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Improve Patient Safety While ReducingStaffing in a Hospital Setting

Writing Total Parenteral Nutrition (TPN) orders for pediatric and neonatal patient populations is a time consuming and clinically difficult process. Most hospitals still use hand written physician orders for this task despite many problems with this paradigm.

The Challenges of Creating a Pedi/Neonatal TPN OrderA typical pediatric hospital has a pre-printed TPN order form that is filled in by a physician on the floors. The order is usually a 2 or 3 part form where the top copy is left in the chart and the other copies are sent to nursing/dietary and pharmacy for compounding.

CalculationsHandwritten orders involve physicians having to base dosing decisions off of calculated values. These calculations are often done on the nursing unit with or without the aid of a calculator. For example, if a new 2 year old patient needs 80 kcal per kilogram per day, the physician must calculate the percentage of dextrose that is required to provide these calories. The rate of the TPN infusion must also be calculated to ensure that the dextrose is not infused too quickly as this can cause negative clinical outcomes for the patient. These are just two examples of the type of thought that must be given to each TPN order. Much of the logic that is used in writing a pediatric or neonatal TPN is rules based and can be done by a series of calculations and if / then statements within a computer program.

Improve patient safety while reducing staffing in a hospital setting

Version 1.3Copyright Apex Custom Software Inc., 2015Page 1 of 8

A key to creating TPN orders is to use technology to prospectively evaluate the order before it is sent to the pharmacy.

LegibilityAnother problem with handwritten orders is that the pharmacy is usually receiving the 2nd or sometimes 3rd copy of the form. Other institutions fax the order to the pharmacy for compounding. Either a carbon copy or faxed order will not help the pharmacist with an age old quandary for hospitals, legibility.

Physicians are usually writing these orders in haste and they are difficult to decipher. An order for 1.0 meq of Sodium Chloride could be misread by the compounding pharmacist as 10 meq. These types of transposition errors occur every day in hospitals around the country and cause patient harm in many instances.(See http://www.ismp.org/Newsletters/acutecare/articles/20010110.asp for details on these types of med errors)

InefficiencyOne of the biggest drawbacks with handwritten TPN orders is that any dosing or calculation errors are caught at the end of the process by the compounding pharmacist rather than at the point of order generation. At the time the pharmacist might catch an error, the physician may have already left the hospital and the pharmacist must track them down to get a verbal order for the changes that are needed. There is a great amount of both pharmacist and physician time spent on the fixing of TPN problems. If an order is misread by the pharmacist during compounding and the nurse catches the error, the TPN must be wasted and a new one made usually when staffing is not adequate for such a task.

Calcium-Phosphate SolubilityThe most difficult aspect of writing a neonatal or pediatric TPN order is how to maximize the amount of calcium and phosphate that can be added to the TPN. Growing children need larger amounts of these electrolytes than adults. It is critical for proper bone development that children and neonates receive as much of these elements as clinically appropriate. The problem is that these elements will bind to each other if the concentrations are too high. When they bind, a precipitate salt is formed in the TPN. If precipitation occurs and is not noticed before administration, patient death can occur.

(See http://www.ismp.org/Newsletters/acutecare/articles/19970507.asp for details)

The Solution: Computerized Physician Order Entry By utilizing technology to help with the problems of handwritten neonatal and pediatric orders, a safer more efficient model can be achieved.

CalculationsComputerized physician order entry (CPOE) would allow calculations to be done by a computer rather than by a process that will ultimately fall prey to human error. All aspects of dosing could be considered by the program and the correct amount of nutrition can be evaluated in seconds rather than minutes or hours. In the image below, values are calculated for the physician rather than by the physician.

LegibilityWith computer order entry, legibility issues are greatly reduced because the order is printed rather than hand written. Printed orders are much easier to read and multiple copies can be produced without any degradation of the quality. The image below is a printed order.

InefficiencyThe inefficiency of retrospective evaluation of TPN orders rather than prospective results in lost pharmacist, nursing, and physician time. The time spent clarifying, correcting, and evaluating TPN orders could be spent on other patient care activities if a CPOE model was adopted. A computer program could warn the provider of any deviation from accepted standards or protocols before the order was ever completed or printed. In the image below, the user is being warned that one the values entered is not acceptable. The program will not allow the order to be completed until the problem is rectified.

Calcium-Phosphate SolubilityThe most difficult aspect of writing a neonatal or pediatric TPN order is how to maximize the amount of calcium and phosphate that can be added to the TPN. This is a perfect job for a sophisticated computer program. A program can perform linear regression of published calcium-phosphate solubility curves to determine if entered values are compatible or not. The text in red below is telling the provider that this solution is not compatible.

The Apex Custom Software Solution: TPN AssistantApex Custom Software, Inc. offers the health systems the only web based solution for computerized physician order entry of TPN orders. An asp.net 4.0 web-based solution offers rapid system wide deployment with no desktop rollout or workstation installation. Orders are generated as a PDF file that can be printed at the workstation or sent via e-mail. The system uses Microsoft SQL Server 2012 as the backend database so scalability is not an issue. Most facilities host the program on an intranet web server that is being used for other web applications within the hospital. TPN order volume is light even in a large hospital and a dedicated server is not required. PDFs can be saved to an EHR document folder for easy integration. Both HL-7 ADT and BAXA compounder interfaces are supported.

Cost Justification and ROI ScheduleI. By prospectively analyzing parenteral nutrition orders to ensure safety and efficacy, the hospital not only improved overall patient care but was also able to free both physicians and pharmacists from the unproductive time burden of correcting and clarifying orders that do not fall within established clinical guidelines.

II. The time spent correcting and clarifying orders has been estimated by A.S.P.E.N. to constitute 25% of a pharmacist's time when assigned to producing 20 or more TPN's. At one installation hospital, this number actually correlated to 27.9%.

a. Given an 8-hour shift of pharmacy time spent producing TPN's, this program will save the pharmacy department on average 2 hours of time per day.

b. If that 2 hour savings is utilized providing other pharmaceutical care, then this can be translated into actual salary dollars saved.

c. At an average rate of $55 per hour for pharmacist salary; (2 hours a day) times (365 days a year) translates into $40,150. The program would easily pay for itself every year as the base cost is $695 / month and it will improve overall patient safety from Ca++ / PO4- salt emboli and other potentially life threatening TPN problems.

III. For a smaller hospital producing less than twenty neonatal TPNs per day, the justification involves clinical expertise as much as it does salary dollars. Many smaller hospitals do not have the specialized staff to safely produce neonatal TPNs. The program will also provide a safety net for a less specialized pharmacy staff that has to prepare highly specialized products.

IV. This cost analysis does not take into account the overall time saved by the physician in calculating doses and being contacted for problems such as incompatible solutions. Most significantly, the ROI does not include the substantial cost of patient harm if an order is written or transcribed with a dangerous or incompatible solution.

About Apex Custom Software Apex Custom Software was founded in 1997 to meet unique clinical and operational needs within the healthcare industry. We develop and support all solutions with in-house resources. Our staff includes clinicians, developers, and implementation experts. All of our staff comes from a healthcare background and they all have a passion for improving patient outcomes and processes. Our applications are developed to fill specific needs in workflow processes that that are best addressed by implementing a structured, rules based software solution.

To learn more about Apex Custom Software or TPN Assistant visit http://www.apexcustomsoftware.com