Impact of Patient-Controlled Analgesia (PCA) Smart Pump-Electronic Health Record (EHR) Interoperability with Auto-Documentation on Chart Completion in a Community Hospital Setting

INTRODUCTION: Complete and accurate documentation of opioids administered by patient-controlled analgesia (PCA) pumps is critical for ensuring a high-quality medication record and an accurate conversion of the intravenous (IV) regimen to oral therapy. Incomplete charting of PCA usage through a manual process may be associated with fragmented documentation of delivered therapy affecting the completeness of the medical record and the IV to oral dose conversion. This study is the first to evaluate the association between auto-documentation of opioid administration provided by PCA smart pump—electronic health record (EHR) interoperability and the completion of PCA opioid administration charting tasks. METHODS: This retrospective cohort study was conducted at Lancaster General Hospital, Lancaster, Pennsylvania. Patients were assigned to pre-auto-documentation (n = 55) or post-auto-documentation groups (n = 58) based on whether they received PCA therapy prior to or after PCA-EHR interoperability was implemented. Charting of PCA therapy included documentation of the number of patient attempts, number of doses given, and total volume infused for both pre- and post-auto-documentation groups. In addition, total dose delivered was documented for the post-auto-documentation group. The overall chart-field completion rate was evaluated as the primary outcome. Individual chart completion percentages were assessed by stratified groups as secondary outcomes. RESULTS: PCA smart pump—EHR interoperability with auto-documentation was associated with an increase in overall chart-field completion rate from 69.9 to 97.0% (p < 0.001). Auto-documentation was also associated with an increase in fully completed charts from 38 to 91% (139.3% increase, p < 0.001) and reductions of incomplete records in each stratified group (p < 0.001). CONCLUSIONS: PCA smart pump—EHR interoperability with auto-documentation is associated with significant improvements in the completion of opioid administration chart-fields. Improved documentation of PCA administered opioids may have implications for the safety of opioid administration. Additional studies will be needed to assess the potential clinical impact of these results. FUNDING: ICU Medical, Inc.