Improve patient safety while reducing staffing in a hospital setting

WHITE PAPER

Improve Patient Safety While Reducing

Staffing 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 Order
A 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.

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

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Improve patient safety while reducing staffing in a hospital setting

Legibility

Another problem
with handwritten
orders is that the

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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.

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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)

Inefficiency
One 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 Solubility
The 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.
Calculations
Computerized 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.

Legibility
With 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.

Inefficiency
The 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 Solubility
The 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 Assistant

Apex 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 Schedule
I.
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