With the move to accountable care, providers need to deliver quality care while managing the cost of delivery. A critical component to delivering the appropriate care in the appropriate setting is having complete patient information available – what you need, when you need it, where you need it.

While technology has helped healthcare professionals do many tasks quicker, they must also do things right. At Covenant Health, safety has always been – and continues to be – of utmost importance, as we strive to deliver care as effectively and efficiently as possible. To that end, we endeavor to leverage patient data and best practices to deliver care proactively. Our goal is to prevent adverse reactions or events before they can occur. We have found that clinical information technology has helped us hard-wire processes that improve patient outcomes.

The Challenge: Avoiding an ADE for Diabetics

Recently our department was approached by a radiology department manager at one of our hospitals to address a potential ADE (adverse drug event) risk to diabetic patients. Patients with type 2 diabetes have a risk of kidney failure if they receive a particular medication within 48 hours of undergoing a CT with contrast. The drug, Metformin, may cause acute renal failure when taken within that period due to a reaction with the contrast dye that is taken to prepare for the CT.

This type of kidney failure is called Contrast Induced Nephropathy (CIN) and is the third most common cause of hospital-acquired renal failure. In addition to its negative impact on patient outcomes, CIN is estimated to cost an average of more than $10,000 per patient to treat.

Radiology had been employing a manual chart review process prior to performing a contrast CT exam to identify scheduled patients who were on Metformin. After each of these patients had the exam, Radiology staff attached a hard-copy “Hold Metformin” sheet to the patient’s chart and phoned the primary nurse on the nursing unit to hold Metformin for 48 hours. The form also served as a patient education sheet reminding them not to take their Metformin medication.

The process involved many manual steps with risk for error and delayed communication. The pharmacy was not advised to hold the order, so nursing was the main function involved in preventing an unsafe administration of an ordered medication. To reduce the risk of CIN among our diabetic patients, we knew we needed a better process, so we gathered a multidisciplinary team to address the challenge.

Finding Solutions: Using Clinical Alerts to Help Prevent Renal Failure

We determined that we already had a powerful tool in our clinical information technology toolkit to help us reduce the risk of error and better communicate across the care team. We created a rule-based care alert that works in the background. When patients check in for the Contrast CT exam, the alert reviews the electronic health record to check whether they have an active order for Metformin (using Service Item Master codes). If the result of that check comes back “true,” the system automatically notifies the pharmacy to temporarily discontinue Metformin for the patient for 48 hours.

The pharmacy, upon discontinuing the Metformin order, creates a Notice of Discontinuation order in our pharmacy system that is seen by nursing staff in both the online care plan and medication administration record, as well as by the Radiology department and by the physician in the physician portal. The order also generates an alert with a warning to pharmacy staff if anyone accidentally orders Metformin for these patients before the 48 hours has elapsed.

Seeing the Benefits: Improved Patient Outcomes, Plus Cost Savings

We saw the benefits from hard-wiring our process almost immediately. First and foremost, this process greatly improves patient safety by discontinuing Metformin until normal kidney function can be validated. The alert is in real time, so as soon as the patient is checked in for the exam, the pharmacy receives the alert to discontinue Metformin. The first month the alert was in production, it resulted in the drug being discontinued for 14 Contrast CT patients.

Achieving Great Results: More than $1 Million in Avoided Potential Costs

During the initial six months of using the new process, we discontinued Metformin for 111 Contrast CT patients. This resulted in potentially “saving” 222 kidneys, and helped the hospital avoid more than $1 million in potential costs. This is a powerful example of how we are beginning to “meaningfully use” healthcare IT as a tool to help us improve patient safety and clinical outcomes. This project has laid the foundation for us to move forward using clinical alerts to address a wider scope of clinical situations.

Covenant Health has been named one of the nation’s “Most Wired” organizations for 2013 by the American Hospital Association’s Hospitals & Health Networks® magazine.

Results from Covenant Health’s Application of Care Alerts

Using an updated process that leveraged clinical alerting, Covenant Health improved patient outcomes for type 2 diabetics taking Metformin and getting a Contrast CT exam.

  • The system prompted clinicians to discontinue Metformin on 111 patients.
  • This new automated process – versus the old manual one – potentially saved 222 kidneys.
  • In six months, one facility potentially saved over $1 million from avoided adverse drug events and renal failure.
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About the author

Donna Lynch is a registered nurse with 23 years of patient care experience, followed by 15 years experience in health care IT. As vice president of Clinical Informatics for Covenant Health, Donna is responsible for strategic leadership and day-to-day operations for its clinical information systems. She has more than 38 years of health care leadership experience in mid- to large-sized health systems in acute and outpatient settings. Her experience includes operations, strategic planning, program development, fiscal management, physician relations and supervision, and system-level management. She served on the InSight user group’s board of directors from 2010 to 2012.