Computerized Physician Order Entry (CPOE) in pediatric and neonatal intensive care: Recommendations how to meet clinical requirements

Abstract

Objective: To identify and summarize the requirements of an optimized CPOE application for pediatric intensive care.

Methods: We analyzed the medication process and its documentation in the pediatric and neonatal intensive care units (PICU/NICU) of two university hospitals using workflow analysis techniques, with the aim of implementing computer-supported physician order entry (CPOE).

Results: In both PICU/NICU, we identified similar processes that differed considerably from adult medication routine. For example, both PICU/NICU prepare IV pump syringes on the ward, but receive individualized ready-to-use mixed IV bags for each patient from the hospital pharmacy on the basis of a daily order. For drug dose calculation, both PICU/NICU employ electronic calculation tools that are either incorporated within the CPOE system, or are external modules invoked via interface.

Conclusion: On the basis of this analysis, we provide suggestions to optimize CPOE applications for use in the pediatric and neonatal intensive care unit in the form of three catalogues of desiderata for drug order entry support.

Keywords: Inpatient; clinical documentation and communications; critical care and emergency; inpatient CPOE; intensive care; neonatology; pediatrics; requirements analysis and design; workflow.

Fig. 1

Diagram of top-level workflow for pediatric drug therapy (mostly identical for both hospitals) (white: physician tasks, blue/dotted: teamwork tasks, dark grey/narrowly dotted: nursing tasks, bright green/lined: pharmacy tasks). The dotted lines show the workflow in hospital B in the event of an error in step 1, 2 or 3. In these error-cases, due to the short delivery-cycle, the individualized IV bags can not be prepared in the pharmacy and must be prepared in the ICU (step 7b), steps 6, 7a and 8 are ommitted.

Fig. 2

Part of the OpenMed drug order application in hospital A. Section three is shown. This is the digital equivalent of the former paper drug request sheet . It has a paper like look, but contains structured data fields. All fields with white backround are in-put/output datafields. Entering or altering a number within one of the data fields e.g. 2 mmol/kg sodium (German Natrium) triggers automated calculation activities in other fields, e.g. remaining basic solution “Basis 1”, caloric information, osmolarity etc. (recalculated fields are highlighted with frames).

Fig. 3

Pediatric drug order entry and drug dose calculation in hospital B. The pre-existing Excel spreadsheets have been integrated and are invoked from the PDMS (highlighted center box). Patient information such as name, birth date, weight and length are automatically transferred from the PDMS (here anonymized). Calculation is done solely within MS Excel. There is no information flow back to the PDMS, it has to be printed for the patient chart and the pharmacy. In the PDMS only a “mixed IV bag” and its flow rate is documented manually. This is an intermediate solution to be resolved when further functionality is available in the PDMS.