Computerized Provider Order Entry (CPOE) integrated with Clinical Decision Support System (CDSS) is regarded as a crucial system for enhancing the quality, safety, and efficiency of care (Simon et al., 2013). This system helps in enhancing care through preventing and/or lessening medication errors and promoting the use of evidence-based treatments. CPOE is basically defined as any system through which clinicians directly enter medications, tests, or procedure orders. Once these orders are entered, they are transmitted to the responsible clinician for executing it such as laboratory and pharmacy department. This paper will discuss the use of CPOE system integrated in a CDSS to address electrolyte replacements in patients who have undergone cardiac surgeries, which is a clinical issue involving medication.

Clinical Issue Involving Medication

The selected clinical issue involving medication for this assignment is electrolyte replacements in patients who have undergone cardiac surgeries given that electrolyte disorders are common after cardiac surgery (Couture, Létourneau, Dubuc, & Williamson, 2013). For instance, it is reported that electrolyte disorders like hypokalemia, hypomagnesemia, hypophosphatemia, and hypocacelmia occur in 34%, 46%, 83%, and 7.8% of these patients respectively (Couture, Létourneau, Dubuc, & Williamson, 2013). Electrolyte disorders in the aftermath of a cardiac surgery has become a major clinical issue because it’s associated with complications like seizure and tetany, hemodynamic instability, impaired diaphragmatic contractility and cardiac arrhythmias.

Existing studies have shown that the complications emerging from electrolyte disorders can be reduced to help enhance clinical outcomes among these critically-ill patients. Based on the findings of recent studies on this clinical issue, the use of repletion protocols is more effective as compared to standard methods of conducting electrolyte repletion. For this project, the researcher will focus on potassium chloride as a medication whereas potassium is the electrolyte contributing to the electrolyte disorder.

Rationale behind the Design Development

The rationale behind development of this CPOE system to be integrated clinical decision support system is that potassium is a major intracellular cation whose imbalance can have severe impacts on tissues. Since potassium is an electrolyte, potassium imbalance contributes to some of the most common electrolyte disorders such as hypokalemia. While there are regulations for repletion of this electrolyte using potassium chloride as the medication, clinicians tend to forget using these guidelines. Actually, clinicians tend to forget checking the laboratories to replace potassium, which in turn contributes to electrolyte disorders. Therefore, this system is developed to help provide reminders to clinicians to carryout suitable laboratory monitoring with regards to this electrolyte (Ranji, Rennke & Wachter, 2013).

The Computerized Provider Order Entry (CPOE) system for this project will provide alerts to help remind nurses to check the laboratory for repletion of this electrolyte to improve patient outcomes. The system will provide alerts on the premise that normal serum potassium is between 3.6mEq/L and 5.0mEq/L, but 4.0mEq/L is the optimal level for most patients (Gwinnett Hospital System, 2017). The alerts in the CPOE system, which will be administered during the duration of care, are as follows:

Serum Potassium

(mmol/L)

Replacement as Potassium Chloride (KCL)

(oral route preferred)

Laboratory

3.8 – 3.9

KCL 20 mEq po or IVPB x 1 dose

Repeat serum potassium

2 hrs after dose

completed

3.5 – 3.7

KCL 20 mEq po q 2 hrs x 2 doses

or

40 mEq IVPB over 2 hrs x 1 dose

3 – 3.4

KCL 40 mEq po, wait 2 hrs then give 20 mEq po for a total of 60 mEq

or

KCL 40 mEq IVPB over 2 hrs, then give 20 mEq IVPB over 1 hr for a total of 60 mEq

< 3

KCL 40 mEq IVPB over 2 hrs, then give 20 mEq IVPB over 1 hr for a total of 60 mEq and call physician

Source: http://www.gwinnettmd.org/forms_active/Physician_Order_Sets/40046-Electrolyte%20Replacement%20Protocol%20for%20Cardiac%20Patients.doc

How the Clinical Decision Support System (CDSS) will be Implemented

One of the most important elements towards the effectiveness of the Computerized Provider Order Entry (CPOE) system is effective implementation of the clinical decision support system and adoption by fellow clinicians. The first steps towards the implementation and adoption by fellow clinicians is creating buy-in among the unit’s management. This will entail holding meetings with the management to discuss and demonstrate the need for clinicians to follow the electrolyte repletion protocol and guidelines and the proposed system. After creating buy-in, the IT department will work collaboratively with the laboratory and pharmacy department to develop a design that contains these alerts to help clinicians. Through the system, physicians will prescribe electrolyte replacement using the CPOE, which is linked to the laboratory and pharmacy data on the electronic health record. The alerts will pop up for clinicians through the Clinical Decision Support System (CDSS). After the development and pilot testing, the IT department will work with the management to educate nurses on how to utilize the potassium replacement alerts in clinical practice.

Challenges and Proposed Solutions

The implementation of this system is likely to be characterized by some challenges, which may hinder its effectiveness. Some of these potential challenges include communication breakdown between the management and clinicians, probable ignorance of the alerts, and technicalities during design development. These challenges will be addressed through conducting comprehensive training and education on nurses regarding the protocol and how to utilize the alerts on daily clinical practice. Secondly, the existing communication channels will be utilized to promote information sharing between the management and the clinicians to help avoid information loss. Third, the technicalities during design development will be addressed through giving the IT team more time to develop the system and conducting pilot testing prior to full implementation of the system.

In conclusion, Computerized Provider Order Entry system integrated in Clinical Decision Support System is a crucial system for enhancing clinical outcomes. These systems act as support tools in electronic health records and help enhance patient care and safety through providing numerous benefits including preventing or lessening medication errors. For this project, the CPOE system will be integrated in CDSS and EHR to help provide alerts to clinicians to provide potassium replacement to critically ill patients suffering from electrolyte disorders after cardiac surgery.

References

Couture, J., Létourneau, A., Dubuc, A., & Williamson, D. (2013). Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients. The Canadian Journal of Hospital Pharmacy, 66(2), 96–103.

Gwinnett Hospital System. (2017). Electrolyte Replacement Cardiovascular Surgery Protocol. Retrieved September 18, 2017, from http://www.gwinnettmd.org/forms_active/Physician_Order_Sets/40046-Electrolyte%20Replacement%20Protocol%20for%20Cardiac%20Patients.doc

Ranji, S.R., Rennke, S. & Wachter, R.M. (2013, March). Computerized Provider Order Entry With Clinical Decision Support Systems: Brief Update Review. In: Making health care safer II: an updated critical analysis of the evidence for patient safety practices (chap. 41). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK133383/#_ncbi_dlg_citbx_NBK133383

Simon et al. (2013, June 24). Lessons Learned from Implementation of Computerized Provider Order Entry in 5 Community Hospitals. A Qualitative Study. BMC Medical Informatics and Decision Making, 13(67). Retrieved from https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/1472-6947-13-67