Use Of Order Set Research Articles

Blood conservation in the critically ill

Anemia of critical illness is common among intensive care unit patients. A blood management pilot program was initiated to study the pharmacodynamic response of epoetin alfa in critically ill patients and assess the impact of the use of a standardized order set of pharmaceuticals, including epoetin alfa and intravenous iron sucrose, on the quantity of red blood cell units transfused in the adult intensive care unit. A pre-printed order set was developed which included baseline and follow-up laboratory monitoring and pharmaceutical options for iron, either intravenous and/or oral, folic acid, ascorbic acid, cyancobalamin, and weight-based epoietin alfa. Laboratory studies included: hemoglobin/hematocrit, reticulocyte count, absolute reticulocyte count, immature reticulocyte fraction obtained at baseline, and on day three and day five; in addition, iron, total iron binding capacity, transferrin saturation, and ferritin were obtained at baseline and on day five. An average hemoglobin response of 0.8 g/dL five days after administration of epoetin alfa was demonstrated in a diverse population of critically ill patients. Patients who received intravenous iron did not have a difference in mortality as compared to those patients who did not receive intravenous iron; however, there was a significantly longer length of stay. The cost of epoetin alfa was $64,000 over 10 months (approximately 8-10 patients/month). Transfusions of RBCs in adult intensive care unit decreased over the initial five months of the pilot study. Use of erythropoiesis stimulating agents (ESAs) in the critically ill is controversial. Implementing a standardized approach in the pharmaceutical management of anemia in the critically ill patient is possible. Limitations with the order set and standardized protocol included errors in selection of dose/weight, incomplete laboratory/monitoring, and inconsistent prospective/concurrent review to guide therapy. The determination of the cost-effectiveness of epoetin alfa therapy in anemia of critical illness was not the purpose of this project, but will be the focus of future studies.

Integrating “Best of Care” Protocols into Clinicians' Workflow via Care Provider Order Entry: Impact on Quality-of-Care Indicators for Acute Myocardial Infarction

ObjectiveIn the context of an inpatient care provider order entry (CPOE) system, to evaluate the impact of a decision support tool on integration of cardiology “best of care” order sets into clinicians' admission workflow, and on quality measures for the management of acute myocardial infarction (AMI) patients. DesignA before-and-after study of physician orders evaluated (1) per-patient use rates of standardized acute coronary syndrome (ACS) order set and (2) patient-level compliance with two individual recommendations: early aspirin ordering and beta-blocker ordering. MeasurementsThe effectiveness of the intervention was evaluated for (1) all patients with ACS (suspected for AMI at the time of admission) (N = 540) and (2) the subset of the ACS patients with confirmed discharge diagnosis of AMI (n = 180) who comprise the recommended target population who should receive aspirin and/or beta-blockers. Compliance rates for use of the ACS order set, aspirin ordering, and beta-blocker ordering were calculated as the percentages of patients who had each action performed within 24 hours of admission. ResultsFor all ACS admissions, the decision support tool significantly increased use of the ACS order set (p = 0.009). Use of the ACS order set led, within the first 24 hours of hospitalization, to a significant increase in the number of patients who received aspirin (p = 0.001) and a nonsignificant increase in the number of patients who received beta-blockers (p = 0.07). Results for confirmed AMI cases demonstrated similar increases, but did not reach statistical significance. ConclusionThe decision support tool increased optional use of the ACS order set, but room for additional improvement exists.