重新设计计算机化决策支持以改善抗菌药物处方。一项前后对照研究。
Redesign of computerized decision support to improve antimicrobial prescribing. A controlled before-and-after study.
作者信息
Baysari Melissa T, Del Gigante Jessica, Moran Maria, Sandaradura Indy, Li Ling, Richardson Katrina L, Sandhu Anmol, Lehnbom Elin C, Westbrook Johanna I, Day Richard O
机构信息
Melissa T. Baysari, Australian Institute of Health Innovation, Level 6 75 Talavera Rd, Macquarie University, NSW 2109 Australia, Phone +612 98502416,
出版信息
Appl Clin Inform. 2017 Sep 13;8(3):949-963. doi: 10.4338/ACI2017040069.
OBJECTIVE
To determine the impact of the introduction of new pre-written orders for antimicrobials in a computerized provider order entry (CPOE) system on 1) accuracy of documented indications for antimicrobials in the CPOE system, 2) appropriateness of antimicrobial prescribing, and 3) compliance with the hospital's antimicrobial policy. Prescriber opinions of the new decision support were also explored to determine why the redesign was effective or ineffective in altering prescribing practices.
METHODS
The study comprised two parts: a controlled pre-post study and qualitative interviews. The intervention involved the redesign of pre-written orders for half the antimicrobials so that approved indications were incorporated into pre-written orders. 555 antimicrobials prescribed before (September - October, 2013) and 534 antimicrobials prescribed after (March - April, 2015) the intervention on all general wards of a hospital were audited by study pharmacists. Eleven prescribers participated in semi-structured interviews.
RESULTS
Redesign of computerized decision support did not result in more appropriate or compliant antimicrobial prescribing, nor did it improve accuracy of indication documentation in the CPOE system (Intervention antimicrobials: appropriateness 49% vs. 50%; compliance 44% vs. 42%; accuracy 58% vs. 38%; all p>0.05). Via our interviews with prescribers we identified five main reasons for this, primarily that indications entered into the CPOE system were not monitored or followed-up, and that the antimicrobial approval process did not align well with prescriber workflow.
CONCLUSION
Redesign of pre-written orders to incorporate appropriate indications did not improve antimicrobial prescribing. Workarounds are likely when compliance with hospital policy creates additional work for prescribers or when system usability is poor. Implementation of IT, in the absence of support or follow-up, is unlikely to achieve all anticipated benefits.
目的
确定在计算机医嘱录入（CPOE）系统中引入新的抗菌药物预写医嘱对以下方面的影响：1）CPOE系统中抗菌药物记录指征的准确性；2）抗菌药物处方的合理性；3）对医院抗菌政策的依从性。同时探讨开方者对新决策支持的看法，以确定重新设计在改变处方行为方面有效或无效的原因。
方法
该研究包括两个部分：一项对照前后研究和定性访谈。干预措施包括重新设计一半抗菌药物的预写医嘱，以便将批准的指征纳入预写医嘱中。研究药剂师对一家医院所有普通病房在干预前（2013年9月至10月）开具的555份抗菌药物处方和干预后（2015年3月至4月）开具的534份抗菌药物处方进行了审核。11名开方者参与了半结构化访谈。
结果
计算机决策支持的重新设计并未导致更合理或更合规的抗菌药物处方，也未提高CPOE系统中指征记录的准确性（干预组抗菌药物：合理性49%对50%；依从性44%对42%；准确性58%对38%；所有p>0.05）。通过我们对开方者的访谈，我们确定了五个主要原因，主要是输入CPOE系统的指征未得到监测或跟进，并且抗菌药物批准流程与开方者工作流程不太匹配。
结论
重新设计预写医嘱以纳入适当指征并未改善抗菌药物处方。当遵守医院政策给开方者带来额外工作或系统可用性较差时，可能会出现变通方法。在缺乏支持或跟进的情况下实施信息技术，不太可能实现所有预期效益。
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