CPOE in Critical Care Andy Steele MD MPH

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 6 th, 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 BWH Experience With CPOE Medication Error Rate (#/1, 000 patient days) JAMIA. 1999; 6: 313 -321

CPOE Benefits in Critical Care BWH Experience With CPOE Medication Error Rate (#/1, 000 patient days) JAMIA. 1999; 6: 313 -321

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 (N=131) Post CPOE (N=111) P 39. 9± 1. 16 39. 3± 1. 19 NS 59% 63% NS Anion Gap (mmol/L) 27. 9± 0. 54 28. 2± 0. 6 NS Bl Sugar (mg/d. L) 565. 1± 17. 5 588. 3± 23. 2 NS 2. 6± 0. 06 2. 6± 0. 07 NS Age Male (%) Ketone (1 -3 U)

CPOE Driven DKA/HHS Protocol Outcomes Pre CPOE (N=131) ICU LOS (hrs) Total LOS (hrs) Time to Anion gap clearance (hrs) Time to Ketone clearance (hrs) Hypoglycemic Episodes (BS<55) Post CPOE (N=111) P 44. 3 ± 2. 43 91. 3 ± 6. 4 34. 2 ± 1. 74 64. 3 ± 3. 9 0. 007 0. 001 15. 4 ± 1. 16 10. 3 ± 0. 44 0. 001 56. 4 ± 5. 45 37. 3 ± 3. 4 0. 003 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 Requirements for Intensive Care Unit Use • http: //www. sccm. org/corpor ate_resources/coalition_for_ critical_care_excellence/ Documents/cpoe. pdf Questions Andy Steele Andy. Steele@dhha. org

Questions? Contact Information Andy Steele, MD Andy. Steele@dhha. org