ABSTRACT
INTRODUCTION: Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. METHODS: We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. RESULTS: We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. CONCLUSION: Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations.
ABSTRACT
BACKGROUND: Previous studies reflect reduced morbidity and mortality with intensive blood glucose control in critically ill patients. Unfortunately, implementation of such protocols has proved challenging. This study evaluated the degree of glucose control using manual paper-based vs computer-based insulin protocols in a trauma intensive care unit. METHODS: Of 1455 trauma admissions from May 31 to December 31, 2005, a cohort of 552 critically ill patients met study entry criteria. The patients received intensive blood glucose management with IV insulin infusions. Using Fisher's exact test, the authors compared patients managed with a computerized protocol vs a paper-based insulin protocol with respect to the portion of glucose values in a target range of 80-110 mg/dL, the incidence of hyperglycemia (> or =150 mg/dL), and the incidence of hypoglycemia (< or =40 mg/dL). RESULTS: Three hundred nine patients were managed with a manual paper-based protocol and 243 were managed with a computerized protocol. The total number of blood glucose values across both groups was 21,178. Mean admission glucose was higher in the computer-based protocol group (170 vs 152 mg/dL; p < .001, t-test). Despite this finding by Fisher's exact test, glucose control was superior in the computerized group; a higher portion of glucose values was in range 80-110 mg/dL (41.8% vs 34.0%; p < .001), less hyperglycemia occurred (12.8% vs 15.1%; p < .001), and less hypoglycemia occurred (0.2% vs 0.5%; p < .001). CONCLUSIONS: A computerized insulin titration protocol improves glucose control by (1) increasing the percentage of glucose values in range, (2) reducing hyperglycemia, and (3) reducing severe hypoglycemia.
