Is there a need for Renal Computerised Clinical Decision Support in a University Hospital Setting?

Background:With a wider number of hospital sites implementing Electronic Prescribing and Medication Administration (EPMA) systems, the prevalence of digitally mature capabilities such as Computerised Clinical Decision Support (CCDS)has increased. CCDS systems match individual patient data to a computerised knowledge base using software algorithms to generate patient-specific recommendations to present to healthcare practitioners. We describe baseline audit data aspart of a larger project exploring the possibility of implementing CCDS for patients with renal impairment.

Aim: To establish if there is a need for renal CCDS in a hospital EPMA system.

Description:Patient demographic, pathology and prescription data were captured from the University Hospitals Birmingham NHS Foundation Trust (UHB) EPMA system (PICS) for eightdrugs identified as requiring dose adjustment according to chapters A-C of the Renal Drug Handbook and beingin the top 250 most prescribed drugs at UHB in 2014.Prescription data included first and last dose within the patient spell, drug name, form, dose frequency, route, speciality andprescriber grade. Patient data included weight and the estimated Glomerular Filtration Rate (eGFR)prior to the first and last doses being administered. Prescriptions thathad no available eGFR at any point, or that were administered on a when required basis were excluded. Data wereinterrogated to identify dose discrepancies for patients with renal impairment according tothe Renal Drug Handbook. Data were also analysed to identify whether there was any correlation between dose discrepancies and patient eGFR, drug, time of day, day of week and month of year,

Results: During a 12-month period, 10,116 first doses were identified for the drugs being considered, of which 133 (1.3%) had dosing discrepancies according to the Renal Drug Handbook. In the subgroup of patients with renal impairment(eGFR<50, 1815 first doses), 128 (7.1%) were identified as having a dosing discrepancy on their first dose. Of these patients, 89 received more than one dose, and had eGFR measurements available at both the first and last dose. Within this group, just over half (54%, n=48) were administered doses that were not consistent with dosing recommendations in the Renal Drug Handbook for the entirety of their prescription.

Conclusion: The overall number of first dose discrepancies for the drugs being considered was small (n=133). Of the 89 patient’s receiving multiple doses,54%(n=48)were not changed to recommended doses by the final dose. The number of inappropriate renal CCDS messages (false positives), which are well documented as causing alert fatigue, would be relatively small. Hence, there is scope for the implementation of clinical decision support in prescribing to patients with renal impairment. This work is currently being extended to incorporate a large number of drugs identified as being high risk for patients with renal impairment.