CPOE in Critical Care

1. 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

2. Outline • WHY CPOE? • CPOE in the Critical Care Unit • MICU CPOE Lessons Learned • Questions

3. 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

4. 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

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

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

7. 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.

8. 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

9. 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/CDSS : Protocol Driven Aggressive Correction Of Diabetic Emergencies

20. CPOE Driven DKA/HHS Protocol

21. CPOE Driven DKA/HHS Protocol Outcomes

22. 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

23. 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

24. 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

25. CPOE System Requirementsfor Intensive Care Unit Use • http://www.sccm.org/corporate_resources/coalition_for_critical_care_excellence/Documents/cpoe.pdf Questions Andy Steele Andy.Steele@dhha.org

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