Pharmacy Department, Repatriation General Hospital, Daw Park, South Australia, Australia.
J Am Med Inform Assoc. 2010 May-Jun;17(3):308-12. doi: 10.1136/jamia.2009.001537.
Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting. The absence of a clinical decision support system (CDSS) from direct clinician workflows such as computerized provider order entry (CPOE) hinders the uptake of CDSS. This study implemented CDSS in an environment independent of CPOE, introduced to prescribers via academic detailing, to address the dosing of renally cleared drugs.
GFR+ was designed to automatically calculate and update renal function, doses of key drugs adjusted for renal function, and highlight clinically significant decreases in renal function. Prescribers were made aware of GFR+, its navigation, and surrounding clinical issues, using academic detailing.
The rate of dosing conformity and management for key renally cleared drugs in hospitalized patients, before and after GFR+ implementation.
Improvements were seen in dosing conformity for enoxaparin (from 68% to 86%, p=0.03), gentamicin (63-87%, p=0.01), and vancomycin (47-77%, p=0.07), as well as the appropriate use of gentamicin therapeutic drug monitoring (70-90%, p=0.02). During episodes of acute renal impairment, renally cleared drugs were held on 38% of instances in the pre-intervention period compared with 62% post-intervention (p=0.01).
Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalized population. Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that cannot be placed directly into the clinician workflow.
在肾功能不佳的情况下，对于经肾脏清除的药物，如果不进行剂量调整，这在医院环境中是一个常见的问题。临床决策支持系统（CDSS）在计算机化医嘱录入（CPOE）等直接临床工作流程中缺失，阻碍了 CDSS 的采用。本研究在独立于 CPOE 的环境中实施 CDSS，通过学术细化向临床医生介绍，以解决经肾脏清除的药物的给药问题。
GFR+ 旨在自动计算和更新肾功能，调整肾功能相关的关键药物剂量，并突出显示肾功能显著下降的临床问题。通过学术细化，让临床医生了解 GFR+、其导航和周围的临床问题。
在实施 GFR+前后，住院患者中主要经肾脏清除的药物的给药一致性和管理情况。
在依诺肝素（从 68%提高到 86%，p=0.03）、庆大霉素（从 63%提高到 87%，p=0.01）和万古霉素（从 47%提高到 77%，p=0.07）的给药一致性方面有所改善，同时也提高了庆大霉素治疗药物监测的合理应用（从 70%提高到 90%，p=0.02）。在急性肾功能损害期间，与干预前相比，干预后经肾脏清除的药物有 38%被停用（p=0.01）。
通过学术细化实施的临床决策支持提高了住院患者中主要经肾脏清除的药物的给药一致性和管理水平。学术细化应被强烈考虑，以促进无法直接纳入临床医生工作流程的 CDSS 系统的引入。
