Pediatric Informatics: Computer Applications in Child Health (Health ...

7 Pediatric Emergency and Pediatric Critical Care Considerations 75
and implemented within 2 weeks of the system “go live” based on additional
provider needs.
Implementation is iterative and break-the-glass functionality is essential:
While order sets are a very effective way to reduce errors and streamline care,
even in arrest situations, they may need modification by clinicians to optimize
care. These modifications may range from being able to add specific orders
to order sets to being able to override lockout rules to emergency medications
when needed. The existence of recurrent modifications may indicate the need for
adjustments in baseline order sets.
Clinical workflow evaluation is important:
Interventions that improve speed
and accuracy of clinician data use and entry are important. Evaluation of these
aspects may be based on studies of task times, error rates and user feedback.
Examples of important process streamlining include:
� Rapid Registration/Preregistration.
The ability to establish orders quickly
for new patient arrivals or transports is essential. Establishment of a record
with minimum data set (name, birth date, etc.), even as a “John Doe” allows
patients to be “in the system” on arrival for tests, drugs and access to EMR/
CPOE systems.
� Order “sentences.” Specification of nonstandard orders (those not already in
an order set) must be fast (minimum number of choices, clicks or keystrokes
to enter). An example is the order for a urine sample: instead of a sequence
of selections: (1) test (urinalysis), (2) source (bag, catheter, suprapubic tap,
or clean catch), (3) urgency (routine or stat), and (4) indication (text entry),
the user should be given a selection of single phrase orders (sentences) at a
single click. The same model is used for medications and other orders, using
standardized weights, routes or medical conditions.
� Calculators:
Inline and dedicated calculators for complex critical care processes
such as continuous infusions45 and total parenteral nutrition46 reduce
arithmetic errors associated with the cognitive burden of manual computation.
Alerts, reminders and automated dose-range checks can be performed,
with great time savings and reduction of errors.
� System response time and security:
Network and workstation capacity must
be anticipated for normal to high work loads, and these must not be underestimated.
In both studies of CPOE in PICUs, this has been an issue. Included in
this planning is time required for security (logging into the system, selecting
the patient, etc.). Clinician expectations for rapid access to a chart are high
with short wait times (1 min from log in to access a patient record) before
they are tempted to perform a workaround (typically a verbal order).
Time and frequency
� : In the ED, most orders have a frequency of once (i.e.
single orders). However, if orders are delayed until a patient is admitted to the
floor or ICU, they may be specified in terms of a frequency (such as every
12 h). However, this may be interpreted as every 12 h per the routine floor
schedule, which may result in overdosing or a missed dose of an essential
medication. Clear policies must be established to avoid this type of error.