Using an Electronic Clinical Decision Support System to Reduce the Risk of Epidural Hematoma

Abstract

Epidural hematoma is a major complication that can occur when neuraxial anesthesia is used concurrently with newer anticoagulation and antiplatelet medications. In complex hospital environments, the opportunity of performing a neuraxial procedure in an anticoagulated patient or starting potent anticoagulants on a patient with existing epidural catheter still exists. We describe a technique to use an electronic clinical decision support ordering system that helps reduce this risk of epidural hematoma. Through a series of automated warnings that bring to light existing anticoagulant or antiplatelet medications at the time of doing the procedure or a secondary warning system to those practitioners initiating anticoagulant medications on a patient with an existing epidural, we hope to reduce the number of medication errors. Before initiating the alert system, we had 26 events noted in the medical chart over a 3-month period. We noted only 11 events after the initiation of the new alert systems and clinical decision support in a similar 3-month period. Using electronic clinical decision support systems can help reduce medication errors related to neuraxial anesthesia and anticoagulation medications in a large hospital system.

Computerized decision support in adult and pediatric critical care

“…Ranson's criteria and various APACHE models are examples that have been validated using real time data to predict mortality risk in critically ill patients [29] . Alert support tools are used to improve workflow, warn practitioners of adverse drug reactions [19,30] , and to notify practitioners of potential adverse consequences of an ordered therapy, such as anticoagulation [31,32] . This type of system decreases reported patient complications from drug-drug interactions and adverse drug events in the ICU following implementation [19] .…”

“…Adult critical care Diagnostic DXplain [28] Mortality and length of stay prediction [9,29] Alert and reminder Ventilator induced lung injury [84] Blood pressure variability while on vasopressors [32] Adverse drug reactions [19] Drug induced thrombocytopenia [30] Epidural hematoma with neuraxial anesthesia [31] Protocol/procedure Acute respiratory distress syndrome [33][34][35] Sepsis [21] VTE prophylaxis and events in trauma patients [37] VTE prophylaxis [38,39] Tidal volume during mechanical ventilation [36] Management…”

The Role of Computerized Clinical Decision Support in Reducing Inappropriate Medication Administration During Epidural Therapy

“…9 To standardize ordering of epidural anesthesia orders, improve monitoring of patients, and decrease the risk of ADEs including bleeding complications, an electronic ordering module with clinical decision support was implemented in the CPOE at our institution. 12 This module includes recommendations to increase and streamline nursing orders for the monitoring of complications as well as warnings to prescribers about concomitant medications that increase risk of complications. Downstream alerts are displayed to other ordering providers when inappropriate medications are ordered after the original epidural orders were placed.…”