Expanding into the wider healthcare community

First DataBank Europe’s (FDBE) clinical decision support is in daily use by thousands of healthcare professionals in GP practices, community pharmacies, hospitals and other healthcare environments. However, there are still certain areas within healthcare that could benefit from effective clinical decision support.

For example, consider what a difference clinical decision support software systems, tailored to the roles of the emergency services or care homes for the elderly, could make to assisting healthcare professionals in delivering improved patient safety and care.

Emergency services

One of the challenges facing the emergency services is how to treat patients at the scene of an incident, without immediate access to medical history and with limited access to drug information. Only conscious patients can offer a verbal history and this may not be accurate or comprehensive.

The emergency services face an additional challenge; where clinical decision support may be available on site, it is often not accessible to mobile professionals. These systems are also not tailored to the specific role of the emergency services professional.

Access to patient data and clinical decision support in the field has the potential to assist the emergency services in ensuring patient safety, by reducing the risk of medication errors at the scene.

Modern clinical IT systems with integrated clinical decision support are designed to automatically alert the user to potential risks, flagging up drug interactions, sensitivities, contraindications, precautions, warnings and duplications. If it were possible to access such a system on the move, it could help emergency services professionals tailor care to each patient, consider their medical history before administering treatment and enable medication to be administered more quickly.

When patients need to be admitted, emergency services staff would be better equipped to advise hospital staff on the condition and history of the patient.

Consider this scenario…

A paramedic is called to a scene where an elderly man has collapsed with chest pain, is conscious and having problems talking. He has been out walking around the shops alone and has been cared for by a passer by who called for an ambulance.

The paramedic is able to establish the patient’s name and address from the man’s identity card but the patient is unable to give details of his medical history. The paramedic suspects that he is having a heart attack and calls up the man’s electronic patient record via a handheld PDA. Before administering care he promptly checks the patient’s medical history. He can see that the patient had a heart attack just three months ago and that he had an allergic reaction to streptokinase which presented as a severe skin rash. The clinical decision support system flags up that the patient should not be given streptokinase again.

In this case, the paramedic consults the clinical decision support system to help him choose an appropriate alternative, given the patient’s recent history. The paramedic administers an alternative drug, alteplase, and the patient is also given high flow oxygen via a mask. In this instance, the patient is treated quickly and safely and a potentially dangerous contraindication is avoided.

Care homes

Another area where clinical decision support could play a crucial role is in care homes for the elderly, where the average resident may be taking five or more different medications. Drug distribution and metabolism within the body is affected by a number of physical changes and the ability of the body to break down medicines changes significantly with advancing age. This may lead to potential drug toxicity at doses which may be therapeutic in younger people and means that the elderly may be twice as likely to develop an adverse drug reaction as younger patients. Good medicines management is clearly even more important in a care home setting and it is generally the pharmacist who provides this essential support. Clinical decision support used at the point of prescribing and dispensing could help flag these potential adverse drug reactions and improve patient care and safety in the care home setting.

Consider this scenario…

An 83 year old care home resident is taking digoxin for a mild heart condition in addition to his anti-Parkinson drug regime and is cared for by a qualified nurse practitioner.

The resident has become generally disinterested and unresponsive recently and the nurse firstly confirms that no medication has been missed. In the hope of trying to understand what else could have affected him, she logs into his electronic patient record via the laptop in the nurses’ station. The system flags up that he had suffered from a period of depression four years ago. Depression in Parkinson’s patients can often be overlooked in the wake of other more obvious symptoms and this discovery prompts her into giving him a thorough assessment. She discovers that he is a little breathless and, becoming worried for his well being, searches his medicine cabinet.

She discovers a half empty bottle of St John’s wort and finds out that the resident’s son had read about herbal treatments for depression. Aware that his father had suffered from a period of depression, he had given the St John’s wort to him in the hope that it might help, rather than adding more drugs to his regime.

Consulting with the clinical decision support system, she is alarmed to discover that St John’s wort can interact adversely with digoxin, especially where the patient has a heart condition. She discusses her findings with the care home’s pharmacist who checks the resident’s electronic patient record and prescribes citalopram into the resident’s regime. Within a couple of weeks, the resident is markedly less withdrawn and breathless and a potentially dangerous interaction with an over the counter remedy is removed.

Changing lives

These examples illustrate just how much clinical decision support could improve patient safety. The real tragedy is that there are still too many medication errors when there are electronic systems with integrated clinical decision support available here and now, which could prevent these errors and save lives. These systems have been used extensively and to great effect across the GP and community pharmacy sectors and in some hospitals but are not used to quite the same extent in the emergency services or care homes yet.

The key to making the possibilities outlined in this article a reality is an increasingly joined up healthcare system. Standardisation of drug terminologies and the centralisation of electronic patient records can and will provide the foundations for effective clinical decision support throughout healthcare. The emergency services and the care home community are two of the groups set to benefit from these changes in the future.

There is massive potential to improve the quality of care as the next generation of clinical systems are developed and rolled out, and the extended application of clinical decision support is key to achieving this goal.