Page 71 - ACCCN's Critical Care Nursing

48 S C O P E O F C R I T I C A L C A R E

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guidelines for medication management. The operator- practice guidelines, real-time clinical alerts, and online
error prevention software is based on a device-based patient historical information via a complete electronic
drug library with institution-established concentrations/ medical record. 78
dosage limits incorporated in the function of the pump.
Resulting software functions include clinician alerts (for Computerised Order Entry and
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keystroke errors) and transaction log data (post-incident Decision Support
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analysis). Medication errors and adverse drug events can
be detected by this software, but further technological Computerised physician (or provider) order entry (CPOE)
and nursing behavioural factors must be addressed before is viewed as an important innovation in reducing medical
25
a measurable impact on serious adverse drug errors can errors, through minimising transcribing errors, trigger-
be achieved. 69 ing alerts for adverse drug interactions and facilitating the
adoption of evidence-based clinical guidelines. 70,73,79,80
The proportion of ICUs in Australia and New Zealand
using a CIS is not known, while the estimate for units Computerised order entry is used for medication and
using electronic charting in North America is 10–15%. 64,70 intravenous fluid prescribing, diagnostic test ordering
Early generation systems held promise of improved and results management, and mechanical ventilation
79,81
efficiencies but did not demonstrate actual decreases or other treatment orders. Implementation of CPOE
in nursing workload or activity patterns, including in and related clinical decision support systems (CDSS)
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one Australian site. Current third-generation systems have demonstrated significant reductions in medication
79
82-84
(Windows NT operating system [or equivalent] with errors and redundant or unnecessary order requests, 85-86
relational databases and enhanced graphic displays and and improved compliance with practice guidelines.
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user interfaces) have reduced documentation time (52 Clinical decision support systems interface with hospital
minutes per 8-hour shift) and increased the proportion databases to retrieve patient-specific and other relevant
87
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of time on direct care activities. Despite these positive clinical data and to generate recommended actions.
findings, it is noted that a CIS would not enable a reduc- Importantly, clinical decision making at the bedside can
tion in nursing staff; on the contrary, at least a half-time be enhanced by providing clinicians with a readily avail-
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nursing position is required to administer the system. able tool that incorporates relevant clinical information
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An Australian study demonstrated significant reductions and evidence-based medicine. Clinician alerts (e.g.
in medication and intravenous fluid errors and the inci- allergies or interaction effects) or prompts (e.g. to check
dence of pressure areas, and improved variance between coagulation when prescribing warfarin) can be generated.
ventilator orders and settings, after implementation of a A number of studies have demonstrated improved
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CIS. A sample of nursing staff perceived that the CIS delivery of patient care after the introduction of such
89-91
also increased time on patient care and decreased docu- reminders. As with CIS implementation, examination
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mentation time, while staffing recruitment and retention of clinician workflow and care delivery patterns and
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rates improved. Findings that critical care nurses are detailed planning is required for successful implementa-
92
accepting of new technologies were previously noted. 74 tion of a CPOE process. In particular, order decryption,
prioritisation and translation steps within the medication
Other issues also need consideration. Accuracy of data or treatment order process require review to minimise
92
(correctness and completeness of the data set) from both potential errors. Additional developments involving
manual and automated inputs to the information system wireless communication, personal digital assistants and
requires evaluation. While automated entry eliminates closed-loop delivery systems will improve the efficiency,
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transcription errors from other data sources, the use of effectiveness and adoption of this innovation in clinical
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‘carry-over’ data to new fields, sampling frequency, and practice. Closed-loop delivery adjusts drug or fluid
clinician acceptance of monitor-generated data can erro- delivery based on active feedback from the target param-
neously affect data accuracy (e.g. damped pulmonary eter (e.g. inotropic dosages adjusted to a range for mean
artery waveform not checked, with erroneously low read- arterial pressure).
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ings documented). In addition to errors related to enter-
ing and retrieving information, errors can also arise if Handheld Technologies
systems are not designed to enhance communication
between healthcare workers and facilitate coordination of Wireless applications enable both clinical access and por-
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work processes. Further, ‘clinical alert’ functions can tability and mobility within a critical care environment
lack the specificity for detecting clinically important at the point of care. Clinical uses for personal digital
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events and may compromise patient safety when used assistant (PDA) and Smartphone technologies continue
93
excessively in clinical settings with one study demonstrat- to evolve at a rapid pace. These handheld computers
ing 49–96% of drug safety alerts were overridden by use operating systems and pen-like styluses that enable
clinicians. 77 touch-screen functionality, handwriting recognition, and
synchronisation with other hospital-based computer
To tackle these and other limitations, future systems will systems. An increasing array of clinical applications and
provide wireless capabilities, remote access, ‘smart’ alerts, content are available for downloading to PDAs, including
handwriting recognition, clinician-configured forms, drug reference information (e.g. MIMS on PDA), clinical
flowcharts and reports using standardised data structures guidelines, medical calculators and internet-based
and terminology. This level of functionality will enable literature searches. 93-95 PDA use has been reported as a
decision support with online evidence-based clinical helpful nursing education tool, 96,97 with nursing students