Over the last 20 years, medicine has become increasingly an evidence-based activity and now software applications are able to collect information on clinical activities within a hospital in an increasingly efficient manner. It is now relatively straightforward for a manager or clinician to obtain management reports of proce- dures undertaken or medicines administered in a hospital, with numbers and details of each event. These reports are used as the basis for clinical audit, whereby clinicians and managers review the information concerning a drug or procedure, to determine the activity level and cost of the intervention, and an estimation of whether the intervention is being done in accordance with local or national clinical guidelines, or accepted best practice for the profession concerned.
In many health environments, there are financial pressures limiting allocation of health resources, and practitioners are under pressure to justify their professional practice, in the eyes of patients and other stakeholders, and also to demonstrate that their interventions have an objective benefit to patient care. Thus, for many healthcare professionals, clinical audit is a useful tool and has profound political significance.
Traditionally, the data for clinical audits has been obtained by a variety of means. For analysis of hospitals admissions, a specific report would be generated
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Use of EP Systems for Clinical Audit 103
from the patient administration system (PAS), based on a search for the coded data entity for the diagnosis or admission type from the patient records. For a review of surgery performed within a hospital, an electronic health record would be queried on the basis of the OPCS procedure codes associated with each patient record. For some, very specific audits of clinical services, data have been collected manually using questionnaire or observational techniques.
Audits of medicine use generally seek to answer questions that managers and clinicians might have about cost-effective and appropriate use of medicines, across the whole population of patients who are admitted to hospital. Audits may be con- ducted to evaluate the following scenarios:
(a) For a relatively expensive medicine, for example, the 5HT3 antagonist antiemetic, ondansetron, an audit of drug use could address the following questions:
• How many dose units are being used, and of which formulation? (tablet or injection)
• Where the drug is being used, is it being used according to the manufacturer’s recommended dosage schedule, or in line with any existing clinical guide- lines within the hospital?
The results of such an audit may be used to establish a guideline for use of the drug in the hospital, if such a guideline is not already in existence.
(b) The extent to which patients commenced on intravenous antibiotics are transferred to equivalent oral antibiotics after 2 days of intravenous dosing.
The transfer to oral antibiotics after a short i/v course is recommended in order to minimise treatment costs, to prevent the emergence of resistant pathogens and reduce the risks associated with intravenous therapy. A clini- cal audit of the route of antibiotic administration would monitor compliance to local clinical guidelines, identify exceptional cases and determine whether there are any consistent features of exceptional cases that could be remedied.
To conduct audits of medicines use, there have, in the past, been two basic approaches. Firstly, a standard starting point has been a product/formulation use report from the pharmacy system, as this would provide a reasonably accurate pic- ture of medicines being issued from the pharmacy, and would be relatively easy to obtain from a pharmacy system. Such reports could be used as the basis of product use comparisons between different wards and specialties. However, the number of packs or dose units issued by the pharmacy, as evidenced by reports from the phar- macy computer system, does not necessarily correspond to actual administration of dose units to patients. Discrepancies may be caused by:
(a) The use of when required (prn) medicines, such as analgesics and antiemetics, where the consumption by the patient is variable and where there may be little correlation to the number of dose units issued by the pharmacy.
(b) The use of ward stock. A stock supply to a ward, issued by the pharmacy, might be used on a variety of patients, depending on the ward’s pattern of admissions.
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(c) The administration of a single dose of a medicine to a patient, as an emergency measure, where the medicine given was borrowed from another ward or depart- ment outside of pharmacy opening hours, and therefore would not be reflected in the pharmacy issues to that ward. This issue would also occur with the use of patient’s own drugs (PODs) within the hospital, a practice that is common in the UK, as a means of reducing hospital expenditure on patient’s long-term medicines that are unlikely to be changed during the course of an acute admission.
In order to surmount the problem of the relationship between doses issued by the pharmacy and doses actually administered to the patient, a second approach to clini- cal audit is therefore for ward-based staff to record the number of actual dose units of a medicine administered to a patient. This approach has the advantage that it would gather an accurate record of all medicine doses administered to a patient – be they when required (prn), single doses, or from stock packs. However, with the traditional system of using paper drug charts for recording administration of medicines, the record of all dose units administered would need to be transcribed manually to audit documentation. By this method, recording administration events for all patients on a ward just for one drug formulation would be a laborious process. Such a manual recording process is far too labor intensive to produce the variety of ad hoc reports of medicine use that may be needed in a routine operational environment.
In addition, there are specific problems arising from the manual transcription or rekeying of medicines administration data from paper drug charts:
(a) Due to the legibility of charts, it may not be clear what dose was administered and on what date.
(b) If details of administration are being recorded in the audit, the prescriber’s administration instructions on the chart may be sufficiently ambiguous that it is not clear how exactly the medicine has been administered on each occasion.
(c) If a prescriber has specified multiple routes for a medicine (e.g. metoclopra- mide 10 mg im/pr/po prn) in a single prescription, it may not be clear from the administration record which route was used for which administration event.
(d) When manually transcribing administration events, inconsistencies in the data may be introduced due to assumptions made by different transcribers.
EP systems with full medicines administration functionality offer the possibility of comprehensive querying functions for conducting clinical audits. Such a system is able to capture data on dose units administered to a patient, at the point of admini- stration, thus providing a detailed accurate record of medicine consumption for a ward, specialty or subgroup of patients.
Furthermore, if an EP system is interfaced with the pharmacy system, it is theo- retically possible to reconcile the stock issued from the pharmacy with the doses actually administered to patients, and to analyse the variance. An accurate usage review will be harder to perform for items that are not issued for a specific patient (stock items). However, usage reviews for drugs issued to specific patients would
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