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

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

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. 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

20. CPOE Driven DKA/HHS Protocol Pre CPOE (N=131) Post CPOE (N=111)P Age39.9±1.1639.3±1.19NS Male (%)59%63%NS Anion Gap (mmol/L)27.9±0.5428.2±0.6NS Bl Sugar (mg/dL)565.1±17.5588.3±23.2NS Ketone (1-3U)2.6±0.062.6±0.07NS

21. CPOE Driven DKA/HHS Protocol Outcomes Pre CPOE (N=131) Post CPOE (N=111)P ICU LOS (hrs)44.3 ± 2.4334.2 ± 1.740.007 Total LOS (hrs)91.3 ± 6.464.3 ± 3.90.001 Time to Anion gap clearance (hrs) 15.4 ± 1.1610.3 ± 0.440.001 Time to Ketone clearance (hrs) 56.4 ± 5.4537.3 ± 3.40.003 Hypoglycemic Episodes (BS<55) 15 ± 0.04%14 ± 0.04 %0.969

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 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

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