Electronic Prescribing: Proactive

Management Model in an

Intensive Care Unit

Prepared byPierre Clement, Manager of Clinical Information Systems and InformaticsDepartment of Intensive Care Medicine, Critical Care and Clinical Support ServicesRoyal Brisbane and Women’s Hospital, Brisbane

Acknowledgements Associate Professor Dr Robert Boots, Deputy DirectorDr Jason Roberts, Consultant PharmacistPatrick Young, Data Quality Nurse / Clinical NurseHiran Bandeshe, Database ManagerDepartment of Intensive Care Medicine, Critical Care and Clinical Support ServicesRoyal Brisbane and Women’s Hospital, Brisbane

Overview

• Understanding the limitations and setting realistic expectations of the end user

• Developing a foundation to support an Electronic Medication Management System (EMMS)

• Establishing a reporting structure to meet the requirements of an ICU

Department of Intensive Care Medicine

Clinical Activity

• Tertiary ICU

• In 2012 there were 2289 admissions into ICU

Department of Intensive Care Medicine

Infrastructure

• 4 integrated 9 bed clinical areas

• Every bedside is equipped with a Computer On Wheels (COW)

• Each clinical area has a central station with 4 dual-screen computers

• Wireless network to go live mid 2013

Clinical Information System

Overview

• ICU has been using a Clinical Information System (CIS) since 1996

• ICIP (Rev D.03) go live in December 2008

• Developed by commercial vendor

• Local solution for ICU

Clinical Information System

Overview

ICIP provides ICU with a complete Electronic Medical Record• ADT Information (Interfaced with the hospital information system)

• Patient Observations (Interfacing with equipment)

• Laboratory Information (Interfaced with the hospital laboratory information system)

• EMMS� 15 Catalogues� 1364 Formulary Items

• Progress Notes

• Procedural Information

• Wound Documentation and Images

• Transfer / Discharge Documentation

• ANZICS Documentation

• Advisories

• Understanding the limitations and setting realistic expectations of the end user

• Developing a foundation to support an Electronic Medication Management System (EMMS)

• Establishing a reporting structure to meet the requirements of an ICU

Motivation for ICIP Review

2009 (1st year following installation)

• 2379 ICU admissions

• 68,927 Medical orders

• 59 Medication errors were reported using the hospitals clinical incident system

• 8 Changes to the medication formulary

However….• ICU staff were frustrated with the EMMS component of ICIP

• Frequent occurrences of medical orders that were

� Incomplete

� Unclear

� Missing

Motivation for ICIP Review

There was no Work Unit Guideline (WUG) in place for the EMMS component of ICIP

Within Queensland Health’s policy framework there are a range of documents.

• WUG provides guidance for best practice (e.g. procedures, medical equipment,

medication administration)

• Outcomes of WUG are:

� Improve patient safety

� Consistent and safe administration of medications

� Safe usage of medical equipment

Q: Were we using the EMMS component of ICIP safely

A: ?

Q: Were there any limitations of the EMMS component of ICIP

A: ?

Review Process

Understanding the Limitations

Review Process

Example – ‘Off Formulary’ Orders

Used the reporting solution to identify all ‘Off Formulary’ orders

Process

Review Process

Example – ‘Off Formulary’ Orders

• Identified how these orders were being used by medical staff BUT not why?

• Identified components of the order that could lead to incomplete and/or confusing prescriptions

• Identified that the dosage bounds of an order are not enforced when signing against the order

• ‘Off Formulary’ orders do not reference allergy information

• ‘Off Formulary’ orders do not reference ‘admission’ or ‘ongoing’ weight

• ‘Off Formulary’ medication orders are not linked to the fluid balance chart

• Not easily reportable

Results

Q: Were we using the CPOE component of ICIP safely

A: No

Q: Were there any limitations of the CPOE component of ICIP

A: Yes

Post Review

Example – ‘Off Formulary’ Orders

Identification of ‘Off formulary’ orders

• Within the EMMS

• Medication audit report

Staff education

• Appropriate use of an ‘Off formulary’ order

• EMMS limitations when using an ‘Off formulary’ order

• Potential issues from using an ‘Off formulary’ order (incomplete, unclear, illegal)

Knowledge base within the EMMS

• ‘How to safely prescribe’ video tutorial

• Manual outlining the safety aspects

Processes to ensure

• These orders are corrected

• The formulary is updated

• There is follow up education and feedback

Strategies Implemented

Post Review

Example – ‘Off Formulary’ orders

Outcome

• Safe usage of ‘Off Formulary’ orders

• Improved patient safety

• Improved medication formulary

• Understanding the limitations and setting realistic expectations of the end user

• Developing a foundation to support an Electronic Medication Management System (EMMS)

• Establishing a reporting structure to meet the requirements of an ICU

Developing a Foundation

Prerequisites• Support from ICU director

• Committed CIS team

• Collaborative relationship with

� Clinical leaders within ICU

� RBWH Safety and Quality Unit

� Local IT department

� Vendor

• Understanding the business

• Knowing the limitations of the EMMS

Developing a Foundation

Key Objectives behind our foundation• Improve patient safety

• Mitigate risk where possible

• Engage end users

• Provide staff with the resources to use the EMMS safely

• Address expectations of end users

• Ensure continuous access to the EMMS

• Provide a consistent approach to change management

• Ensure the EMMS continues to evolve

• Proactive support model where possible

Testing Environment (Sand Pit)

Benefits

• Testing does not impact the production environment

• Supports the ‘test to break’ attitude

• Provides an environment that has allowed for a deeper understanding of the EMMS

• Enhances change management processes

Application

• Trouble shooting

• Testing

� User acceptance

� Patches

� New software functionality

Knowledge Base – End Users

Help file within the EMMS• Collection of HTML Pages

� Customisable

� Indexed and searchable

• Resource Information

� Contact information

� EMMS issues

� EMMS limitations

� Video tutorials

� PDF manuals

� Links to websites

� Change request forms

Benefits• Provides end users with 24*7 support at point of care

• Centralises support information

• Improves end user satisfaction and engagement

• Reduces in-bound support requests

• Improves the quality and efficiency of staff support

Change Management Processes – Formulary

Change Management Processes1) Change requests from end users and the Medication Safety Portfolio

� Ad hoc

� Medication errors

� New equipment

� Initiatives

� Infusion pump formulary changes

� Compliance with standards

2) Changes driven by medication audit

3) Change requests from research staff

Benefits • Reduces the number of ‘off formulary’ medication orders

• Improves efficiency of changes to the formulary

• Provides clear communication of the processes for safe changes to the formulary

Formulary Changes - Medication Audit

Change Management Processes – Formulary

‘Outcome’

Measurable outcome• 65% reduction in the use of ‘Off Formulary’ orders (comparing 2009 to 2012)

• Understanding the limitations and setting realistic expectations of the end user

• Developing a foundation to support an Electronic Medication Management System (EMMS)

• Establishing a reporting structure to meet the requirements of an ICU

Reporting Structure - Overview

Reporting Structure - Overview

Strengths

• Customisable reports

• Target multiple patients and data within one report

• Flexible in the delivery of reports

� Scheduled

� On demand within the EMMS

• End users can access the reporting server and run reports

• Reports are able to export results in a variety of formats

Weakness

• Data in reporting database is not available in real time

Reporting Solution – Proactive Monitoring

Purpose• Notify when problem arises

• email

• SMS

• Details of the problem

Benefits• Address the problem before any clinical impact occurs

• Able to inform staff of potential disruption to reports

• Improves effectiveness and efficiency of support

Reporting Solution - Management of an EMMS

Benefits

• Crucial in the review process

� Identification of medication errors

� Not reliant on the clinical incident management system

� Streamlined chart reviews

• Continually meeting the reporting needs at a clinical, business and research level

• Streamlined business processes

• Improved risk mitigation

• Assists with tailoring ongoing end user education

• Supports change management processes

Reporting Solution - Additional Benefits

Research Report Requirement• Scheduled Report (delivered daily)

• SIRS Criteria

� Vital signs

� Ventilation information

� Lab Results

• Antibiotic usage

• Admission and discharge information

Reporting Solution - Additional Benefits

Clinical Report – Ad Hoc• Antibiotic usage

• Admission and discharge Information

• Diagnostic information

• Procedural information

Summary

2012 (4th year following installation)

• 2287 ICU admissions

• 75,430 Medical orders

• 90 Medication errors were reported using the hospitals clinical incident system

• 82 Changes to the medication formulary

• New ICU Staff

� 61 Medical Staff

� 32 Nursing Staff

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100

2009 2010 2011 2012

ICU MedicationErrors

YEAR

Q: Has the new foundation resulted in reducing medication errors

A: ?

Summary

Outcomes of the new foundation

• Developed a complete understanding of the EMMS functionality and limitations

• Improved medication formulary

• Comprehensive risk mitigation

• Utilising the EMMS within realistic boundaries

• Implemented a foundation that is more effective, efficient and sustainable

• Transitioned from a reactive to proactive support model

• Reporting solution that meets the needs of an ICU

• Improved end user awareness of the functional limitations of the EMMS

• Set realistic end user expectations

• Improved end user engagement

• Improved staff satisfaction