Linking Lab and Pharmacy: Clinical Decision Support to Manage Inpatient Hyperkalemia

Abstract

Linking Lab and Pharmacy: Clinical Decision Support to Manage Inpatient Hyperkalemia

Shengsheng Yu, PhD Department of Pharmacy Administration University of Illinois at Chicago Chicago, Illinois (2012)

Dissertation Chairperson: Bruce Lambert, PhD

This study was conducted to evaluate clinicians’ responses to the presence of hyperkalemia before and after implementing laboratory-pharmacy decision support in an inpatient setting. A synchronous and a real-time asynchronous CDS rules were implemented at University of Illinois Hospital (UIH) in June 2003. In May 2010, another once-daily asynchronous drug-laboratory alert report was implemented to detect any missed safety signals.

On average, the clinicians’ compliance with the synchronous alerts was 88.31% for [K+]↔ACE/ARB and 69.46% for [K+]↔K-sup. As the indirect effect of the asynchronous CDS alerts, the alert rate of the real-time asynchronous CDS for [K+]↔K-sup dropped significantly after CDS implementation (28.8% vs. 30.4%, p = 0.005). The change in alert rate was not significantly for [K+]↔ACE/ARB (12.1% vs. 12.5%, p = 0.752). The segmented regression analysis indicated that, after controlling for all the covariates, the asynchronous alerts had limited influence on accelerating clinicians’ action for both [K+]↔ACE/ARB and [K+]↔K-sup. Nevertheless, the asynchronous alert had a lasting effect on reducing patient time to normal [K+] for K-sup users. Such benefit was not observed for ACE/ARB users.

No significant decrease in the action time to K-sup cancellation was observed immediately after the implementation of once daily report in May 2010. But there was a gradually descending trend given the significant coefficient estimate for the difference in the slope and the negative slope for the post-intervention period. For the action time to K-sup cancellation or repeating [K+], the segmented regression estimates did not confirm the ascending trend for the pre-intervention period, but did ascertain the impact of once daily report in gradually reducing time to either cancel the K-sup order or repeat [K+].

In sum, clinicians complied with synchronous CDS alerts in managing hyperkalemia in inpatient settings. The real-time asynchronous alert failed to demonstrate its effect in accelerating clinicians’ action, but had potential effect in improving patient outcomes for K-sup users. The once daily report was effective in detecting potentially hazardous situations that had not been corrected after real-time asynchronous alert. But its impact on changing clinicians’ practice behavior and improving patient outcomes was difficult to establish given the rare alert rate.