Implementation of computerized provider order entry in a neonatal intensive care unit: Impact on admission workflow

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Abstract

Objective

The study objective was to determine if computerized provider order entry (CPOE) systems impaired or enhanced workflow in the neonatal intensive care unit (NICU) by comparing the timing of administration of the first dose of antibiotics before and after CPOE system implementation.

Methods

We conducted a pre-post intervention comparative study of the length of time between admission and administration of initial antibiotics in neonates before and after a CPOE system was implemented. Clinical information and timing of antibiotic administration were collected on all inborn infants, who were admitted to the NICU in the first 4 h of life and treated with antibiotics, for one year prior to the implementation of computerized order entry and for one year after the implementation.

Results

Infants admitted to the NICU were similar in both periods (mean birth weight 2183 g vs. 2091 g, gestational age 33.3 weeks vs. 33.0 weeks). There was no significant difference in mean length of time from admission to antibiotic administration in the pre-CPOE group (131 min [CI 124–139]) compared to the post-CPOE group (125 min [CI 116–133]) (p = 0.07). The mean time to pharmacy verification for a subset of patients was significantly shorter for patients in the post-CPOE group (61 ± 58 min) compared to the pre-CPOE group (88 ± 76 min) (p = <0.001).

Conclusions

While the introduction of a CPOE system in the NICU did not significantly improve antibiotic administration times, the timeliness of an important aspect of the medication process, time to pharmacy verification, was improved. These findings imply other factors are impeding workflow. Further studies are needed to evaluate how CPOE systems combined with patient care activities affect workflow and overall patient care.

Highlights

► Introduction of CPOE improved pharmacy turnaround times. ► Despite improved pharmacy turnaround, there was no change in the time to the first dose of antibiotics. ► Admission workflow is a complex process, and will require a multifaceted approach in order to further improve antibiotic administration time in the neonatal intensive care unit.

Introduction

Health information technology (HIT) is being introduced into hospitals throughout the United States in an effort to improve the safety and efficiency of health care delivery. One form of HIT is computerized provider order entry (CPOE), which eliminates the need for handwritten orders through electronic generation and transmission of orders. CPOE systems have been shown to reduce medication errors and improve the safety for patients by checking doses, allergies and possible medication interactions, as well as alleviating the problem of illegibly written orders [1]. While implementing CPOE systems improves some aspects of safety and efficiency, unintended consequences of these systems have been documented. Studies have shown an increase in mortality associated with the introduction of CPOE in a pediatric intensive care unit [2] and an increase in medical errors and adverse events [3]. Some suggest that CPOE, as well as other patient care information systems, may actually promote errors rather than decrease their incidence [4].

Given the potential negative impact CPOE systems can have on patient care, it is important to evaluate how these systems alter workflow and patient care delivery. Workflow is a term used to describe the tasks, procedural steps, people involved, information, and tools needed for each step in a process to produce a product or service [5]. The implementation of a CPOE system changes the way healthcare providers coordinate their work activities and collaborate to deliver health care [6]. The complexity of workflow required in patient care has been broken down into a number of potential tasks that can be impacted negatively by computerized order entry [4]. These include factors such as frequent interruptions during human computer interaction, errors in communication with loss of feedback and interaction between health care workers, and inflexibility of instructions [7]. It is important to ensure that the efficiency and safety of a CPOE system is as good, if not better, than the previous handwritten order system.

Improved efficiency with CPOE systems has been suggested by studies reporting improved medication turn-around times after CPOE implementation [8], [9], [10], [11]. The CPOE system at Johns Hopkins Hospital (Sunrise Clinical Manager by Allscripts) was implemented in the neonatal intensive care unit (NICU) in January 2008. Our objective was to evaluate the impact that this system has on the care provided to our patients by evaluating its effect on the workflow in the NICU. As a proxy for our ability to provide prompt care to our patients, we examined the time to antibiotic administration for patients newly admitted to the NICU. The administration of antibiotics within 2 h after admission to the NICU for the treatment of neonatal sepsis is an established NICU guideline, based on studies in adults which have shown that prompt antibiotic administration reduces mortality in the setting of septic shock [12]. The primary outcome of this study was the length of time from admission to administration of the first dose of antibiotic for any inborn neonate admitted to the NICU and being treated for possible sepsis.

Section snippets

Study population

This study was a pre-post intervention comparative study of the time to administration of initial antibiotics before and after CPOE was implemented in our institution. The Institutional Review Board for Johns Hopkins Medical Institutions approved the study. The study population included all neonates born at Johns Hopkins Hospital and admitted to the NICU from January 2007 to through January 2009 who received antibiotics for possible sepsis as part of their admission orders. Excluded were any

Results

During the study period, 717 infants admitted to the NICU met study criteria. There were 376 infants in the pre-CPOE period and 341 infants in the post-CPOE period. There were no significant differences in demographics between the two groups (Table 1).

The mean length of time from admission to antibiotic administration in the pre-CPOE group was 131 min (95% confidence interval (CI) 124–139) compared to 125 min (CI 116–133) in the post-CPOE group (p = 0.07). Additional regression analysis did not

Discussion

While the implementation of a CPOE system in the NICU reduced time to pharmacy verification, it did not significantly reduce the amount of time it took for an inborn neonate to receive the first dose of antibiotics following admission. The implementation of CPOE systems has been shown to reduce medication error and improve patient safety [14], [15]. However, we are still learning how these systems otherwise affect patient care through changes in workflow, particularly in the unique patient

Authors’ contributions

A.K. Chapman, C.U. Lehmann, P.K. Donohue and S.W. Aucott all contributed substantially to the concept and design of the study, interpretation of data, drafting and revision the article for intellectual content and gave final approval of the version to be submitted. Additionally, A. Chapman and C.U. Lehmann performed data acquisition, and P. Donohue performed data analysis.

Conflict of interest

None declared.

Acknowledgements

We would like to thank Carol Wesolowski, Pharm D., for assistance in pharmacy data interpretation. In addition, we would like to thank Schelly Webber, RN for assistance in interpretation of CPOE nursing documentation.

References (19)

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