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