A computerized provider order entry intervention for medication safety during acute kidney injury: a quality improvement report

Abstract

Background: Frequently, prescribers fail to account for changing kidney function when prescribing medications. We evaluated the use of a computerized provider order entry intervention to improve medication management during acute kidney injury.

Study design: Quality improvement report with time series analyses.

Setting & participants: 1,598 adult inpatients with a minimum 0.5-mg/dL increase in serum creatinine level over 48 hours after an order for at least one of 122 nephrotoxic or renally cleared medications.

Quality improvement plan: Passive noninteractive warnings about increasing serum creatinine level appeared within the computerized provider order entry interface and on printed rounding reports. For contraindicated or high-toxicity medications that should be avoided or adjusted, an interruptive alert within the system asked providers to modify or discontinue the targeted orders, mark the current dosing as correct and to remain unchanged, or defer the alert to reappear in the next session.

Outcomes & measurements: Intervention effect on drug modification or discontinuation, time to modification or discontinuation, and provider interactions with alerts.

Results: The modification or discontinuation rate per 100 events for medications included in the interruptive alert within 24 hours of increasing creatinine level improved from 35.2 preintervention to 52.6 postintervention (P < 0.001); orders were modified or discontinued more quickly (P < 0.001). During the postintervention period, providers initially deferred 78.1% of interruptive alerts, although 54% of these eventually were modified or discontinued before patient death, discharge, or transfer. The response to passive alerts about medications requiring review did not significantly change compared with baseline.

Limitations: Single tertiary-care academic medical center; provider actions were not independently adjudicated for appropriateness.

Conclusions: A computerized provider order entry-based alerting system to support medication management after acute kidney injury significantly increased the rate and timeliness of modification or discontinuation of targeted medications.

Figure 1. Example of a Passive Acute Kidney Injury Intervention Alert

The passive alert displayed as descriptive text in the “pharmacy alert” sections of the order entry environment (A) and printed rounding reports, and as a simple text notification marking each affected prescription in the “medication list” sections (C). When a provider clicked the “pharmacy alert” text, a popup window appeared (B) with detailed information about the order, displaying graphs of serum creatinine and recent recorded urine output, and recommendations about whether current prescriptions should be avoided, dose-adjusted, or reviewed.

Figure 2. Example of an Interruptive Acute Kidney Injury Intervention Alert

The interruptive alert appeared to providers for medications requiring discontinuation or adjustment when no immediate response was made to the passive alert. The alert interrupted the provider when he or she tried to exit the computerized provider order entry system, requiring the provider to modify or discontinue the drug, to suppress the alert by confirming that the dose was correct, or defer the alert until the next computerized provider order entry session.

Figure 3. Kaplan-Meier Curves for Time to Provider Response and Multivariate Time Series Analyses of Intervention Effect on Rate of Provider Response

The first row shows Kaplan-Meieir curves for the univariate time to response analysis. A response is defined as modification of discontinuation of a medication order prior to patient death, discharge, or transfer. In the second row, results are based on logistic regression analyses that included as predictors: a post-intervention indicator, day of the study period, and the interaction between time by intervention interaction. Solid and dotted lines describe the model derived number of response per 100 events and pointwise confidence intervals, respectively. The points on the plots depict observed rates of responses per 100 event averaged over 30 day time periods. The shaded area between study periods represents implementation and piloting of software where no outcome data was analyzed. The response rate is defined as the proportion of eligible medication orders modified or discontinued within 24 hours of a study event in response to an intervention alert.

Figure 4. Change in Rate of Drug Modification or Discontinuation by Individual Drug or by Drug Class

Response rates represent the proportion of eligible medication orders modified (M) or discontinued (D) within 24 hours of an increase in serum creatinine following an order for a target nephrotoxic or renally cleared drug. Drugs or drug classes with fewer than 10 increasing serum creatinine events were excluded.

Figure 5. Provider Responses to Alerts in Post-Intervention Period

Displayed are provider responses to passive and interruptive alerts generated from drug orders with medications requiring discontinuation or adjustment during acute kidney injury. The provider’s interaction are categorized as response (modifying or discontinuing the alerted order) after viewing only a passive alert, immediate response after an interruptive alert, or delayed response Also represented is the number of alerts which expired after 48 hours, or when the patient died or was discharged from the hospital. N represents the number of alerts displayed, or the opportunities to respond.