compliance with perioperative antibiotic prophylaxis and clinical documentation. Additional research is needed in many other areas of AIMS-based CDS.

Effect of a cognitive aid on adherence to perioperative assessment and management guidelines for the cardiac evaluation of noncardiac surgical patients

BACKGROUND

The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline.

METHODS

Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool.

RESULTS

All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001).

CONCLUSIONS

Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.