PhD

dissertationComputerized medical decision support tools have been shown to improve the quality of care and have been cited as one method to reduce pharmaceutical errors by the Institute of Medicine. An existing adult antiinfective decision support tool was enhanced by adding medical logic to make it appropriate for pediatric patients. Pediatric modifications to the medical logic and new antiinfective and dosage recommendations were implemented into the decision support tool. Measurements of appropriate antiinfective use, antiinfective costs, the rate of adverse drug events secondary to antiinfectives, antimicrobial-bacterial susceptibility mismatches, and pharmacy staff interventions for antiinfective agents were prospectively monitored during a six-month control and a six-month intervention period. Mandatory use of the decision support tool was initiated for all antiinfective orders in a 26-bed pediatric intensive (PICU) during the intervention period. Clinician opinions of the decision support tool were surveyed at the end of the intervention period. The patient populations during both the control period (n = 809) and the intervention period (n = 949) were similar with respect to their PICU and hospital lengths of stay, severity of illness, risk of mortality, and total hospital costs. The intervention group was significantly younger (5.5 years vs. 6.2 years, p < 0.05), and a greater percentage were treated with antibiotics (66.5 percent vs. 60.2 percent, p < 0.01). There was not a significant difference in type of antiinfectives ordered, or the number of antiinfectives, or antiinfective doses. Neither was there a difference in the rate of adverse drug events, or antibiotic-bacterial susceptibility mismatches. However, the rate of pharmacy interventions on erroneous drug doses declined by 59 percent from 35.5 to 14.5 interventions per 1000 patient-antiinfective courses (p < 0.01). The rate of antiinfective subtherapeutic patient days decreased by 36 percent from 7.4 to 4.7 subtherapeutic days per 100 patient days (p< 0.0001), and the rate of excessive-dose days declined by 28 percent from 8.5 to 6.1 excessive-dose days per 100 patient days (p < 0.0001). Additionally, the number of orders placed per antibiotic course decreased 11.5 percent from an average of 1.56 to 1.38 orders/pt-antiinfective (p < 0.01), and the robust estimate of the antiinfective costs per patient decreased 9 percent from $86.60 to $78.43 (p < 0.05). These data are supported by the surveyed clinicians who cited the dosage calculation assistance to be most helpful, and reported the program improved their antiinfective agent choices, increased their awareness of impairments in renal function, and reduced the likelihood of adverse drug events. Use of the pediatric antiinfective decision support tool in a PICU was considered beneficial to patient care by the clinicians, and positively impacted the rates of erroneous drug orders and antiinfective sub- and supratherapeutic risk-days