management systems on physician drug ordering have not been previously studied. Importance Replacement of manual systems with computerized systems has occurred throughout the health care industry, sometimes with important unforeseen consequences.1-4 Supplementation of the traditional central hospital pharmacy with computerized ED automated medication management systems is a widespread phenomenon that may also have unsuspected consequences. The establishment of such a system creates 2 tiers of ED drugs: those readily obtainable through the ED automated medication management system and those that must be obtained from outside the ED, usually from a central hospital pharmacy. Obtaining drugs from the central hospital pharmacy rather than from an ED automated medication management system typically takes more time because of increased physical distance
INTRODUCTION
Background An important goal in modern emergency medicine care is to treat patients rapidly, as well as safely and effectively. One aspect of this care is rapid administration of ordered drugs. Many emergency departments (EDs) maintain a limited ED-based drug inventory, allowing rapid dispensing and administration of selected drugs. These drugs are usually selected according to such considerations as frequency of use, storage and compounding considerations, and the urgency with which they are needed. Other drugs require delivery from a hospital’s central pharmacy. Many EDs now use computerized ED-based automated medication management systems to store and manage their ED-based drug inventories. The effects of ED automated medication 414 Annals of Emergency Medicine
Volume , . : October
Conners & Hays
Editor’s Capsule Summary
Emergency Department Drug Orders drug inventories are selected from the hospital formulary by ED-based pharmacists to reflect the needs of a particular region of the ED (eg, pediatrics, trauma). Drugs included in any station were considered available from the ED automated medication management system. Data analyzed included drugdispensing dates and source from which drug orders were actually filled (ED automated medication management system or central hospital pharmacy). Drug ordering procedures were identical whether or not the drug was stored in the ED automated medication management system. Drug preparations were considered eligible for the study if they were available to ED patients from the central hospital pharmacy but not the ED automated medication management system for at least 3 months, and then were available from the central hospital pharmacy and the ED automated medication management system for at least 12 months, all from January 2002 to December 2005. Drugs directly affected by changes in hospital prescribing policy changes or internal prescribing guidelines were excluded from analysis. Drug orders that did not result in the drug’s being dispensed (ie, cancelled orders) were not included in this analysis. Outcome Measures and Primary Data Analysis For all drug preparations meeting study criteria, we calculated the “pre-ED automated medication management system rates” with which they were ordered in either the 12 months preceding inclusion into the ED automated medication management system or, if that period was less than 12 months, the period in which they were available to ED patients. These rates were calculated by dividing the number of times a drug preparation had been ordered for any ED patient by the number of months in the period. We similarly calculated “postED automated medication management system rates” for the 12 months after each drug preparation’s introduction into the ED automated medication management system. Dividing the postED automated medication management system rate by the preED automated medication management system rate yielded a rate ratio describing the change in relative order frequency associated with inclusion of the drug preparation in the ED automated medication management system. Using the conditional exact binomial test, we also calculated 95% confidence intervals for each rate ratio by using StatsDirect statistical software (StatsDirect, Ltd, Cheshire, UK). Drugs available from the ED automated medication management system were also available through the hospital central pharmacy. We calculated the frequency with which orders for study drugs were actually filled from the ED automated medication management system (rather than the hospital central pharmacy). We then calculated the Spearman’s correlation coefficient between these frequencies and the previously calculated rate ratios5 to determine the extent to which changes in frequency of drug ordering after inclusion in the ED automated medication management system were correlated with the site from which the drug order was actually filled.