Persistence of PRN Conscious Sedation Orders in Inpatients Following Interventional Radiology Procedures and Usage of an Automatic Discontinuation Policy

From the 2018 HVPAA National Conference

Derek McCleaf (Presence Health System), Michael Hamblin (Presence Health System)

Background

This study describes the widespread safety risk produced by procedural sedation medications ordered in a PRN fashion.  These orders remained active within the patient’s EHR beyond the duration of services, representing a significant risk for an adverse event.

Objectives

Current literature notes that rapid implementation of electronic health records (EHR) has resulted in medication orders persisting beyond their therapeutic need. This study evaluated the persistence of PRN sedation medication orders following inpatient interventional radiology procedures occurring at a single site over two years. This study then evaluated the efficacy of a timed automatic discontinuation mechanism to reduce the persistence of the medication orders.

Methods

Inpatient-only procedures (n=75) were analyzed to determine the baseline length of time PRN sedation orders persisted following procedure completion. After implementing a time-dependent automatic discontinuation mechanism, a second cohort of procedures (n=75) was analyzed to assess for changes in exposure time due to this policy change.

Results

At baseline, PRN sedation medication orders were active in the inpatient EHR an average of 12.4 hours following the end of the procedure. Ordering physicians manually discontinued only 19% of the PRN orders they had placed. Usage of an automatic discontinuation mechanism reduced this time to 2.0 hours and increased the total discontinuation rate to 84%.

Conclusion

Sedation orders from inpatient IR services persist beyond the procedural time, posing a significant risk for an adverse medication administration. This persistence is primarily due to the lack of safety controls within the EHR and the baseline low level of physician manual discontinuation. An automatic discontinuation mechanism in PRN orders is a low-cost, high-value intervention to improve the safety of IR procedures.

Implications for the Patient

With regard to procedural sedation orders, current literature lacks consensus guidelines to direct standardized, safe practices.  This study demonstrates the degree of safety risk posed by PRN medications, as well as demonstrating the efficacy of an engineering-based solution utilizing time dependent auto expiration.