Computer Tool Cuts Medication Errors in ACS Patients on Dialysis

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NEW ORLEANS—New data demonstrate that a computer-assisted decision support (CADS) tool can significantly reduce the number of medication errors and adverse events, particular major bleeding, that occur in patients with acute coronary syndromes (ACS) who require dialysis.

The results, released at the 60th Annual Scientific Session of the American College of Cardiology, show that 17% of ACS patients on dialysis received a contraindicated antithrombotic medication when their unstable angina or acute myocardial infarction was managed by standard pre-printed, guideline-based orders versus 0% of patients who got CADS-generated orders. 

The study, from the John Ochsner Heart and Vascular Institute in New Orleans, also found that 63% of patients who received a contraindicated antithrombotic agent had in-hospital significant  bleeding compared with only 10% of patients who did not receive a contraindicated antithrombotic. 

Patients who got standard ACS orders were hospitalized for a mean of 9.1 days versus 4.8 days for patients who got CADS-generated orders.

“The significant decrease in major bleeding is very important since decreased bleeding helps patients avoid transfusions, shortens hospital stay, and has been shown in large studies of ACS patients to reduce mortality,” researcher Carl J. Lavie, MD, told Renal & Urology News.

“Importantly,” added Dr. Lavie, Professor of Medicine and Medical Director of the Cardiac Rehabilitation and Prevention Division and Director of the Stress Testing Laboratory, “our study was not sufficiently powered to demonstrate a mortality reduction; however, I am certain that we would have shown a mortality benefit had we included a much larger number of  patients.” 

As part of an initiative to optimize cardiovascular outcomes in ACS patients, the Ochsner investigators developed a CADS tool for use in ACS patients and tested its impact in 80 ACS patients with end-stage renal disease needing dialysis who presented consecutively to their institution over a recent two-year period.

Research has shown that medication errors are the eighth leading cause of death in the United States, accounting for more than 100,000 deaths each year, Dr. Lavie pointed out. Roughly 450,000 preventable medication-related adverse events occur annually at a cost of 4.5 billion dollars. Medication errors include adverse drug reactions due to inappropriately prescribed or administered drugs. Dialysis patients are known to be at increased risk of medication-related adverse events, he added. 

In the present study, admitting physicians had the option of using the standard pre-printed guideline-based orders or CADS-generated orders. The CADS system required entry of key clinical variables in order to calculate the patient's thrombolysis in myocardial infarction (TIMI) and bleeding risk and devise a therapy plan and drug dosing based on creatinine clearance and consensus guidelines. Specific recommendations were made for patients with severe renal dysfunction, cocaine-induced myocardial infarction, and patients with various levels of TIMI and bleeding risk.

“With the rapid growth in the number of patients with end-stage renal disease needing dialysis coupled with the high rate of ACS in these patients  as well as the high rate of medication errors in dialyzed ACS patients, it is increasingly important to find better ways to safeguard this population,” Dr. Lavie said. “Computer-assisted decision support tools have been successfully implemented for venous thromboembolism prevention, pulmonary embolism risk stratification, and anticoagulation management, and our results suggest a role for the CADS tool in ACS patients on dialysis.”

Finally, he cautioned that the data are from a small study conducted at a single institution. Also, patients were not prospectively randomized to CADS-generated versus standard ACS orders. Study findings were presented by Sylvia Oleck, MD; Richard Milani, MD, was the senior author.

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