Download PDF
CC BY 4.0 · ACI open 2018; 02(01): e41-e49
DOI: 10.1055/s-0038-1667296
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Clinical Decision Support Improves Adherence to Pediatric Antimicrobial Renal Dosing Guidelines

Andrew Quach
1   The Robertson Group, Portland, Oregon, United States
,
Mohammad B. Ateya
2   Health Information Technology and Services, Michigan Medicine, Ann Arbor, Michigan, United States
,
Christopher Zimmerman
2   Health Information Technology and Services, Michigan Medicine, Ann Arbor, Michigan, United States
› Author Affiliations
Further Information

Publication History

23 March 2018

18 June 2018

Publication Date:
27 July 2018 (online)

   Permissions and Reprints

Abstract

Background Antimicrobial drug dosage selection requires consideration of patient demographics, renal function, and indication(s) of use. We developed a strategy that employed upfront passive dose-guidance clinical decision support (CDS) in addition to noninterruptive/interruptive maximum dose warnings to guide providers to order renally appropriate antimicrobial drug therapy.

Objectives Our objective was to assess the impact of passive dose-guidance CDS, along with a successive CDS strategy that provided renal dosing assistance at multiple points throughout order entry, on provider adherence to pediatric antimicrobial dosing guidelines.

Methods A single-center, observational, retrospective cohort study at an academic pediatric hospital. The study compared the proportion of orders adherent to the institutional guidelines across three time points: a historical control (October 2014 to March 2015), phase I implementation (March 2015 to May 2015), and phase II implementation (May 2015 to October 2015).

Results The proportion of adherent orders with respect to dose and frequency was 74% in the control period, 76% (odds ratio [OR] = 1.11; 95% confidence interval [CI], 0.76–1.16, p = 0.6) in phase I of the study, and increased to 81% (OR = 1.54; 95% CI, 1.16–2.03, p = 0.003) in phase II of the study.

Conclusion Provider adherence to institutional antimicrobial dosing guidelines improved following the implementation of a successive CDS combining passive and noninterruptive/interruptive approaches. This study displays the value of designing CDS that occurs at multiple points within ordering workflow and minimizes intrusiveness. Our CDS strategy can be considered for implementation by other institutions using similar electronic health record systems.

Keywords

computerized provider order entry - clinical decision support - electronic health record - renal dose adjustment - medication alert systems

Clinical Relevance Statement

A successive CDS system utilizing passive and noninterruptive/interruptive CDS at multiple points of the order entry workflow improves provider adherence to recommended renally appropriate antimicrobial dosing regimens in hospitalized pediatric patients.


Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by the University of Michigan's Institutional Review Board.


 

  • References

  • 1 Troiano D, Jones MA, Smith AH. , et al; American Society of Health-System Pharmacists. ASHP guidelines on the design of database-driven clinical decision support: strategic directions for drug database and electronic health records vendors. Am J Health Syst Pharm 2015; 72 (17) 1499-1505
    CrossrefPubMedGoogle Scholar
  • 2 ASHP Section of Pharmacy Informatics and Technology. ASHP guidelines on pharmacy planning for implementation of computerized provider-order-entry systems in hospitals and health systems. Am J Health Syst Pharm 2011; 68 (06) e9-e31
    CrossrefPubMedGoogle Scholar
  • 3 Bates DW, Kuperman GJ, Wang S. , et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003; 10 (06) 523-530
    CrossrefPubMedGoogle Scholar
  • 4 Wright A, Phansalkar S, Bloomrosen M. , et al. Best practices in clinical decision support: the case of preventive care reminders. Appl Clin Inform 2010; 1 (03) 331-345
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Clinical Decision Support (CDS). HealthIT.gov website. Available at: http://www.healthit.gov/providers-professionals/clinical-decision-support-cds . Updated March 28, 2016 . Accessed May 1, 2016
    PubMed
  • 6 Payne TH, Hines LE, Chan RC. , et al. Recommendations to improve the usability of drug-drug interaction clinical decision support alerts. J Am Med Inform Assoc 2015; 22 (06) 1243-1250
    CrossrefPubMedGoogle Scholar
  • 7 Bryant AD, Fletcher GS, Payne TH. Drug interaction alert override rates in the Meaningful Use era: no evidence of progress. Appl Clin Inform 2014; 5 (03) 802-813
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Chertow GM, Lee J, Kuperman GJ. , et al. Guided medication dosing for inpatients with renal insufficiency. JAMA 2001; 286 (22) 2839-2844
    CrossrefPubMedGoogle Scholar
  • 9 Paterno MD, Maviglia SM, Gorman PN. , et al. Tiering drug-drug interaction alerts by severity increases compliance rates. J Am Med Inform Assoc 2009; 16 (01) 40-46
    CrossrefPubMedGoogle Scholar
  • 10 Schwartz GJ, Haycock GB, Edelmann Jr CM, Spitzer A. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics 1976; 58 (02) 259-263
    CrossrefPubMedGoogle Scholar
  • 11 Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16 (01) 31-41
    CrossrefPubMedGoogle Scholar
  • 12 Verbeeck RK, Musuamba FT. Pharmacokinetics and dosage adjustment in patients with renal dysfunction. Eur J Clin Pharmacol 2009; 65 (08) 757-773
    CrossrefPubMedGoogle Scholar
  • 13 Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy 2009; 29 (05) 562-577
    CrossrefPubMedGoogle Scholar
  • 14 Zuppa AF. Understanding renal replacement therapy and dosing of drugs in pediatric patients with kidney disease. J Clin Pharmacol 2012; 52 (1, Suppl): 134S-140S
    CrossrefPubMedGoogle Scholar
  • 15 Jackson EA, McLeod DC. Pharmacokinetics and dosing of antimicrobial agents in renal impairment, part II. Am J Hosp Pharm 1974; 31 (02) 137-148
    PubMedGoogle Scholar
  • 16 ASHP statement on the pharmacist's role in antimicrobial stewardship and infection prevention and control. Am J Health Syst Pharm 2010; 67 (07) 575-577
    CrossrefPubMedGoogle Scholar
  • 17 Evans RS, Pestotnik SL, Classen DC. , et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998; 338 (04) 232-238
    CrossrefPubMedGoogle Scholar
  • 18 Killelea BK, Kaushal R, Cooper M, Kuperman GJ. To what extent do pediatricians accept computer-based dosing suggestions?. Pediatrics 2007; 119 (01) e69-e75
    CrossrefPubMedGoogle Scholar
  • 19 Scharnweber C, Lau BD, Mollenkopf N, Thiemann DR, Veltri MA, Lehmann CU. Evaluation of medication dose alerts in pediatric inpatients. Int J Med Inform 2013; 82 (08) 676-683
    CrossrefPubMedGoogle Scholar
  • 20 Stultz JS, Nahata MC. Computerized clinical decision support for medication prescribing and utilization in pediatrics. J Am Med Inform Assoc 2012; 19 (06) 942-953
    CrossrefPubMedGoogle Scholar
  • 21 Awdishu L, Coates CR, Lyddane A. , et al. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc 2016; 23 (03) 609-616
    PubMedGoogle Scholar