making it easier to do it right - knmg
TRANSCRIPT
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Workshop 5
Dr. Carolien van der Linden, klinisch geriater en farmacoloog
Ashley De Bie Dekker, PhD-kandidaat, AIOS inwendige geneeskunde
CLINICAL DECISION SUPPORT
Making it easier to do it right
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Opbouw presentatie
Inleiding
Deel 1:
CDSS voor vergroten medicatie veiligheid
- Bij medicatiebewaking
- Bij documenteren en overdracht medicatiegegevens
Deel 2:
Intelligent dynamic clinical checklists op ic
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Doe, J. M121212112 60 jr / 12-12-1912
Doe, J. M121212112 60 jr / 12-12-1912
44 tabs53 buttons
Complexity of care
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Clinical Decision Support, hoe werkt dat?
alert
CDSS
Elektronisch Patiënten Dossier
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Deel 1: CDSS bij medicatiebewaking
• Arthur Wasylewicz
• Rene Grouls
• Marieke Kerskes
• Erik Korsten
• Winnie van ‘t Geloof
• Ken Ho Hue
• Martine Vromen
• Anne-Marie Scheepers-Hoeks
• Farmacie studenten
• Expertteams
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De (r)evolutie van medicatiebewaking
1e generatie
2e generatie
VERLEDEN
Op papier
Digitaal
• Contra-indicaties• Interacties• Doseringscontrole• Dubbel medicatie• Pseudo dubbel medicatie
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2de generatie medicatiebewaking
EPD en digitale recepten met EVS en automatische controle
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Casus stijgend kalium
2,4
3,6
4,5
5,3
6,4
0
1
2
3
4
5
6
7
1 2 3 4 5
mm
ol/
L
dag
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3e generatie medicatiebewaking
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Een clinical rule, wat is het?
“Een clinical rule is een algoritme waarin patiëntkenmerken aan elkaar gekoppeldworden, met als doel patiënt-specifieke beoordelingen of adviezen te genereren en zo de patiëntveiligheid te bevorderen.”
HEDEN
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Welke ontwikkelen?
o Klinisch relevant / hoogrisico (o.a. CMR)
o Realiseerbaar met huidige systemen
o Efficiëntiewinst t.o.v. huidige systemen
o “Laaghangend fruit”
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Waar te beginnen?
Proces Patient Pil
TDM (6x) Maagprotectie Opiaat+laxans
Oncolytica Elektrolyten (Na/K/Ca) Methotrexaat
INR Nierfunctie Lithium therapie
Switch antibiotica Hartfalen Thyroxine en sondevoeding
* Indeling volgens NVZA risico toolkit
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Een clinical rule bouwen
o Doel₋ Bv preventie van ulcus door NSAID
o Wat zijn triggers?₋ Start NSAID
₋ Dosisaanpassing NSAID
₋ Ontstaan risicofactor
o Beschikbare evidence, richtlijnen etc
o Wanneer alert?
o Expertteam, geneesmiddelencommissie, staf
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Validatie
1) Technisch
2) retrospectief therapeutisch
3) prospectief therapeutisch4) Praktijk
Interventies
Scheepers-Hoeks A, Grouls R, Neef C, Korsten H: Stud Health Technol Inform. 2009;148:142-8
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Dagelijkse verwerking
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Resultaten
o Oude Methodeo 600 – 800 meldingen/dag
o PIL-georiënteerd
o Interventie/opgevolgd: circa 1%
o Alert-fatigue!!
o Je kunt (nog) niet zonder ?
Clinical Ruleso Circa 30 – 40 meldingen/dag
o PATIENT-georiënteerd
o Interventie/opvolging: 20-30%
o Toegevoegde waarde: medicatieveiligheid
o Interactief tijdens proces
o De toekomst
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Resultaten
p<0.001
Tijd
to
t n
orm
alis
atie
kal
ium
(u
ur)
Controle Interventie
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Landelijke ontwikkelingen
Werkgroep Clinical Rules – Commissie FPZ
Clinical rule antibiotica switch
Clinical rule cumarines
Clinical rule hyponatriëmie
Clinical rule kalium
Clinical rule maagprotectie
Clinical rule methotrexaat – niet oncologisch
Clinical rule nierfunctie
Clinical rule opiaat-laxans
Clinical rule orale oncolytica met stopdatum
Clinical rule TDM aminoglycosiden en vancomycine
Clinical rule vitamine D suppletie
CRISP studyThe Clinical Rules in Santeon Collaboration Pilot study
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Adverse drug reactions
in individual patient caredocumentation and prevention of represcription
prof.dr. Erik Korsten
prof.dr. Toine Egberts
dr. René Grouls
dr. Paul Jansen
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Casus mw G, 85jr• VG: DM, struma, prim hyperparathyreoidie
• Opname: delier, Ca 3,06mmol/l
• Vochtinfusie, hydrochloorthiazide gestaakt
• Ged 10 mnd stabiel Ca oiv cinecalcet
• Daarna plots Ca 3,44mmol/l en opnieuw delier wvheropname
• Thuis opnieuw hydrochloorthiazide gekregen
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Represcriptie na bijwerking
Praktijk
• Evaluatie farmacotherapie tijdens opname
• Herstart na staken tijdens opname
Onderzoek:
• Worden geneesmiddelen, na staken ivmbijwerking, opnieuw voorgeschreven?
• Oorzaken?
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Represcriptie na bijwerking
• Opname’s 2 afdelingen geriatrie (n=215)
• 104 bijwerkingen bij 69 patiënten
• 53 bijwerkingen in ontslagbrief genoemd
• 22% van vermelde bijwerkingen door verwijzer verwerkt
• Apotheken nooit op de hoogte
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Optimalisatie
pharmacommunicatie
27% van medicijnen die in het ziekenhuis werden gestaakt vanwege
een bijwerking werd binnen 6 maanden herstart
CMJ van der Linden et al. Represcription after Adverse Drug
Reaction in the Elderly. Arch Int Med 2006;166:1666-67
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Oorzaken
• Onvoldoende communicatie naar huisarts en apotheek
• Onvoldoende bewaking
• Voorwaarde: reden van staken wordt vastgelegd (bij 40% van gestaakte medicijnen geen reden vastgelegd)
Reasons for discontinuation of medication
Arch Int Med 2010;170:1085-86
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Gaston®
de Clercq PA, et al. Design and implementation of a
framework to support the development of clinical guidelines. Int J Med Inform 2001;64(2-3):285-318
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• Als medicijn gestopt wordt verschijnt een pop-up die vraagt naar de reden van staken.
• Pick-list redenen. Na selectie reden direct terug in medicatiemodule
• Bij een bijwerking
₋ welk verschijnsel
₋ ernst
₋ advies tav opnieuw voorschrijven
• Bij opnieuw voorschrijven na een bijwerking verschijnt een waarschuwing
Clinical rule:
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Resultaten geriatrie en interne (n=728)
Table 1 Reasons for discontinuation of medication
van der Linden et al. Drugs&Aging 2012;29(12):957-62
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Waarschuwingen represcriptie
• 31 maal waarschuwing bij herstart van een middeldat eerder gestaakt werd vanwege een bijwerking(binnen ziekenhuis!)
• adviezen:
- 29x: extra monitoring nodig
- 2x: niet meer voorschrijven
• 27 van 31 adviezen gevolgd (87%)
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Koppeling eerste lijn
• Koppeling aan test-omgeving HA-informatiesysteem SGE (barriers)
• Informatie over ADR in dossier HA en apotheekNB in intolerantiemodule
• Daardoor bewaking binnen eigen systeem
• HA en apothekers zijn enthousiast
Pharmaceutisch Weekblad 2014, 16 mei: 124-9
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Vervolgstappen
• Documentatie redenen van staken in EVS
• Documentatie incl bewaking binnen EPD
• Koppeling aan systeem eerste lijn; via LSP?
• …
• Koppeling aan Lareb (Nederlands BijwerkingenCentrum)
• ...
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PhD-kandidaat: Ashley De Bie Dekker
PhD-kandidaat: Eveline Mestrom
Ir. PDeng: Wilma Compagner
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The Doctor – Luke Fildes; 1891
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± 700 beds ± 30.000 admissions/yr
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301 Hospital Beijing4.000 beds
± 65.000 surgery admissions/yr
± 100.000 admissions/yr
3.8 million outpatient appointments/yr
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Cardiology department expansion
Oncology department expansion
Operation room expansion
Emergency
department
expansion
Women’s health expansion
Hospitals within hospitals.
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Clinical information overload
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*Five system barriers to achieving ultrasafe health care, Amalberti et all; annals of internal medicine 142 (9): 756 -64, 2005
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Operations
230.000.000/yr
Permanent disability
7.000.000/yr
Mortality
1.000.000/yr
2003
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2007 Surgical safety checklist, A Gawande. (n=7688)
Complications
11 7%*
Mortality
1.5 0.8%*
A surgical safety checklist, A. Haynes, NEJM 2009; Checklist manifesto, A. Gawande
*Significant
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Reduction in:
MORTALITY
COMPLICATIONS
2010SURPASS
Effect of a Comprehensive surgical safety system, E de Vries, NEJM 2010
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Nature and timing of incidents intercepted by the SURPASS, E de Vries, BMJ Qual Saf 2012
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New evidence
ProcesImprovement
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
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Checklist transformatie
Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
2014 Simulation Trial INTENSIVE CARE.
Number of checked
(critical) items
6 Intensive Care scenario’s
20 participants
Daily round
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
Checklist (paper) at the
bedsideClinical rules (Pharmacy; GASTON)
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
All daily items
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
Critical items
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
Pharmacist alerts (phone; after scenario)
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Intelligent dynamic clinical checklists improved checklist compliance in the Intensive Care Unit . A.J.R. De Bie, BJA 2017.
Acceptance score
4.13/5
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ClinicalProof of Concept
2018
Next…
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DANK U
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Casus: 68-jarige man
Voorgeschiedenis:• 1995 Diabetes mellitus type 2
• 2010 Hartinfarct
• 2012 Ritmestoornis: atriumfibrilleren.
• 2016 COPD (roker)
Reden van opname IC:Dag 3: • Ernstige longontsteking
• Beademing en hartondersteuning.
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Casus: 68-jarige man
Medicatie:• Dobutamine intraveneuze pomp (stimulans hart)
• Noradrenaline intraveneuze pomp (bloeddruk)
• Midazolam intraveneuze pomp (sedatie)
• Ceftazidim 2d 1000mg (antibiotica)
• Nutrison 12x 50cc (voeding)
• Fragmin 1d 2500EH (voorkomen trombose)
• SDD suspensie (voorkomen suspensie)
Conclusie nu:• Blijft ziek, knapt na drie dagen antibiotica nog niet op.
• Hoog suiker (22 (<12)) in het bloed
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Take home message
“Slimme beslissingsondersteuning biedt direct hulp aan patiënt en diverse zorgverleners, terwijl het overzicht binnen uitdijende zorgprocessen terugkeert.”