Lehigh Valley Med Ctr

A “Success Story” of the CDS Collaborative

“It works in MY head, why doesn’t everyone else get it”

I was invited on short notice to a meeting of the Neuroscience Division, who is attempting National Stroke Center designation.

On the initial evaluation, there were several RFI’s noted (Request for Improvement) that had to be addressed within 30 days. One of the issues was the use of anti-platlet meds within 24 hrs or tPA infusion.

When I met with the group, their initial solution was to create an rule that would pop when a provider ordered anti-platlet meds IF the patient had received tPA within the past 24 hrs. However, I knew that this was a complex rule that would include timing the tPA and designating the list of anti-platlet meds that would trigger the alert. Consequently, I also realized that we could not complete the rule within the required 30 days. I discussed this with the team, and suggested that we begin working on the rule, and they could report to the certifying body that work was being done; but that we should also look for other alternatives.

I began to run through the Five Rights of CDS and the worksheet in my head to try and determine where else we could leverage CDS to solve this issue.

Was there a way to identify these at risk patients before they received tPA? Could patients at risk for needing tPA be flagged on admission?

I ran through the Five Rights and realized that our system already presents a drug-drug interaction alert if anti-platelet meds were ordered and tPA had been charted. However, these DDI alerts are frequently over-ridden and do not explain why this is contraindicated, and thus another layer of decision support would be needed.

My next thought along the continuum of care was at the nursing care level. If Nursing was made aware and reminded not to administer anti-platelet meds if the pt had received tPA within 24 hrs, that could augment the DDI that the provider already sees. The group discussed the possibility and we decided on adding a pre-selected order that would reside in the tPA order set, that would be a Nursing reminder order regarding the interaction. Because the order was part of the tPA orders, and already pre-selected, there would be no extra clicks for the ordering provider, and the reminder order would appear on the electronic nusing kardex for the following 24 hrs.

Everyone was in agreement that these measures, along with the rule (when developed) would provide appropriate protection for the patient.

I was excited that I used the CDS tools as described by the Collaborative to resolve this issue. My only frustration was that I did not have the opportunity to fully share my though process and transfer the knowledge (and utility) of the CDS Tools such as the Five Rights and the worsheet. As someone who “gets it,” – it was easy for me to deliver the fish to this group. Finding the appropriate venue to “teach them to fish for themselves,” remains an ongoing challenge of this work.

Donald Levick, M.D., MBA, FHIMSS

Chief Medical Information Officer

Lehigh Valley Health Network