Electronic Ordering System Improves Postoperative Pain Management after Total Knee or Hip Arthroplasty

M.K. Urban; T. Chiu; S. Wolfe; S. Magid

doi:10.4338/ACI-2014-12-RA-0114

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2015; 06(03): 591-599
DOI: 10.4338/ACI-2014-12-RA-0114

Research Article

Schattauer GmbH

Electronic Ordering System Improves Postoperative Pain Management after Total Knee or Hip Arthroplasty

M.K. Urban

¹Hospital for Special Surgery, Anesthesiology, New York, NY, United States

,

T. Chiu

²Auckland, New Zealand

,

S. Wolfe

³New York, NY, United States

,

S. Magid

⁴Hospital for Special Surgery, Quality Research Center, New York, NY, United States

› Author Affiliations

Abstract

Summary

Objectives: The authors investigated the impact of computerized provider order entry (CPOE) on the delivery times of analgesia and subsequent patient outcomes. We hypothesized that patients would report less pain and use less pain medications compared with the previous paper-based system.

Methods: Two groups of patients after a total hip (THA) or knee arthroplasty (TKA) were retrospectively compared: one comprising 106 patients when the paper-based ordering system was in effect (conventional group), and one comprising 96 patients after CPOE was installed (electronic group). All patients received a regional anaesthetic at surgery (combined spinal-epidural). TKA patients also received a single-injection femoral nerve block. After transfer to the postoperative anaesthesia care unit (PACU), a patient-controlled epidural analgesia (PCEA) infusion was initiated. The following data was collected from the PACU record: time to initiation of analgesia, visual analog scale (VAS) pain scores at initiation of analgesia and hourly for the first postoperative day (POD), volume of pain medication used, length of stay (LOS) in the PACU and the hospital.

Results: The time to initiation of analgesia from arrival in the PACU was significantly lower in the electronic group compared to the conventional group (24.5 ± 28.3 minutes vs. 51.1 ± 26.2 minutes; mean ± SD, p < 0.001), as were VAS pain scores (0.82 ± 1.08 vs. 1.5 ± 1.52, p < 0.001) and the volume of PCEA needed to control pain (27.9 ± 20.2 ml vs. 34.8 ± 20.3 ml, p = 0.001) at 4 hours postoperatively. PACU LOS and hospital LOS did not significantly differ in the two groups.

Conclusions: After implementation of CPOE, patients received their postoperative analgesia faster, had less pain, and required less medication.

Citation: Urban M,Chiu T, Wolfe S, Magid S. Electronic Ordering System Improves Postoperative Pain Management after Total Knee or Hip Arthroplasty. Appl Clin Inform 2015;6: 591–599

http://dx.doi.org/10.4338/ACI-2014-12-RA-0114

Keywords

Patient controlled anesthesia (PCA) - computerized physician order entry (CPOE) - arthroplasty - electronic health records and systems - medication management

Full Text

References

References
1 White RH, Henderson MC. Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med. 2002; 8 (05) 365-371.
2 United States Acute Pain Management Guideline Panel.. Acute pain management: operative or medical procedures and trauma. Publication No. 92–0032. Rockville, MD: United States Department of Health and Human Services; Public Health Service Agency for Healthcare Policy and Research, 1992
3 Apfelbaum JL, Chen C, Mehta S, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97: 534-540.
4 Sinatra RS, Toress J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg 2002; 10 (02) 117-129.
5 Joint Commission on Accreditation of Healthcare Organizations.. Pain Standards for 2001. Oakbrook Terrace, IL: JCAHO; 2000
6 YaDeau JT, Cahill JB, Zawadsky MW, Sharrock NE, Bottner F, Morelli CM, Kahn RL, Sculco TP. The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg 2005; 101 (03) 891-895.
7 Crile GW. The kinetic theory of shock and its prevention through anoci-association. Lancet 1913; 185: 7-16.
8 Wall PD. The prevention of postoperative pain. Pain 1988; 33 (03) 289-379.
9 Woolf CJ. Central mechanisms of acute pain. In Bond MR, Charlton JE, Woolf CJ. (eds). Proc 6th World Congr on Pain Amsterdam; Elsevier: 1991: 24-34.
10 Woolf CJ, Chong MS. Preemptive analgesia--treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993; 77 (02) 362-379.
11 Møiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief –the role of timing of analgesia. Anesthesiology 2002; 96 (03) 725-741.
12 Dahl JB, Møiniche S. Pre-emptive analgesia. Br Med Bull 2004; 71: 13-27.
13 Urban MK, YaDeau JT, Wukovits B, Lipnitsky JY. Ketamine as an adjunct to postoperative pain management in opioid tolerant patients after spinal fusion: a prospective randomized trial. HSS J 2008; 4 (01) 62-65.
14 Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163 (12) 1409-1416.
15 Niazkhani Z, Pirnejad H, Berg M, Aarts J. The impact of computerized provider order entry systems on in-patient clinical workflow: a literature review. J Am Med Inform Assoc 2009; 16 (04) 539-549.
16 Jensen JR. The effects of computerized provider order entry on medication turn around time: A time to first does study at the Providence Portland Medical Center. AMIA Annu Symp Proc 2006; 384-388.
17 Cunningham TR, Geller ES, Clarke SW. Impact of electronic prescribing in a hospital setting: A process focused evaluation. Int J Med Inform 2008; 77 (08) 546-554.
18 Lehman ML, Brill JH, Skarulis PC, Keller D, Lee C. Physician Order Entry impact on drug turn around times. Proc AMIA Symp 2001: 359-363.
19 Mekhjian HS, Kumar RR, Kuehn L, Bentley TD, Teater P, Thomas A, Payne B, Ahmad A. Immediate benefits realized following implementation of physician order entry at an academic medical center. J Am Med Inform Assoc 2002; 9: 529-539.
20 Cordero L, Keuhn L, Kumar RR, Mekhjian HS. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. J Perinatol 2004; 24 (02) 88-93.
21 Refuerzo JS, Straub H, Murphy R, Salter L, Ramin SM, Blackwell SC. Computerized physician order entry reduces medication turnaround time of labor induction agents. Am J Perinatol 2011; 28 (04) 253-258.
22 Davis L, Brunetti L, Lee EK, Yoon N, Cho SH, Suh DC. Effects of computerized physician order entry on medication turnaround time and orders requiring pharmacist intervention. Res Social Adm Pharm 2014; 10 (05) 756-767.
23 Cartmill RS, Walker JM, Blosky MA, Brown RL, Djurkovic S, Dunham DB, Gardill D, Haupt MT, Parry D, Wetterneck TB, Wood KE, Carayon P. Impact of electronic order management on the timeliness of antibiotic administration in critical care patients. Int J Med Inform 2012; 81 (11) 782-791.
24 Agency for Healthcare Research and Quality’s National Resource Center for Health Information Technology: Medication Turnaround Time in the Inpatient Setting, 2009 AHRQ Publication No. 09-0045.
25 Weber LM, Ghafoor VL, and Phelps P. Implementation of standard order sets for patient-controlled anal-gesia. Am J Health Syst Pharm 2008; 65 (12) 1184-1191.
26 Prewitt J, Schneider S, Horvath M, Hammond J, Jackson J, Ginsberg B. PCA safety data review after clinical decision support and smart pump technology implementation. J Patient Saf 2013; 9 (02) 103-109.