Computerized Order Entry System Research Articles

Implementation of a care pathway based computerized order entry system streamlines test ordering and offers tools for benchmarking clinical practice

Background and aimsThis is a narrative report on the development of specifications and of the stepwise implementation of a computerized physician order entry system (CPOE) in the University Hospitals Leuven, based on order sets integrated in care pathways. Integration of the CPOE into the electronic health record optimally supports those care pathways. Materials and methodsWe investigated adherence to consensus-based use of laboratory tests. We analysed data post- versus pre-implementation test requests for departments selected to cover various patient populations, using the Mann-Whitney U test corrected for the False Discovery Rate. ResultsWe investigated the effect on the number of tests post- versus pre-implementation. In the emergency and inpatient wards, the CPOE implementation resulted in decreases in requests for uric acid, total protein, direct bilirubin, reticulocyte count, and increases in requests for albumin, glucose and calcium. In the outpatient clinics, where the medical specialties already used non-computerized consensus-based test requesting strategies, effects on the number of requested tests were marginal. In all settings, operational improvements could be inferred: the centrally managed CPOE system resulted in fast and well-controlled management of test strategies, digital traceability of the laboratory test requesting process, automatic archiving of requests, assurance of availability of obligatory information. ConclusionsOverall, test requesting strategies improved towards more consensus-based and operational benefits resulted in time gains and improved efficiency of time spend.

Development and assessment of PharmaCheck: an electronic screening tool for the prevention of twenty major adverse drug events

BackgroundAdverse drug events (ADEs) can be prevented by deploying clinical decision support systems (CDSS) that directly assist physicians, via computerized order entry systems, and clinical pharmacists performing medication reviews as part of medical rounds. However, physicians using CDSS are known to be exposed to the alert-fatigue phenomenon. Our study aimed to assess the performance of PharmaCheck—a CDSS to help clinical pharmacists detect high-risk situations with the potential to lead to ADEs—and its impact on clinical pharmacists’ activities.MethodsTwenty clinical rules, divided into four risk classes, were set for the daily screening of high-risk situations in the electronic health records of patients admitted to our General Internal Medicine Department. Alerts to clinical pharmacists encouraged them to telephone prescribers and suggest any necessary treatment adjustments. PharmaCheck’s performance was assessed using the intervention’s positive predictive value (PPV), which characterizes the proportion of interventions for each alert triggered. PharmaCheck’s impact was assessed by considering clinical pharmacists as a filter for ruling out futile alerts and by comparing the final clinical PPV with a pharmacist (the proportion of interventions that led to a change in the medical regimen) to the final clinical PPV without a pharmacist.ResultsOver 132 days, 447 alerts were triggered for 383 patients, leading to 90 interventions (overall intervention PPV = 20.1%). By risk class, intervention PPVs made up 26.9% (n = 65/242) of abnormal laboratory value alerts, 3.1% (4/127) of alerts for contraindicated medications or medications to be used with caution, 28.2% (20/71) of drug–drug interaction alerts, and 14.3% (1/7) of inadequate mode of administration alerts. Clinical PPVs reached 71.0% (64/90) when pharmacists filtered alerts and 14% (64/242) if they were not doing it.ConclusionPharmaCheck enabled clinical pharmacists to improve their traditional processes and broaden their coverage by focusing on 20 high-risk situations. Alert management by pharmacists seemed to be a more effective way of preventing risky situations and alert-fatigue than a model addressing alerts to physicians exclusively. Some fine-tuning could enhance PharmaCheck's performance by considering the information quality of triggers, the variability of clinical settings, and the fact that some prescription processes are already highly secured.

Implementation of pharmacist-managed early switch from intravenous to oral therapy using electronic identification at a tertiary academic hospital

Overutilization of intravenous (IV) medications can result in drug shortages, which is one of the major health care crisis, in addition to increasing costs, length of hospital stays (LOS) and the associated complications. We hypothesized that IV therapy was overused at our hospital where oral (PO) was applicable, and that the implementation of IV-PO protocol could result in a cost-effective practice. Hence, we aimed at assessing impact and outcomes of implementing such a protocol.A single center, prospective quasi-interventional study conducted at tertiary academic hospital. A protocol was implemented targeting 17 medications, with educational sessions to medical staff during a 5-month phase. IV orders of 48 h or more, among adult patients at medical or surgical wards with no contraindication to PO route were eligible. Once eligible, pharmacists send interventions using hospital’s computerized order entry system, and physicians’ responses were monitored on daily basis. Efficacy was estimated by percentage of switch recommendations that resulted in effective switch to PO medication. Cost-minimization analysis was used for course cost between the control phase and intervention phase. Length of hospital stay (LOS), readmissions within 90 days and in-hospital mortality were analyzed as secondary outcomes.During intervention phase, 781 patients had at least one IV order switched to PO. Gastric acid-reducing agents (GARAs) accounted for the most IV prescriptions (50.4%), followed by antibiotics (39.6%). Pharmacists carried out 2677 interventions to which switch recommendations were issued in 1185 (44.3%). Primary switch recommendations (N = 677) led to effective switch in 60.7% cases. These included per protocol switch (8.9%), switch to another PO (2.5%), spontaneous switch by physician (17.6%) and IV discontinuation (31.8%). The overall efficacy was estimated as 62.8%. The intervention was associated with reduced IV consumption from 4,574–18,597 vials in control phase to 3,654–15,546 vials in intervention phase, which resulted in overall cost saving of 50,960.8 SAR ($13,589.5), with an average monthly cost saving of 10,192.2 SAR ($2,717.9).Pharmacist-managed early switch from IV-PO therapy, with physicians’ education, showed significant reduction in IV medication use in our hospital. By reducing unnecessary IV use, this strategy enabled considerable cost savings, besides the potential advantages of convenience and safety.

Risk factors associated with medication ordering errors.

We utilized a computerized order entry system-integrated function referred to as "void" to identify erroneous orders (ie, a "void" order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors. We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors-based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems-based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety. During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors. The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.

Deployment of a Clinical Pathway to Improve Postcardiac Arrest Care: A Before-After Study.

Postcardiac arrest care bundles following adult cardiac arrest are associated with improved survival to discharge. We aimed to evaluate whether a clinical pathway and computerized order entry were associated with improved pediatric postcardiac arrest care and discharge outcomes. Single-center retrospective before-after study. Academic PICU. Patients who suffered an in- or out-of-hospital cardiac arrest from January 2008 to December 2015 cared for in the PICU within 12 hours of sustained return of circulation. Deployment of a postcardiac arrest clinical pathway and computerized order entry system. There were 380 patients included-163 in the pre-pathway period and 217 in the post-pathway period. Primary outcome was percent adherence to pathway clinical goals at 0-6 and 6-24 hours post-return of circulation and to diagnostics (continuous electroencephalogram monitoring, head CT for out-of-hospital cardiac arrests, echocardiogram). Secondary outcomes included survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). The pre-pathway and post-pathway groups differed in their baseline Pediatric Cerebral Performance Category scores and the following causes of arrest: airway obstruction, arrhythmias, and electrolyte abnormalities. Pathway adherence was not significantly different between the pre-pathway and post-pathway groups, with the exception of higher rates of continuous electroencephalogram monitoring (45% vs 64%; p < 0.001). There was no difference in survival to hospital discharge between the two groups (56% vs 67%; adjusted odds ratio, 1.68; 95% CI, 0.95-2.84; p = 0.05). Survival to discharge was higher in the post-pathway group for the in-hospital cardiac arrest cohort (55% vs 76%; adjusted odds ratio, 3.06; 95% CI, 1.44-6.51; p < 0.01). There was no difference in favorable neurologic outcome between all patients (adjusted odds ratio, 1.21; 95% CI, 0.72-2.04) or among survivors (adjusted odds ratio, 0.72; 95% CI, 0.27-1.43). After controlling for known potential confounders, the creation and deployment of a postcardiac arrest care pathway and computerized order entry set were not associated with improvement in pathway adherence or overall outcomes, but was associated with increased survival to hospital discharge for children with in-hospital cardiac arrests.

Diabetic Ketoacidosis Management in the Emergency Department: Implementation of a Protocol to Reduce Variability and Improve Safety.

Emergency departments (EDs) are the primary venue for diagnosis and initiation of treatment of diabetic ketoacidosis (DKA). Typically managed in an intensive care unit (ICU), in many medical centers, limited ICU bed availability necessitates DKA-extended ED management until sufficient improvement for admission to a non-ICU bed. Although DKA treatment is well established, coordinating safe and effective extended care in a busy ED is complex. Recurrent problems in this high-risk transition of care led us to improvement efforts. We studied the impact of a standardizing ED DKA management in two phases: rollout of a DKA pathway in our computerized order entry system followed by audit and feedback. We evaluated adherence, clinical process, operational, and safety measures following these interventions. Adherence to the pathway was initially slow, improving significantly after audit and feedback. We observed mixed improvements in clinical processes, no changes in operational metrics (as expected), and reductions in variability for several measures. There were no deteriorations and improvements in measures of safety, and a reduction in the number of adverse event reports in the postimplementation periods.

Subcutaneous Insulin Dosing Calculators for Inpatient Glucose Control.

The goal of this review is to summarize information about insulin dosing software and calculators used as computerized decision support systems or electronic glucose management systems (eGMS). These are used for hospitalized, insulin-treated patients with diabetes. We describe the advantages and disadvantages and the rationale for their use. We compared commercially available insulin dosing software, namely, Glucommander™, EndoTool®, GlucoStabilizer®, and GlucoTab®, in addition to computerized order entry systems that are available in electronic health records. The common feature among these eGMS is their ability to limit occurrences of hypoglycemia while achieving and maintaining patients at target blood glucose level. More research needs to be done examining the efficacy of eGMS in disease-specific states and their benefits and utility in preventing adverse outcomes. Their long-term benefits to health care systems are beginning to emerge in cost-saving benefits and prevention of readmissions.

VP25 HTA Enables Nurses To Discontinue Continuous ECG Monitoring

IntroductionProviders frequently issue orders for telemetry (continuous ECG monitoring) of hospital inpatients, but they rarely issue orders to discontinue telemetry. This can cause telemetry beds to be unavailable for patients who need them.MethodsOur hospital health technology assessment (HTA) center conducted a rapid systematic review of evidence on algorithms, guidelines, and other tools for nurses to identify patients who no longer need telemetry. Databases searched included Medline, CINAHL, the Cochrane Library, National Guideline Clearinghouse, and Joanna Briggs Institute.ResultsWe found no guidelines or existing systematic reviews of nurse-driven protocols for discontinuing telemetry. There were three published articles describing projects where protocols for discontinuing telemetry were tested. All three of these studies were of low methodologic quality. They all found that use of the protocol reduced the number of hours of telemetry monitoring that were used in the hospital. Two studies published in letter form reported adaptations of computerized order entry systems where nurses assess the patient's readiness for discontinuing telemetry and either discontinue telemetry or report to the ordering physician when the stated discontinuation criteria are met.ConclusionsOur hospitals are now implementing the HTA findings in our electronic ordering system.

Utilizing a standardized order set to increase speech pathology referrals in head and neck cancer patients.

324 Background: Treatment of head and neck cancers may include radiation, and side effects will result in short and long-term dysphagia. This can lead to feeding tube usage, malnutrition, loss of social interaction, and reduced quality of life. Rehabilitation therapies are available with speech pathologists to improve outcomes. Evidence supports initiating therapy prior to radiation. Computerized order entry systems (CPOE) support standardization of evidence- based order sets. The purpose of this study was to examine the effect of a standardized order set on referral rates to speech pathology in adult patients undergoing radiation treatment for head and neck cancer. Methods: A quality improvement project was implemented an outpatient oncology clinic within an academic hospital using the PDSA format. Approval was obtained through the hospitals quality assurance officer, and it was determined that IRB approval was not necessary. A chart review was completed to assess the rate of speech pathology consults. A brief education program targeting ordering providers was completed including demonstration of the order set. Post intervention chart review was performed to assess the change in referral rates. Results: A chi square analysis was used to compare the difference in referral rates and found to be statistically significant, x² (1, n = 56) = 17.147, p &lt; 0.01. Demographic data was analyzed using descriptive statistics. The sample was mostly Caucasian (82%), male (84%) with an average age of 63. The most common cancer diagnosis was larynx (36%). The percentage of referrals post intervention (82%) was significantly higher than pre-intervention (18%) consistent with the hypothesis that a standardized order set would increase speech referral rates. Conclusions: Use of a CPOE system with standardized order sets increased the rate of speech pathology referrals. The success of this order set has led to an expansion of the project, and creation of additional order sets. Standardized computerized order sets should be considered to increase referrals to underutilized ancillary services. Providers should be encouraged to create relationships with these services to improve patient’s quality of life and long- term outcomes.

Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing

Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, -6.12 to -4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, -41.36 to -27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41). Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.

Risk factors for opioid overdose among hospitalized patients.

Hospitalized patients are at risk for opioid overdose. Little is known about the risk factors for these events. Opioid overdose cases were identified by naloxone orders in computerized order entry system from a single institution. For each case, two controls were randomly selected. Data were collected on factors including age, gender, weight, opioid dose, route of administration, concomitant CNS depressants, renal function and comorbid conditions. Between 2010 and 2013, we identified 44 cases of opioid overdose (OD), none of which were fatal, and matched these to 88 controls (no OD). Patients with a history of substance use disorder were excluded from the study. Factors associated with opioid overdose included age of 65 or older (40.9% OD vs 29.5% no OD, P=.026), being in an ICU (MICU/CICU 27.3% OD vs. 3.4% no OD, P<.001; SICU 18.1% OD vs 5.7% no OD, P=.031) and renal impairment (eGFR ≤60, 50.0% OD vs 28.4% no OD, P=.034). Total 24-hour opioid dose was lower in OD group, but the difference was not statistically significant (71.9 vs 107.2mg morphine equivalent, P=.116). OD cases were more likely to have received concomitant CNS depressants, but the difference was statistically significant only for those who received 3 or more (15.9% OD vs 0% no OD, P=<.001). Heart disease was the only comorbidity significantly associated with an increased risk of opioid overdose (43.2% vs 20.5%, P=.025). Patient's BMI, duration of opioid use, route of administration and history of COPD and/or psychiatry were not associated with opioid overdoses. Among hospitalized patients, risk factors of opioid overdose include age of 65 or greater, being in an ICU, renal impairment and concomitant administration of CNS depressant medications. These findings may help with the development and implementation of measures to prevent overdose.

Correlation between different carboplatin dosing patterns and its toxicity analysis in patients with advanced lung cancers: A retrospective study.

To evaluate the current NCI-CTEP recommendation and the clinical use of Calvert Formula-derived carboplatin dosing pattern in the treatment of advanced lung cancer patients and assess carboplatin-related toxicity in relation to the degree of dose fluctuation. This retrospective study involved all histologically confirmed inoperable lung cancer patients receiving palliative-intent carboplatin or carboplatin-combination chemotherapy from 2012 to 2016 at Kingston Health Sciences Centre. The carboplatin dosing pattern and carboplatin-related toxicity were collected and analysed on SPSS IBM for Windows version 24.0 (IBM Corp., Armonk, NY, USA). Results were expressed in percentages and P values. Our findings ( N = 75) suggested that 24% of patients had a high-degree of fluctuation in carboplatin dose (>10% variation from initial dose) if carboplatin dose was readjusted with each new creatinine. In practice, 16% of patients had a fluctuation of greater than 10% in ordered dose in the absence of planned dose reductions. Our study found no significant association between prescribed high-risk dosing fluctuation (>10% increased from initial dose) and carboplatin-related toxicities. In contrast to some prescribing recommendations such as NCI-CTEP, our study suggested that most medical oncologists incorporate new serum creatinine in calculating carboplatin dose for each cycle. Only 9% of patients were treated with a fixed dosing pattern (i.e. no fluctuation). Nonetheless, no significant associations were found between high-risk carboplatin dosing fluctuation and its-related toxicity. Whether such practice was due to the forcing function of the computer order entry system (CPOE), or conscious decisions by medical oncologists was unknown. Further analysis in evaluating physicians' preferences and influencing factors on dosing pattern decision would be recommended.

National Survey of Hospital Medication Safety Practice during Mass Gathering (Hajj-2016) in Makkah, Saudi Arabia: Patient Information

<p style="text-align: justify;"><strong>Objective:</strong> To explore the national hospital medication safety survey during mass gathering (Hajj -2016) in Makkah, Saudi Arabia: Patient information, the finding of ISMP (2011) self-assessment of medication safety at the hospitals. <strong>Methods:</strong> It is 15 days cross-sectional national survey of hospital medication safety at Makkah region. The survey modified from Institution of Safe Medication Practice (ISMP) self-assessment of hospital medication safety. It consisted of a demographic section and ten domains with 270 questions. The ten areas included patient information, drug information, communication of medication orders, drug preparation, medication distribution, medication devices, work environment, staff competency, patient education, quality process with risk management domain. The medications safety officer at Makkah region distributed the questionnaire and made follow up on a daily basis used physical visiting and through the telephone call. <strong>Results:</strong> The total score of all ISMP-self assessment of medication safety was 3.39 +/-0.51 (67.68 %) with CI (3.2-3.6) P&lt; 0.05. The average rating of patient information domain at all hospital was 2.75+/- 0.57 (55 %) with CI (2.52-2.98) P&lt; 0.05. The highest score of patient information section was the core information of the patient transmitted to the pharmacy 3.91 (78.2%). The lowest score of patient information section was computerized physician order entry (CPOE) with drug allergies 1.73 (34.6%), computerized order entry system with drug allergies alerting severity 1.73 (34.6%), and bar-coding used to verify patient identity during drug administration 1.9 (38%). <strong>Conclusion:</strong> Despite the patient information is very crucial for medication safety; the critical base information missed with the emphasis on patient allergies related issues and verification of medication administration by using new technology. An electronic prescription with complete medication history and alerting system highly recommended to during mass gathering Hajj is essential. Targeting to correct all related patient information measure will prevent drug misadventures, improved patient clinical outcomes, and quality of life. <p style="text-align: justify;"><strong>Key words:</strong> Medication Safety, Hajj, Patient, Information, Ministry of Health, Saudi Arabia.

Indications for Antibiotic Orders: How Accurate Are They?

BackgroundDocumentation of antibiotic indications at the time of ordering can provide helpful information for antimicrobial stewardship programs to track antibiotic utilization patterns and improve antibiotic prescribing. Yet accuracy of indications is not fully understood; antibiotics are often ordered empirically without a clear-cut indication, and orders are not often updated once a diagnosis has been made, or the first listed option may be chosen for convenience. As hospitals are implementing antibiotic indications at the time of order entry to meet stewardship standards, our study sought to assess the accuracy of indications in an antibiotic order compared with true indication for the drug.MethodsIndications for antibiotics, selected from a standardized list, are a required field in the computerized order entry system at our institution. Study investigators, including at least one infectious diseases attending, performed an in-depth post-hoc review to assess antibiotic indication and appropriateness. The frequency that the true antibiotic indication, as assessed by study investigators, matched with the indication in the antibiotic order was analyzed.ResultsOf 396 antibiotic orders reviewed by the study team, 100 had discordant indications between what was written in the order and the investigator-assessed indication (25.3%). The highest rates of discordance were seen with GU-UTI (11/18 incorrect, 61.1%) followed by bacteremia/sepsis (44 of the 116 incorrect, 37.9%). For GU-UTI, the most common investigator assessed true indications were pulmonary including CAP, HAP and empyema. For bacteremia/sepsis, the discordance was often due to a more specific diagnosis or source being identified.ConclusionDiscordant indications between what was entered at the time of initial order compared with an investigator assessed indication occurred frequently. This finding is of concern as evaluations of antibiotic appropriateness, utilization and benchmarking by the antimicrobial stewardship team rely on the accuracy of indications in the system. Entering a revised indication during an antibiotic time out could improve the accuracy of antibiotic indications and antimicrobial stewardship data.Disclosures All authors: No reported disclosures.

To Assess the Success of Computerized Order Sets and Pharmacy Education Modules in Improving Antiretroviral Prescribing

Purpose: To assess the success of order set and pharmacist training improvement (OSPTI) in improving prescription of antiretroviral therapy (ART) in a tertiary care, public, teaching hospital. Methods: In this pre-OSPTI (January 2012 through June 2013) and post-OSPTI study (July 2013 through September 2014), an infectious disease pharmacist reviewed all patients on ART. A review of intervention data in July 2013 led to order-set changes in the hospital’s computerized order entry system for frequently intervened on antiretrovirals: ritonavir, tenofovir, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF), and lamivudine. Concurrently, case-based education modules were conducted to help pharmacists identify ART errors. The number of patients on ART, number of interventions, and types of ritonavir interventions were compared between pre- and post-OSPTI periods. Results: In the pre-OSPTI period, an average of 239 patients were reviewed per quarter compared to an average of 216 per quarter in the post-OSPTI period. After implementing enhanced order sets, the number of interventions decreased by approximately 34% (P < .0001). The number of ritonavir interventions decreased on average by 45% (P < .0001), although the types of ritonavir interventions were similar. Conclusion: Enhanced antiretroviral order sets and pharmacy education modules improved ART prescription by reducing the overall number of antiretroviral interventions required per quarter. This modality was effective in improving prescribing of ART and reducing the need for pharmacist interventions.

Optimizing preoperative prophylaxis in patients with reported β-lactam allergy: a novel extension of antimicrobial stewardship.

Use of alternative second-line antibiotics is associated with adverse events in patients reporting β-lactam allergy. In the perioperative setting, we hypothesized that structured allergy histories, without the use of skin testing, can reduce alternative prophylactic antibiotic use. Assess the impact of structured allergy histories on patients with self-reported β-lactam allergy (SRBA) undergoing elective surgical procedures. Structured allergy histories were performed by a pharmacist and reviewed with an infectious diseases physician. Patients were deemed safe to proceed with cefazolin prophylaxis if they did not describe a history of type I-mediated or severe reaction. Antibiotic prophylaxis orders (with approval by the surgical team) were scheduled into the computerized order entry system to be given prior to first incision of the operation. Of the 485 patients with SRBA that underwent structured allergy histories, 117 (24.1%) reported a type I-mediated allergy history; 267 (55.1%) patients received cefazolin prophylaxis and none subsequently experienced an adverse reaction. After intervention implementation, the overall use of alternative antibiotic prophylaxis at Michael Garron Hospital (Toronto, Canada) among those with SRBA decreased from 81.9% to 55.9%. This drop was associated with the number of monthly assessments (P < 0.001) in a regression analysis. Using a simple structured history and the principles of prospective audit and feedback, we were able to increase the use of cefazolin perioperative prophylaxis without any serious adverse events and in the absence of skin testing or diagnostic challenges.

P118: Effects of system design on laboratory utilization in the emergency department: the case for INR &amp; aPTT

Introduction: In the context of a shrinking healthcare budget, poor physician cost awareness, and continued over-utilization of low-value tests in the emergency department, we re-designed our computerized order entry system to reduce the use of coagulation testing. Methods: A hospital-based prospective pre-post analysis following de-bundling of INRPTT testing in two academic hospital emergency departments (annual visits 140,000). All participants aged 18 years or older undergoing evaluation and/or treatment at either of during the period of August 1, 2015 to July 24, 2016 were included. Primary outcome is coagulation testing utilization rates and associated costs. Results: Unbundling INR and aPTT testing resulted in significantly decreased bundled INRPTT testing relative to baseline (INRPTT tests per patient per day: 0.60 [95% CI: 0.57-0.62] vs. 0.98 [95% CI: 0.98-0.99], p=0.000), with significantly increased targeted testing (INR tests per patient per day: 0.39 [95% CI: 0.37-0.42] vs. 0.00 [95% CI: 0.00-0.01], p=0.000; PTT tests per patient per day: 0.33 [95% CI: 0.30-0.36] vs. 0.01 [95% CI: 0.00-0.01], p=0.000). As a result of unbundling, there was a significant decrease in costs associated with coagulation testing relative to baseline (Cost per day: $958.52 [INRPTT $592.78+INR $183.91+PTT $181.83] vs. $1,074.50 [INRPTT $1,069.76+INR $2.06+PTT $2.68], p=0.000), realizing estimated daily and yearly savings of $115.98 and $42,332.70, respectively. Conclusion: Compared to baseline practice patterns, unbundling coagulation testing resulted in the reduction of coagulation testing suggesting system design and user workflows to be an integral factor to provider practice patterns. Given the significant cost-savings, we recommend institutions carefully re-evaluate their system design and user workflows to optimize emergency department laboratory utilization.

Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion.

To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.

Organizational Benefits of Computerized Physican Order Entry (CPOE) System in Pakistan.

Electronic prescribing is also known as Computerized Physician Order Entry (CPOE). It is a computer-aided system which offers the health professionals a robust platform for entering the prescription electronically. Due to paucity of facilities in Pakistan which are available around the world, there is an observable overburden on the health professionals and practitioners. CPOE system has shown to be very effective in minimizing medication errors. CPOE is beneficial for both patient and health organizations. There is great deal of interest in the adoption of this system in our healthcare system. The results state clearly that this system is equally beneficial for organizations who want to adopt this system as perceived by the health professionals. It supports the idea of adoption and implementation of CPOE in healthcare facilities healthcare institutes. CPOE must be adopted to ease and optimize nursing services in Pakistani healthcare system.

Prevalence and risk factors for medication reconciliation errors during hospital admission in elderly patients.

Background Care transitions are risk points for medication discrepancies, especially in the elderly. Objective This study was undertaken to assess prevalence and describe medication reconciliation errors during admission in elderly patients and to analyze associated risk factors. We also evaluate the effect of these errors on the length of hospital stay. Setting General surgery, orthopedics, internal medicines and infectious diseases departments of a 1070-bed Spanish teaching hospital. Method This is a prospective observational study. Patients >65years and taking ≥5 medications were randomly selected from those admitted to hospital. The pharmacist obtained the best possible medication history based on medical records, medical notes from patients' previous admissions to hospital, "brown bag" review, community care prescriptions, and comprehensive patient interviews. It was compared to current inpatient prescription to detect unintentional discrepancies (discrepancy with no apparent clinical explanation), which were reported to the physician. When the physician accepted the discrepancy by changing the medication order, it was recorded as a medication reconciliation error and classified by type of error. Several variables were analyzed as possible risk/protective factors. Main outcome measure Is prevalence of medication reconciliation errors at admission. Results Reconciliation was performed on 206 patients. Medication reconciliation errors occurred in 49.5% (102/206) of patients. 1996 medications were recorded, and 359 had unintentional discrepancies (56.0% (201/359) medication reconciliation errors). The most common was omission (65.1%). Identified risk factors were as follows: physician experience, number of pre-admission prescribed medications, and previous surgeries. Computerized order entry system was a protective factor. Conclusion Medication reconciliation errors occur in almost half of the elderly patients at admission, especially omissions. Risk factors were a larger number of previous medications, less physician years of experience, and more previous surgeries. Having a computerized order entry system in the hospital protected against some errors.