Advanced Clinical Decision Support & Acute Kidney Injury

Transcription

1 Advanced Clinical Decision Support & Acute Kidney Injury Dr Jamie Coleman Senior Lecturer in Clinical Pharmacology and Honorary Consultant Physician eprescribing & CDS in Birmingham, UK Jamie Coleman 1

2 Conflicts of Interest / Support JJC works within the University Hospital Birmingham NHS Foundation Trust which is collaborating with CSE Healthcare Systems to commercialise the PICS system in the UK. JJC s work is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care based in Birmingham and Black Country. The views expressed are those of the presenter and not necessarily those of the NHS, the NIHR or the Department of Health. Overview Clinical Decision Support Drug dosing and AKI Risk of AKI The future Jamie Coleman 2

3 CLINICAL DECISION SUPPORT Clinical Decision Support in eprescribing Systems CDS = tool within eprescribing application Provides guidance / incorporates knowledge Assists the prescriber in entering complete, accurate and appropriate orders BASIC TOOLS e.g. Order templates ADVANCED TOOLS e.g. Rules based surveillance Jamie Coleman 3

4 CDS and Nephropharmacology CDS categories in kidney disease At selection: Drug choice / Contraindication Drug Dosing During Therapy: Drug Contraindication Corollary Orders (monitoring) Recognising harm: Developing AKI The Five Rights (of CDS) Right information, patient to the Right person, drug in the Right format dose for intervention, through the Right route Right channel, at the Right time Right time in workflow Adapted from Improving Medication Use and Outcomes with CDS HIMSS 2009 Jamie Coleman 4

5 Lab Drug Interactions eprescribing (CDS) systems need access to lab data Interoperability of systems is key If linked with Lab Order Comms can drive corollary ordering as well Third party information Laboratory Data Patient diet Diagnoses Allergy / hypersensitivity GP Drug Hx Lab Order Comms Drug interactions / duplication checking Drug Lab interactions Drug food interactions Contraindication checking Allergy & ADR checking Medicines reconciliation Therapeutic drug monitoring The role of CDS in drug selection / dosing Rely on expert knowledge or third party CDS provision Alerts and warnings at medication ordering stage Contraindicated medication Dose adjustment based on egfr Avoid drug-drug interactions Sometimes message out to pharmacist Jamie Coleman 5

6 CDS and Appropriate Dosing Use of guided dosing algorithms for patients with renal insufficiency drug orders analysed 15% had warnings 4 x 8-week periods (alternating CDS intervention & no CDS control) Frequency of appropriate orders (intervention vs. control): 51% vs. 30% (all orders) 67% vs. 54% (dose orders) 59% vs. 35% (frequency orders) Length of stay reduced during intervention BUT 49% orders still inappropriate even during intervention Ref: Chertow et al. JAMA. 2001; 286(22): CDS and Appropriate Dosing (2) Using CDS for long term care residents with renal insufficiency Data from 22 long stay units over 12 months Variety of unit types (e.g., Alzheimer's, Stroke) Wards randomized into Alert and Control Alert Type Alert Ward (% appropriate) Control Ward (% appropriate) Total Daily Dose Frequency Avoid Missing Info TOTAL Significant difference? Ref: Field T, Rochon P, Lee M, et al. JAMIA 2009; 16(4): Jamie Coleman 6

7 DRUG-INDUCED KIDNEY INJURY CDS and Drug-Induced Kidney Injury Overview of Drug- Induced AKI: Use of nephrotoxic drugs causal factor in up to 25% of AKI cases in critically ill patients Reactive alerting may limit/ prevent administration of nephrotoxic drugs in developing AKI Ref: Pannu N, Nadim, M. Crit Care Med. 2008; 36(4): S216-S223. Jamie Coleman 7

8 Detecting risk of AKI University Hospitals Birmingham Risk factors involved in post-admission AKI Using data from 112,987 medical & surgical emergency admissions Risk Factors: Peak CRP Age Lower admission egrf Pre-admission diabetes mellitus Pre-admission hypertension Administration of: Gentamicin Administration of: Amphotericin Administration of: ACEi/ ARB Data from QEHB - Ref: Pankhurst T, et al. Submitted for Publication. Data From QEHB The odds ratio of postadmission AKI mortality Whole population Group A SCr 50%-99% Group B SCr 100% or first RRT Admissions Patients Age/ years (median (IQR)) 61 (41-78) 76 (63-85) 72 (59-82) Male % LOS / days (mean, median (IQR)) 8.0, 3 (1 8) 28.4, 20 (10-36) 32.9, 23 (12-43) Number of admissions in which patient died 4931 (4.4%) 484 (27.7%) 489 (42.8%) Post admission AKI Mortality: Group A adjusted OR 5.2 (95%: ) Group B adjusted OR 11.4 (95% CI: ) (Adjusted for Age, Sex and Multiple Co-morbidities) Jamie Coleman 8

9 Data From QEHB The odds ratio of postadmission AKI correlated with the peak CRP Odds ratio of post-admission AKI Peak CRP / mg/l Role of CDS in detecting risk Real time alerting using an AKI sniffer use of the RIFLE classification system 2593 AKI alerts in an ICU in Belgium over 6 months Pre-alert Control (1.5m) vs. Real Time Alert Intervention (3m) vs. Post-alert Control (1.5m) Treatment within 60 mins: 7.9% vs. 28.7% vs. 10.4% More intervention group patients received fluid therapy, diuretics and vasopressors Shorter time to intervention and greater return to baseline kidney function Ref: Ref: Colpaert K, Hoste EA, Steurbaut K, et al. Crit Care Med 2012; 40(4): Jamie Coleman 9

10 Costs of CDS Potential Drawbacks of CDS identified : Over-reliance, threat to clinical judgement, integration into practice, alert fatigue Unanticipated Consequences: Workarounds, technology induced errors Ref: Chang et al Nature Reviews Nephrology 2011; 7: Technology-induced problems an unanticipated consequence The computer couldn t cope with the > sign in the egfr value and reported an incorrect Drug-Lab contraindication Jamie Coleman 10

11 Costs of CDS Potential Drawbacks of CDS identified : Over-reliance, Threat to clinical judgement, integration into practice, alert fatigue Unanticipated Consequences: Workarounds, technology induced errors Financial considerations: Expense of delivering / maintaining systems Requires constant updating as knowledge evolves Ref: Chang et al Nature Reviews Nephrology 2011; 7: THE FUTURE OF CDS & AKI Jamie Coleman 11

12 The Future What needs to be achieved? Optimising systems for the most important drugs Mitigating against development / worsening of AKI Predicting & Preventing AKI Reacting to developing AKI Consider the best way of alerting prescribers But are more alerts the answer?! Jamie Coleman 12

13 QUESTIONS? Jamie Coleman 13