Computerized Clinical Decision Leads to Medication Stewardship in IVIG
Carefully implemented order sets may encourage evidence-based or institution-specific care though the influence of provider behavior.
Health care organizations are continuingly using information technology (IT) to develop tools within computerized physician order entry (CPOE) and clinical decision support (CDS) to enhance efficiency, quality, and safety of medication use, while promoting fiscal stewardship of medication therapy management, according to a study by The British Pharmacological Society.
Order configuration begins with basic order entry capabilities for admission/transfer/discharge, nursing orders etc. Oftentimes, preconfigured orders such as “order set[s]” may facilitate standardized treatment. Although these are time consuming and expensive, carefully implemented order sets may encourage evidence-based or institution-specific care though the influence of provider behavior, according to the study.
Therefore, researchers wanted to design a CDS solution to provide medication stewardship, using input from the providers as an iterative approach. For this approach’s first target drug, the researchers chose intravenous immunoglobulin (IVIG), since it has potent immunomodulatory, immunoregulatory, and anti-inflammatory properties.
A multi-disciplinary team comprised of clinical pharmacists, physicians, nurses, informaticians, and IT specialists undertook a comprehensive project to improve and standardize IVIG use throughout their health care organization. They used the following 4-step approach:
- Automate dose rounding to commercial vial strength to facilitate optimized dispensing practice.
- Generate of a complete list of indications for IVIG, from internal data capture.
- Development and implementation of an order set with coded indications and dosing including dose adjustment for indications and patient’s weight.
- Evaluation and ongoing tool optimization.
Rounding to Commercial Vial Strength
A workflow analysis found that the prescribing practices and pharmacy preparation process was contributing to drug waste. This process included pooling IVIG from individual vials into a large glass bottle to indicate the precise grams prescribed. In addition to drug waste, pooled preparations only had a 24‐hour expiration time, so if there was a delay in therapy or the patient being treated developed a reaction during the infusion, the entire or the large majority of a dose had the potential to be wasted.
Dose rounding to the commercially available increments (such as rounding a 32 g dose to 30 g) allowed for dispensation of the entire product vial, which enabled the dispensing practice to change from pooling to commercial bottle dispensing. The latter prevented the waste of unused vials that had expiration dates much longer than 24 hours if stored appropriately.
Generate Complete List of Indications for IVIG
To ascertain IVIG usage patterns at the study site, researchers used a prospective, observational method to collect information as medication orders that were placed in the CPOE system.
An IVIG order entry item was created, which included a free‐text field for prescribers to input the indication for which they were prescribing IVIG therapy. The field was mandatory, but not validated, and providers could enter any information. This choice was deliberately made to ensure that providers who did not choose to elaborate their decision could still easily continue with order entry.
Using the indication and dose entered by providers in combination with patient demographics, the researchers conducted an evaluation on the usage and dosing ranges of IVIG. After an 18‐month period, a literature search was conducted for supportive scientific evidence and recommended dosing information for the most frequently prescribed clinical indications.
Development and Implementation of an Order Set
Over 6 months, clinical experts in each therapeutic area convened to discuss appropriateness of IVIG use and dosing for each indication. Specific recommendations were aggregated into an IVIG order set using contextualization, in which the order-set was adapted according to the medical condition of the patient as the basis of the next step in the approach, the study authors wrote.
This new order set consisted of 4 main sections. The first section included 2 drop‐down menu options for the therapeutic category and specific indications and a free‐text field for indications not found among the provided options.
In the second section, the prescriber was prompted to answer whether a patient had a known immunoglobulin A deficiency, which would select the correct IVIG product for dispensing. Prescribers were also prompted to answer a question as to whether the patient would undergo plasmapheresis treatment. When plasmapheresis was planned, it was important to administer IVIG after the procedure to avoid removal of the drug from plasma during this process. In these cases, a general nursing order was generated so that the nurse knew to coordinate with the pharmacy for drug dispensation to occur after plasmapheresis.
A medical logic module (MLM) was programmed with the specific details regarding the weight‐based dosing for each indication as well as defaulted frequencies and durations. The MLM determined the recommended dosage based on the provider’s choices in the first 2 parts of the order set.
In the third section, the MLM was programmed to identify the latest recorded weight and height for the patient, determine whether actual weight or adjusted body weight should be used in the dosing calculation, and perform the dosing corrections as necessary.
In the last section of the order set, the IVIG dose was recorded. The recommended dosage was calculated and entered, but providers could override the dosage based on their clinical judgment. Pre-medications (acetaminophen and diphenhydramine) to prevent or mitigate infusion-related reactions and preset infusion rates (initial and titration instructions) were generated in the order and comment fields to optimize the safe administration of IVIG.
Evaluation and Ongoing Tool Optimization
During 36 months before the implementation of the IVIG order set, 1965 IVIG orders were reviewed. The prescribed IVIG dose varied considerably from the expected dose (mean = −1.8, range = −4.9‐1.5). In the 27 months after order set implementation, 848 IVIG orders were reviewed. Furthermore, the prescribed IVIG dose was closer to the expected dose (mean = −1.2, range = −3.9‐2.6, P < .0001).
According to the study authors, a better understanding of institution‐specific ordering patterns may facilitate more efficient and effective order configuration and optimize drug use.
- Tsapepas D, Der-Nigoghossian C, Patel K, et al. Medication stewardship using computerized clinical decision support: A case study on intravenous immunoglobulins. British Pharmacological Society. https://doi.org/10.1002/prp2.508. Published August 23, 2019. Accessed October 25, 2019.