Background
Methods
Setting
Study Design
CPOE Implementation
Measurements and outcomes
Statistical analysis
Results
General characteristics of all patients
Variable | 24 months pre N = 1638 | 12 months post N = 898 | P-value | 12 months pre N = 813 | 12 months post N = 898 | P-value | 3-months pre N = 192 | 3-months post N = 239 | P-value | 1-month pre N = 69 | 1-month post N = 75 | P-value |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Age in years, mean ± SD | 52.1 ± 21.5 | 52.4 ± 21.1 | 0.74 | 51.7 ± 21.7 | 52.4 ± 21.1 | 0.51 | 50.1 ± 21 | 53.6 ± 21.1 | 0.09 | 48.0 ± 22.2 | 50.3 ± 21.0 | 0.52 |
Female gender, N (%) | 567 (34.7) | 349 (38.9) | 0.04 | 284 (34.9) | 349 (38.9) | 0.09 | 64 (33.3) | 97 (40.6) | 0.12 | 28 (40.6) | 32 (42.7) | 0.80 |
APACHE II, mean ± SD | 24.1 ± 9.4 | 24.2 ± 9.7 | 0.83 | 24.7 ± 9.6 | 24.2 ± 9.7 | 0.36 | 25.1 ± 10.2 | 25.1 ± 10.4 | 1.0 | 25.3 ± 9.3 | 24.7 ± 10.9 | 0.75 |
Source of admission, N (%) | ||||||||||||
Emergency department | 450 (27.5) | 179 (19.9) | 223 (27.4) | 179 (19.9) | 64 (33.3) | 50 (20.9) | 25 (36.2) | 22 (29.3) | ||||
Ward | 668 40.8) | 331 (36.9) | 0.0001 | 326 (40.1) | 331 (36.9) | < 0.0001 | 75 (39.1) | 101(42.3) | 0.02 | 28 (40.6) | 22 (29.3) | 0.14 |
Operating room | 418 (25.5) | 335 (39.8) | 214 (26.3) | 335 (39.8) | 43 (22.4) | 73 (30.5) | 14 (20.3) | 27 (36.0) | ||||
Other hospital | 100 (6.1) | 53 (5.9) | 43 (5.3) | 53 (5.9) | 10 (5.2) | 15 (6.3) | 2 (2.9) | 4 (5.3) | ||||
Main reason for admission, N (%) | ||||||||||||
Respiratory | 304 (18.6) | 150 (16.7) | 0.24 | 136 (16.7) | 150 (16.7) | 0.99 | 44 (22.9) | 46 (19.3) | 0.35 | 22 (31.9) | 16 (21.3) | 0.15 |
Cardiovascular | 514 (31.4) | 258 (28.7) | 0.16 | 269 (33.1) | 258 (28.7) | 0.05 | 47 (24.5) | 70 (29.3) | 0.26 | 11 (15.9) | 21 (28) | 0.08 |
Neurologic | 119 (7.3) | 66 (7.4) | 0.94 | 60 (7.4) | 66 (7.4) | 0.98 | 22 (11.5) | 23 (9.6) | 0.54 | 10 (14.5) | 2 (2.7) | 0.01 |
Other medical | 83 (5.1) | 35 (3.9) | 0.18 | 35 (4.3) | 35 (3.9) | 0.67 | 7 (3.7) | 8 (3.4) | 0.87 | 3 (4.4) | 1 (1.3) | 0.27 |
Non-operative trauma | 229 (14) | 83 (9.2) | 0.0005 | 108 (13.3) | 83 (9.2) | 0.008 | 30 (15.6) | 23 (9.6) | 0.06 | 9 (13) | 9 (12) | 0.85 |
Post-operative trauma | 387 (23.7) | 306 (34.1) | < 0.0001 | 205(25.2) | 306 (34.1) | < 0.0001 | 42 (21.9) | 69 (28.9) | 0.10 | 14 (20.3) | 26 (34.7) | 0.05 |
Cardiac arrest as admission diagnosis | 135 (8.3) | 45 (5.0) | 0.002 | 76 (9.4) | 45 (5.0) | 0.0005 | 17 (8.9) | 13 (5.4) | 0.17 | 6(8.7) | 2 (2.7) | 0.11 |
Sepsis on admission | 420 (25.7) | 251 (28.0) | 0.21 | 241 (29.6) | 251 (28.0) | 0.21 | 51 (26.6) | 67 (28.0) | 0.73 | 16 (23.2) | 19 (25.3) | 0.76 |
Chronic health illnesses, N (%) | ||||||||||||
Chronic liver disease | 259 (15.8) | 97 (10.8) | 0.0005 | 117 (14.4) | 97 (10.8) | 0.03 | 26 (13.5) | 32 (13.4) | 0.96 | 10 (14.5) | 7 (9.3) | 0.34 |
Chronic cardiovascular | 451 (27.6) | 289 (32.2) | 0.01 | 250 (30.8) | 289 (32.2) | 0.52 | 59 (30.7) | 114 (47.7) | 0.0004 | 24 (34.8) | 31 (41.3) | 0.42 |
Chronic respiratory | 413 (25.2) | 224 (24.9) | 0.87 | 259 (31.9) | 224 (24.9) | 0.0015 | 57 (29.7) | 94 (39.3) | 0.04 | 27 (39.1) | 26 (34.7) | 0.58 |
Chronic renal disease | 349 (21.3) | 157 (17.5) | 0.02 | 210 (25.8) | 157 (17.5) | < .0001 | 54 (28.1) | 64 926.8) | 0.76 | 19 (27.5) | 23 (30.7) | 0.68 |
Immunocompromised | 228 (13.9) | 124 (13.8) | 0.93 | 117 (14.4) | 124 (13.8) | 0.93 | 19 (9.9) | 42 (17.6) | 0.02 | 7 (10.1) | 11 (14.7) | 0.41 |
Glasgow coma scale | 9.2 ± 4.3 | 8.9 ± 4.5 | 0.17 | 8.7 ± 4.5 | 9.2 ± 4.3 | 0.01 | 8.4 ± 4.4 | 9.0 ± 4.2 | 0.15 | 8.4 ± 4.0 | 9.3 ± 4.0 | 0.22 |
Admission creatinine in μmol/L | 163 ± 161 | 158 ± 146 | 0.44 | 166 ± 164 | 158 ± 146 | 0.37 | 195 ± 214 | 162 ± 142 | 0.08 | 162 ± 170 | 167 ± 165 | 0.87 |
Admission INR | 1.6 ± 1.1 | 1.5 ± 0.8 | 0.10 | 1.6 ± 1.0 | 1.5 ± 0.8 | 0.24 | 1.5 ± 0.8 | 1.4 ± 1.0 | 0.57 | 1.4 ± 0.8 | 1.8 ± 1.5 | 0.09 |
Vasopressor use* | 822 (50.2) | 327 (36.4) | < 0.0001 | 373 (45.9) | 327 (36.4) | < 0.0001 | 92 (47.9) | 97 (40.6) | 0.13 | 28 (40.6) | 33 (44.0) | 0.68 |
Mechanically ventilated, No.% | 1265 (77.3) | 662 (73.7) | 0.04 | 636 (78.2) | 662 (73.7) | 0.03 | 152 (79.2) | 179 (74.9) | 0.29 | 55 (79.7) | 62 (82.7) | 0.65 |
Outcomes of patients pre- and post-CPOE implementation
A. Comparisons in the 24 months pre- vs. 12 months post-CPOE implementation | |||||
---|---|---|---|---|---|
Variable
|
Pre-CPOE
|
Post-CPOE
|
Adjusted OR
a
or β
b
coefficient
|
95% CI
|
P-value
|
ICU mortality, N (%) | 382 (23.4) | 187 (20.8) | 0.98 | 0.7 - 1.3 | 0.87 |
Hospital mortality, N (%) | 633 (38.7) | 319 (35.5) | 1.00 | 0.8 - 1.3 | 0.80 |
Mechanical ventilation duration in days, mean ± SD | 7.2 ± 9.8 | 6.3 ± 10.8 | -0.30 | -1.3 - 0.7 | 0.54 |
ICU LOS in days, mean ± SD | 8.0 ± 10.5 | 8.1 ± 16.9 | 1.13 | -0.2 - 2.5 | 0.10 |
Hospital LOS in days, mean ± SD | 46.8 ± 77.5 | 46.6 ± 84.6 | 3.60 | -4.5 - 11.8 | 0.39 |
B. Comparisons in the 12 months pre- vs. 12 months post-CPOE implementation
| |||||
Variable | Pre-CPOE | Post-CPOE | Adjusted OR
a
or β
b
coefficient | 95% CI | P-value |
ICU mortality, No.% | 190 (23.4) | 187 (20.8) | 0.96 | 0.7 - 1.3 | 0.78 |
Hospital mortality, No.% | 296 (36.4) | 319 (35.5) | 1.24 | 0.9 - 1.6 | 0.13 |
MV duration, mean ± SD | 7.6 ± 10.3 | 6.3 ± 10.8 | -0.56 | -1.7 - 0.6 | 0.35 |
ICU LOS, mean ± SD | 8.4 ± 10.5 | 8.1 ± 16.9 | 0.78 | -0.9 - 2.5 | 0.37 |
Hospital LOS, mean ± SD | 44.2 ± 64.5 | 46.6 ± 84.6 | 5.04 | -4.1 - 14.2 | 0.28 |
C. Comparisons in the 3 months pre- vs. 3 months post-CPOE implementation
| |||||
Variable | Pre-CPOE | Post-CPOE | Adjusted OR
a
or β
b
coefficient | 95% CI | P-value |
ICU mortality, N (%) | 52 (27.1) | 55 (23.0) | 0.83 | 0.5 - 1.5 | 0.55 |
Hospital mortality, N (%) | 74 (38.5) | 90 (37.7) | 1.04 | 0.6 - 1.8 | 0.90 |
Mechanical ventilation duration in days, mean ± SD | 8.0 ± 9.9 | 6.1 ± 8.0 | -1.49 | -3.2 - 0.2 | 0.09 |
ICU LOS in days, mean ± SD | 9.2 ± 11.2 | 6.9 ± 8.4 | -1.77 | -3.6 - 0.1 | 0.06 |
Hospital LOS in days, mean ± SD | 41.2 ± 53.9 | 41.1 ± 53.1 | 1.21 | -10.4 - 12.8 | 0.84 |
D. Comparisons in the 1 month pre- vs. 1 month post-CPOE implementation
| |||||
Variable | Pre-CPOE | Post-CPOE | Adjusted OR
a
or β
b
coefficient | 95% CI | P-value |
ICU mortality, N (%) | 16 (23.2) | 16 (21.3) | 1.17 | 0.4 - 3.2 | 0.77 |
Hospital mortality, N (%) | 24 (34.8) | 28 (37.3) | 2.10 | 0.8 - 5.5 | 0.14 |
Mechanical ventilation duration in days, mean ± SD | 8.3 ± 9.8 | 5.8 ± 9.8 | -2.74 | -5.4 - (-0.1) | 0.04 |
ICU LOS in days, mean ± SD | 9.1 ± 10.0 | 6.5 ± 6.7 | -2.52 | -5.3 - 0.3 | 0.08 |
Hospital LOS in days, mean ± SD | 39.0 ± 45.9 | 41.2 ± 55.1 | -1.28 | -19.2 - 16.6 | 0.89 |
Outcomes of patient subgroups according to CPOE status
Variable | Pre-CPOE No. (%) | Post-CPOE No. (%) | Adjusted ORa or βb coefficient | 95% CI | P value |
---|---|---|---|---|---|
A. patients in the age group 12-17 years, N = 129
| |||||
ICU mortality, No.% | 9 (11) | 5 (10.6) | 0.78 | 0.1 - 4.1 | 0.77 |
Hospital mortality, No.% | 14 (17.1) | 7 (14.9) | 0.93 | 0.3 - 3.2 | 0.90 |
Mechanical ventilation duration in days, mean ± SD | 7.7 ± 7.2 | 6.3 ± 9.0 | -0.19 | -3.2 - 2.8 | 0.90 |
ICU LOS in days, mean ± SD | 8.2 ± 7.2 | 8.6 ± 17.0 | 2.41 | -2.6 - 7.4 | 0.34 |
Hospital LOS in days, mean ± SD | 42.8 ± 59.4 | 31.6 ± 44.1 | -6.70 | -30.8 - 17.4 | 0.58 |
B. Admission diagnosis of sepsis, N = 638
| |||||
ICU mortality, No.% | 152 (39) | 96 (40.3) | 1.09 | 0.7 - 1.7 | 0.70 |
Hospital mortality, No.% | 230 (59) | 141 (59.2) | 1.01 | 0.7 - 1.6 | 0.96 |
Mechanical ventilation duration in days, mean ± SD | 8.4 ± 10.6 | 7.3 ± 8.1 | -1.62 | -3.3 - 0.1 | 0.06 |
ICU LOS in days, mean ± SD | 9.4 ± 10.7 | 8.4 ± 8.7 | -1.41 | -3.2 - 0.4 | 0.13 |
Hospital LOS in days, mean ± SD | 40.7 ± 75.6 | 50.1 ± 125 | 13.07 | -5.2 - 31.3 | 0.16 |
C. Traumatic brain injury, N = 322
| |||||
ICU mortality, No.% | 34 (14.5) | 6 (6.7) | 0.53 | 0.1 - 1.1 | 0.06 |
Hospital mortality, No.% | 44 (19) | 10 (11.1) | 0.62 | 0.3 - 1.5 | 0.28 |
Mechanical ventilation duration in days, mean ± SD | 10.7 ± 7.9 | 9.8 ± 9.6 | -0.69 | -2.7 - 1.3 | 0.50 |
ICU LOS in days, mean ± SD | 11.2 ± 8.2 | 12.8 ± 15.1 | 2.24 | -0.3 - 4.8 | 0.09 |
Hospital LOS in days, mean ± SD | 72.2 ± 118.7 | 72.2 ± 82.2 | 13.7 | -14.2 - 41.6 | 0.33 |
D. APACHE II > 23, N = 1065
| |||||
ICU mortality, No.% | 256 (35.6) | 121 (35) | 1.03 | 0.8 - 1.4 | 0.87 |
Hospital mortality, No.% | 419 (58.3) | 197 (56.9) | 1.00 | 0.7 - 1.3 | 1.00 |
Mechanical ventilation duration in days, mean ± SD | 10.1 ± 10.9 | 10.4 ± 14.1 | 0.02 | -1.5 - 1.5 | 0.98 |
ICU LOS in days, mean ± SD | 10.9 ± 11.3 | 11.7 ± 14.8 | 0.38 | -1.2 - 2.0 | 0.64 |
Hospital LOS in days, mean ± SD | 49.6 ± 88.2 | 52.2 ± 110.8 | 5.02 | -7.2 - 17.3 | 0.42 |
Discussion
Conclusions
Key messages
-
Implementation of Computerized physician order entry (CPOE) was found to be associated with no significant changes in morbidity and mortality of critically ill patients in the immediate period and up to 12 months afterwards.
-
These findings were also seen in four high risk groups of patients: age 12-17 years, traumatic brain injury, diagnosis of sepsis on admission and admission APACHE II ≥ 23.
-
CPOE effectiveness in the ICU may require ICU-specific reengineering and customization to achieve the goal of mortality reduction.