Abstract:

Purpose:
Computerized physician order entry systems (CPOE) increase the accuracy of orders for inpatient care. However, adherence to clinical treatment metrics are still variable and subject to the orders inputted. We hypothesize that a well-constructed CPOE Order-set can improve adherence to treatment metrics.

Over two one-year time periods, physician orders and clinical documentation were compared between pre- and post- CPOE Order-set implementation for treatment of inpatient pediatric asthma. After a well-constructed CPOE Order-set for inpatient pediatric asthma went live, statistical increases were seen for Pediatric Asthma Severity Score (PASS) and use of MDI albuterol treatments, while seven other metrics showed a consistent degree of compliance.

Methods:
A retrospective chart review of physician orders; medication administration; respiratory therapy documentation; nursing notes; and educational plans was undertaken for pediatric patients admitted to the pediatric unit of Evergreen Hospital. Charts were examined in two one-year time periods (January 2010-December 2010 and July 2011-June 2012) with CPOE implementation occurring between.

Patients with diagnoses codes 493.xx (Asthma) were considered for the study. Patients who were less than 2 years of age or if clinical documentation did not support asthma as a diagnosis for admission were excluded. Of the 70 charts reviewed, 34 charts met inclusion criteria.

Nine metrics were examined: Documentation of PASS on Admission; Use of MDIs on unit; Ipratropium limited to first 24 hours; Administration of systemic corticosteroids; Use of oral systemic corticosteroids; Documentation of chronic asthma severity assessment; Written Asthma Action Plan; Parental education documentation; and Follow up with PMD.

Statistical analysis using a two tailed t-test with unequal variance assumptions around the mean were conducted on the nine metrics and appropriate p-values reported.


Results:
All nine metrics showed an increase in compliance after CPOE implementation. Two demonstrated statistically significant increases: Documentation of PASS on Admission, with the greatest increase from 22% to 91% (P=<0.05) and the Use of MDIs on unit increased from 9% to 45% (P=0.048).

Five of the metrics (Ipratropium limited to first 24 hours; Administration of systemic corticosteroids; Use of oral systemic corticosteroids; Parental education documentation; and Follow up with PMD) maintained a high compliance (65%-96%) but did not show a statistically increase.

The remaining two metrics (Documentation of chronic asthma severity assessment; Written Asthma Action Plan) remained at a low compliance (52% and 22% to 55% and 36%) and were not statistically improved.

Conclusion:
While the implementation of a CPOE Order-set showed improvement in two clinical measures (PASS on Admission and MDI use) there is room for improvement in other metrics for pediatric asthma care. A well-constructed CPOE Order-set should have pre-written orders that are aligned with clinical best practice metrics and include pre-selecting orders. Further, comments such as “METERED DOSE INHALER … IS THE PREFERRED DELIVERY METHOD FOR BRONCHODILATORS” were reminders at the time the orders were placed. Improvements in physician documentation of chronic asthma severity and completing a written asthma action plan are unlikely to be related to the CPOE process and will require a different approach to demonstrate improvement.

Keywords:

Asthma, Inpatient, Quality Improvement, QI, CPOE, Computerized Physician Order Entry.