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Bogale TN, Derseh L, Abraham L, Willems H, Metzger J, Abere B, Tilaye M, Hailegeberel T, Bekele TA. Effect of electronic records on mortality among patients in hospital and primary healthcare settings: a systematic review and meta-analyses. Front Digit Health 2024; 6:1377826. [PMID: 38988733 PMCID: PMC11233798 DOI: 10.3389/fdgth.2024.1377826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 06/13/2024] [Indexed: 07/12/2024] Open
Abstract
Background Electronic medical records or electronic health records, collectively called electronic records, have significantly transformed the healthcare system and service provision in our world. Despite a number of primary studies on the subject, reports are inconsistent and contradictory about the effects of electronic records on mortality. Therefore, this review examined the effect of electronic records on mortality. Methods The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline. Six databases: PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and Google Scholar, were searched from February 20 to October 25, 2023. Studies that assessed the effect of electronic records on mortality and were published between 1998 and 2022 were included. Joanna Briggs Institute quality appraisal tool was used to assess the methodological quality of the studies. Narrative synthesis was performed to identify patterns across studies. Meta-analysis was conducted using fixed effect and random-effects models to estimate the pooled effect of electronic records on mortality. Funnel plot and Egger's regression test were used to assess for publication bias. Results Fifty-four papers were found eligible for the systematic review, of which 42 were included in the meta-analyses. Of the 32 studies that assessed the effect of electronic health record on mortality, eight (25.00%) reported a statistically significant reduction in mortality, 22 (68.75%) did not show a statistically significant difference, and two (6.25%) studies reported an increased risk of mortality. Similarly, among the 22 studies that determined the effect of electronic medical record on mortality, 12 (54.55%) reported a statistically significant reduction in mortality, and ten (45.45%) studies didn't show a statistically significant difference. The fixed effect and random effects on mortality were OR = 0.95 (95% CI: 0.93-0.97) and OR = 0.94 (95% CI: 0.89-0.99), respectively. The associated I-squared was 61.5%. Statistical tests indicated that there was no significant publication bias among the studies included in the meta-analysis. Conclusion Despite some heterogeneity among the studies, the review indicated that the implementation of electronic records in inpatient, specialized and intensive care units, and primary healthcare facilities seems to result in a statistically significant reduction in mortality. Maturity level and specific features may have played important roles. Systematic Review Registration PROSPERO (CRD42023437257).
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Affiliation(s)
| | | | - Loko Abraham
- John Snow Research and Training Institute, Inc. (JSI), Addis Ababa, Ethiopia
| | - Herman Willems
- John Snow Research and Training Institute, Inc. (JSI), Boston, MA, United States
| | - Jonathan Metzger
- John Snow Research and Training Institute, Inc. (JSI), Washington, DC, United States
| | - Biruhtesfa Abere
- John Snow Research and Training Institute, Inc. (JSI), Addis Ababa, Ethiopia
| | - Mesfin Tilaye
- United State Agency for International Development, Addis Ababa, Ethiopia
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Pichardo-Lowden AR, Haidet P, Umpierrez GE, Lehman EB, Quigley FT, Wang L, Rafferty CM, DeFlitch CJ, Chinchilli VM. Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay. Diabetes Care 2022; 45:2526-2534. [PMID: 36084251 PMCID: PMC9679255 DOI: 10.2337/dc21-0829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Paul Haidet
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Humanities and the Woodward Center for Excellence in Health Sciences Education, Penn State College of Medicine, Hershey, PA
| | | | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Francis T. Quigley
- Department of Medicine, Penn State Health St. Joseph Medical Center, Reading, PA
| | - Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Colleen M. Rafferty
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Christopher J. DeFlitch
- Department of Emergency Medicine, Office of the Chief Medical Information Officer, Penn State Health, Hershey, PA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Mathioudakis N, Aboabdo M, Abusamaan MS, Yuan C, Lewis Boyer L, Pilla SJ, Johnson E, Desai S, Knight A, Greene P, Golden SH. Stakeholder Perspectives on an Inpatient Hypoglycemia Informatics Alert: Mixed Methods Study. JMIR Hum Factors 2021; 8:e31214. [PMID: 34842544 PMCID: PMC8665392 DOI: 10.2196/31214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 12/25/2022] Open
Abstract
Background Iatrogenic hypoglycemia is a common occurrence among hospitalized patients and is associated with poor clinical outcomes and increased mortality. Clinical decision support systems can be used to reduce the incidence of this potentially avoidable adverse event. Objective This study aims to determine the desired features and functionality of a real-time informatics alert to prevent iatrogenic hypoglycemia in a hospital setting. Methods Using the Agency for Healthcare Research and Quality Five Rights of Effective Clinical Decision Support Framework, we conducted a mixed methods study using an electronic survey and focus group sessions of hospital-based providers. The goal was to elicit stakeholder input to inform the future development of a real-time informatics alert to target iatrogenic hypoglycemia. In addition to perceptions about the importance of the problem and existing barriers, we sought input regarding the content, format, channel, timing, and recipient for the alert (ie, the Five Rights). Thematic analysis of focus group sessions was conducted using deductive and inductive approaches. Results A 21-item electronic survey was completed by 102 inpatient-based providers, followed by 2 focus group sessions (6 providers per session). Respondents universally agreed or strongly agreed that inpatient iatrogenic hypoglycemia is an important problem that can be addressed with an informatics alert. Stakeholders expressed a preference for an alert that is nonintrusive, accurate, communicated in near real time to the ordering provider, and provides actionable treatment recommendations. Several electronic medical record tools, including alert indicators in the patient header, glucose management report, and laboratory results section, were deemed acceptable formats for consideration. Concerns regarding alert fatigue were prevalent among both survey respondents and focus group participants. Conclusions The design preferences identified in this study will provide the framework needed for an informatics team to develop a prototype alert for pilot testing and evaluation. This alert will help meet the needs of hospital-based clinicians caring for patients with diabetes who are at a high risk of treatment-related hypoglycemia.
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Affiliation(s)
- Nestoras Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Moeen Aboabdo
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Christina Yuan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - LaPricia Lewis Boyer
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Scott J Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Erica Johnson
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
| | - Sanjay Desai
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Amy Knight
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
| | - Peter Greene
- Department of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Sherita H Golden
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
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Kyi M, Wraight PR, Rowan LM, Marley KA, Colman PG, Fourlanos S. Glucose alert system improves health professional responses to adverse glycaemia and reduces the number of hyperglycaemic episodes in non-critical care inpatients. Diabet Med 2018; 35:816-823. [PMID: 29575134 DOI: 10.1111/dme.13623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 12/12/2022]
Abstract
AIM To investigate the effect of a novel glucose alert system, comprising the Melbourne Glucose Alert Pathway and glucose-alert-capable networked blood glucose meters, on nursing and hospital medical officer responses to adverse glycaemia. METHODS A prospective, pre- and post-observational study was undertaken in non-critical care wards of a tertiary hospital over 4 months (n=148 or 660 patient-days). The intervention consisted of two components designed to promote a consistent staff response to blood glucose measurements: (1) a clinical escalation pathway, the Melbourne Glucose Alert Pathway, and (2) networked blood glucose meters, which provide a visual alert for out-of-range blood glucose measurement. All consecutive inpatients with diabetes were assessed for diabetes management and capillary blood glucose. The primary outcome was documented nursing and medical staff action in response to episodes of adverse glycaemia (blood glucose >15 mmol/l or <4 mmol/l). Secondary outcomes consisted of glycaemic measures. RESULTS In response to episodes of adverse glycaemia, nursing action increased (proportion with nursing action: 45% to 73%; P<0.001), and medical action increased (proportion with medical action: 49% to 67%; P=0.011) with the glucose alert system in place. Patient-days with hyperglycaemia (any blood glucose value >15 mmol/l: 24% vs 16%; P=0.012) and patient-days with mean blood glucose >15 mmol/l (7.4% vs 2.6%; P=0.005) decreased. There was no difference in hypoglycaemia incidence. CONCLUSIONS Use of a novel glucose alert system improved health professional responses to adverse glycaemia and decreased hyperglycaemia in the hospital setting.
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Affiliation(s)
- M Kyi
- Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Departments of General Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Departments of Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - P R Wraight
- Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - L M Rowan
- Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - K A Marley
- Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - P G Colman
- Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - S Fourlanos
- Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Departments of General Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Varghese J, Kleine M, Gessner SI, Sandmann S, Dugas M. Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review. J Am Med Inform Assoc 2018; 25:593-602. [PMID: 29036406 PMCID: PMC7646949 DOI: 10.1093/jamia/ocx100] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/10/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023] Open
Abstract
Objectives To systematically classify the clinical impact of computerized clinical decision support systems (CDSSs) in inpatient care. Materials and Methods Medline, Cochrane Trials, and Cochrane Reviews were searched for CDSS studies that assessed patient outcomes in inpatient settings. For each study, 2 physicians independently mapped patient outcome effects to a predefined medical effect score to assess the clinical impact of reported outcome effects. Disagreements were measured by using weighted kappa and solved by consensus. An example set of promising disease entities was generated based on medical effect scores and risk of bias assessment. To summarize technical characteristics of the systems, reported input variables and algorithm types were extracted as well. Results Seventy studies were included. Five (7%) reported reduced mortality, 16 (23%) reduced life-threatening events, and 28 (40%) reduced non-life-threatening events, 20 (29%) had no significant impact on patient outcomes, and 1 showed a negative effect (weighted κ: 0.72, P < .001). Six of 24 disease entity settings showed high effect scores with medium or low risk of bias: blood glucose management, blood transfusion management, physiologic deterioration prevention, pressure ulcer prevention, acute kidney injury prevention, and venous thromboembolism prophylaxis. Most of the implemented algorithms (72%) were rule-based. Reported input variables are shared as standardized models on a metadata repository. Discussion and Conclusion Most of the included CDSS studies were associated with positive patient outcomes effects but with substantial differences regarding the clinical impact. A subset of 6 disease entities could be filtered in which CDSS should be given special consideration at sites where computer-assisted decision-making is deemed to be underutilized. Registration number on PROSPERO: CRD42016049946.
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Affiliation(s)
- Julian Varghese
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Maren Kleine
- Bioinformatics/Medical Informatics Department, Bielefeld University, Bielefeld, Germany
| | | | - Sarah Sandmann
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Martin Dugas
- Institute of Medical Informatics, University of Münster, Münster, Germany
- Institute of Medical Informatics, European Research Center for Information Systems (ERCIS), Münster, Germany
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Lachance P, Villeneuve PM, Rewa OG, Wilson FP, Selby NM, Featherstone RM, Bagshaw SM. Association between e-alert implementation for detection of acute kidney injury and outcomes: a systematic review. Nephrol Dial Transplant 2017; 32:265-272. [PMID: 28088774 DOI: 10.1093/ndt/gfw424] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 10/28/2016] [Indexed: 01/18/2023] Open
Abstract
Background Electronic alerts (e-alerts) for acute kidney injury (AKI) in hospitalized patients are increasingly being implemented; however, their impact on outcomes remains uncertain. Methods We performed a systematic review. Electronic databases and grey literature were searched for original studies published between 1990 and 2016. Randomized, quasi-randomized, observational and before-and-after studies that included hospitalized patients, implemented e-alerts for AKI and described their impact on one of care processes, patient-centred outcomes or resource utilization measures were included. Results Our search yielded six studies ( n = 10 165 patients). E-alerts were generally automated, triggered through electronic health records and not linked to clinical decision support. In pooled analysis, e-alerts did not improve mortality [odds ratio (OR) 1.05; 95% confidence intervals (CI), 0.84-1.31; n = 3 studies; n = 3425 patients; I 2 = 0%] or reduce renal replacement therapy (RRT) use (OR 1.20; 95% CI, 0.91-1.57; n = 2 studies; n = 3236 patients; I 2 = 0%). Isolated studies reported improvements in selected care processes. Pooled analysis found no significant differences in prescribed fluid therapy. Conclusions In the available studies, e-alerts for AKI do not improve survival or reduce RRT utilization. The impact of e-alerts on processes of care was variable. Additional research is needed to understand those aspects of e-alerts that are most likely to improve care processes and outcomes.
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Affiliation(s)
- Philippe Lachance
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Pierre-Marc Villeneuve
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Francis P Wilson
- Section Nephrology, Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT, USA.,Veterans Affairs Health Center, West Haven, CT, USA
| | - Nicholas M Selby
- Division of Medical Sciences and Graduate Entry Medicine, Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
| | - Robin M Featherstone
- Department of Paediatrics, Faculty of Medicine and Dentistry, Alberta Research Center for Health Evidence (ARCHE), University of Alberta, Edmonton, AB, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
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Fedosov V, Dziadzko M, Dearani JA, Brown DR, Pickering BW, Herasevich V. Decision Support Tool to Improve Glucose Control Compliance After Cardiac Surgery. AACN Adv Crit Care 2017; 27:274-282. [PMID: 27959310 DOI: 10.4037/aacnacc2016634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hyperglycemia control is associated with improved outcomes in patients undergoing cardiac surgery. The Surgical Care Improvement Project metric (SCIP-inf-4) was introduced as a performance measure in surgical patients and included hyperglycemia control. Compliance with the SCIP-inf-4 metric remains suboptimal. A novel real-time decision support tool (DST) with guaranteed feedback that is based on the existing electronic medical record system was developed at a tertiary academic center. Implementation of the DST increased the compliance rate with the SCIP-inf-4 from 87.3% to 96.5%. Changes in tested clinical outcomes were not observed with improved metric compliance. This new framework can serve as a backbone for development of quality control processes for other metrics. Further and, ideally, multicenter studies are required to test if implementation of electronic DSTs will translate into improved resource utilization and outcomes for patients.
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Affiliation(s)
- Vitali Fedosov
- Vitali Fedosov is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Mikhail Dziadzko is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Joseph A. Dearani is Professor of Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Daniel R. Brown is Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Brian W. Pickering is Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Vitaly Herasevich is Associate Professor of Anesthesiology and Medicine, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Mikhail Dziadzko
- Vitali Fedosov is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Mikhail Dziadzko is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Joseph A. Dearani is Professor of Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Daniel R. Brown is Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Brian W. Pickering is Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Vitaly Herasevich is Associate Professor of Anesthesiology and Medicine, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Joseph A Dearani
- Vitali Fedosov is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Mikhail Dziadzko is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Joseph A. Dearani is Professor of Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Daniel R. Brown is Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Brian W. Pickering is Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Vitaly Herasevich is Associate Professor of Anesthesiology and Medicine, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Daniel R Brown
- Vitali Fedosov is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Mikhail Dziadzko is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Joseph A. Dearani is Professor of Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Daniel R. Brown is Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Brian W. Pickering is Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Vitaly Herasevich is Associate Professor of Anesthesiology and Medicine, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Brian W Pickering
- Vitali Fedosov is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Mikhail Dziadzko is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Joseph A. Dearani is Professor of Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Daniel R. Brown is Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Brian W. Pickering is Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Vitaly Herasevich is Associate Professor of Anesthesiology and Medicine, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Vitaly Herasevich
- Vitali Fedosov is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Mikhail Dziadzko is Research Fellow, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Joseph A. Dearani is Professor of Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Daniel R. Brown is Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Brian W. Pickering is Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Vitaly Herasevich is Associate Professor of Anesthesiology and Medicine, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
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Fisch MJ, Chung AE, Accordino MK. Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records. Am Soc Clin Oncol Educ Book 2017; 35:200-8. [PMID: 27249700 DOI: 10.1200/edbk_156682] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Digital engagement has become pervasive in the delivery of cancer care. Internet- and cellular phone-based tools and systems are allowing large groups of people to engage with each other and share information. Health systems and individual health professionals are adapting to this revolution in consumer and patient behavior by developing ways to incorporate the benefits of technology for the purpose of improving the quality of medical care. One example is the use of social media platforms by oncologists to foster interaction with each other and to participate with the lay public in dialogue about science, medicine, and cancer care. In addition, consumer devices and sensors (wearables) have provided a new, growing dimension of digital engagement and another layer of patient-generated health data to foster better care and research. Finally, electronic health records have become the new standard for oncology care delivery, bringing new opportunities to measure quality in real time and follow practice patterns, as well as new challenges as providers and patients seek ways to integrate this technology along with other forms of digital engagement to produce more satisfaction in the process of care along with measurably better outcomes.
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Affiliation(s)
- Michael J Fisch
- From AIM Specialty Health, Chicago, IL; Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC; Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Arlene E Chung
- From AIM Specialty Health, Chicago, IL; Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC; Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Melissa K Accordino
- From AIM Specialty Health, Chicago, IL; Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC; Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
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Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis. Crit Care Med 2015; 43:1276-82. [PMID: 25756413 DOI: 10.1097/ccm.0000000000000948] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate effects of health information technology in the inpatient and ICU on mortality, length of stay, and cost. Methodical evaluation of the impact of health information technology on outcomes is essential for institutions to make informed decisions regarding implementation. DATA SOURCES EMBASE, Scopus, Medline, the Cochrane Review database, and Web of Science were searched from database inception through July 2013. Manual review of references of identified articles was also completed. STUDY SELECTION Selection criteria included a health information technology intervention such as computerized physician order entry, clinical decision support systems, and surveillance systems, an inpatient setting, and endpoints of mortality, length of stay, or cost. Studies were screened by three reviewers. Of the 2,803 studies screened, 45 met selection criteria (1.6%). DATA EXTRACTION Data were abstracted on the year, design, intervention type, system used, comparator, sample sizes, and effect on outcomes. Studies were abstracted independently by three reviewers. DATA SYNTHESIS There was a significant effect of surveillance systems on in-hospital mortality (odds ratio, 0.85; 95% CI, 0.76-0.94; I=59%). All other quantitative analyses of health information technology interventions effect on mortality and length of stay were not statistically significant. Cost was unable to be quantitatively evaluated. Qualitative synthesis of studies of each outcome demonstrated significant study heterogeneity and small clinical effects. CONCLUSIONS Electronic interventions were not shown to have a substantial effect on mortality, length of stay, or cost. This may be due to the small number of studies that were able to be aggregately analyzed due to the heterogeneity of study populations, interventions, and endpoints. Better evidence is needed to identify the most meaningful ways to implement and use health information technology and before a statement of the effect of these systems on patient outcomes can be made.
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Electronic alerts for triage protocol compliance among emergency department triage nurses: a randomized controlled trial. Nurs Res 2015; 64:226-30. [PMID: 25932701 DOI: 10.1097/nnr.0000000000000094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alerts embedded in electronic health records (EHRs) are designed to improve processes at the point of care. OBJECTIVE The aim of this study was to determine if an EHR alert-at emergency department (ED) triage-increases the ED triage nurse's utilization of triage protocols. METHODS ED triage nurses were randomized to receive either a passive EHR alert or no intervention for patients with the following complaints: minor trauma with extremity injuries or female patients with abdominal pain. The EHR alert notified the nurse that the patient was eligible for diagnostic testing: radiographs for patients with injured extremities or urinalysis for female patients with abdominal pain. RESULTS Twenty-eight nurses triaged 20,410 patients in the 6 months before the intervention and 19,157 in the 6 months after the intervention. Before the intervention, the urinalysis protocol was implemented in 101/624 (16.2%) patients triaged by the intervention group and 116/711 (16.3%) triaged by the control group. After the intervention, the urinalysis protocol was implemented in 146/530 (27.6%) patients triaged by the intervention group and 174/679 (25.6%) triaged by the control group. Before the intervention, the radiograph protocol was implemented in 58/774 (7.5%) patients triaged by the intervention group and 45/684 (6.6%) triaged by the control group. After the intervention, the radiograph protocol was implemented in 78/614 (12.7%) patients triaged by the intervention group and 79/609 (13.0%) triaged by the control group. CONCLUSION The use of a passive EHR alert to promote ED triage protocols showed little benefit. Before the widespread implementation of EHR alerts for patient care, rigorous studies are required to determine the best alert methods and the impacts of such interventions.
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Cheung A, van Velden FHP, Lagerburg V, Minderman N. The organizational and clinical impact of integrating bedside equipment to an information system: a systematic literature review of patient data management systems (PDMS). Int J Med Inform 2015; 84:155-65. [PMID: 25601332 DOI: 10.1016/j.ijmedinf.2014.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 09/30/2014] [Accepted: 12/28/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The introduction of an information system integrated to bedside equipment requires significant financial and resource investment; therefore understanding the potential impact is beneficial for decision-makers. However, no systematic literature reviews (SLRs) focus on this topic. This SLR aims to gather evidence on the impact of the aforementioned system, also known as a patient data management system (PDMS) on both organizational and clinical outcomes. MATERIALS AND METHODS A literature search was performed using the databases Medline/PubMed and CINHAL for English articles published between January 2000 and December 2012. A quality assessment was performed on articles deemed relevant for the SLR. RESULTS Eighteen articles were included in the SLR. Sixteen articles investigated the impact of a PDMS on the organizational outcomes, comprising descriptive, quantitative and qualitative studies. A PDMS was found to reduce the charting time, increase the time spent on direct patient care and reduce the occurrence of errors. Only two articles investigated the clinical impact of a PDMS. Both reported an improvement in clinical outcomes when a PDMS was integrated with a clinical decision support system (CDSS). CONCLUSIONS A PDMS has shown to offer many advantages in both the efficiency and the quality of care delivered to the patient. In addition, a PDMS integrated to a CDSS may improve clinical outcomes, although further studies are required for validation.
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Affiliation(s)
- Amy Cheung
- Department of Information, Communication and Medical Technology (ICMT), Catharina Hospital, PO Box 1350, 5602ZA Eindhoven, The Netherlands
| | - Floris H P van Velden
- Department of Information, Communication and Medical Technology (ICMT), Catharina Hospital, PO Box 1350, 5602ZA Eindhoven, The Netherlands; Department of Radiology & Nuclear Medicine, VU University Medical Center, PO Box 7057, 1007MB Amsterdam, The Netherlands.
| | - Vera Lagerburg
- Department of Information, Communication and Medical Technology (ICMT), Catharina Hospital, PO Box 1350, 5602ZA Eindhoven, The Netherlands
| | - Niels Minderman
- Department of, Medical Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands
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Colpaert K, Oeyen S, Sijnave B, Peleman R, Benoit D, Decruyenaere J. Influence of smart real-time electronic alerting on glucose control in critically ill patients. J Crit Care 2014; 30:216.e1-6. [PMID: 25194590 DOI: 10.1016/j.jcrc.2014.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/24/2014] [Accepted: 07/27/2014] [Indexed: 01/18/2023]
Abstract
PURPOSE Hyperglycemia and hypoglycemia are frequently encountered in critically ill patients and associated with adverse outcomes. We configured a smart glycemia alert (S-GLY alert) with our Intensive Care Information System to decrease the number of hyperglycemic values and increase the proportion of time within the glucose interval of 80 to 150 mg/dL. MATERIALS AND METHODS Prospective intervention study in surgical intensive care unit in a tertiary care hospital. An 11-week prealert phase was followed by a 15-week intervention phase where the S-GLY alert was alerting the nurses through the Clinical Notification System of the Intensive Care Information System. RESULTS Overall, 2335 S-GLY alerts were recorded. There were less hyperglycemic values and less persistent hyperglycemic episodes in the alert phase (19.5% vs 26.5% [P < .001] and 9.9% vs 15.4% [P < .001], respectively). More time was spent within target glucose interval (82.3% vs 75.0%, P = .009). A lower proportion of patients experienced a new-onset hypoglycemic event (<70 mg/dL) in the alert phase (9.2% vs 15.2%, P = .016). The Sequential Organ Failure Assessment score was significantly reduced (5.2 vs 4.2, P < .001). CONCLUSIONS The implementation of a real-time smart electronic glycemia alert resulted in significantly less episodes of persistent hyperglycemia and a higher proportion of time with normoglycemia, while decreasing the number of hypoglycemic events.
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Affiliation(s)
- Kirsten Colpaert
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium.
| | - Sandra Oeyen
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium.
| | - Bart Sijnave
- Department of Information Technology, Ghent University Hospital, Ghent, Belgium.
| | - Renaat Peleman
- Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Dominique Benoit
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium.
| | - Johan Decruyenaere
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium.
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Ghassemi MM, Richter SE, Eche IM, Chen TW, Danziger J, Celi LA. A data-driven approach to optimized medication dosing: a focus on heparin. Intensive Care Med 2014; 40:1332-9. [PMID: 25091788 DOI: 10.1007/s00134-014-3406-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/11/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE To demonstrate a novel method that utilizes retrospective data to develop statistically optimal dosing strategies for medications with sensitive therapeutic windows. We illustrate our approach on intravenous unfractionated heparin, a medication which typically considers only patient weight and is frequently misdosed. METHODS We identified available clinical features which impact patient response to heparin and extracted 1,511 patients from the multi-parameter intelligent monitoring in intensive care II database which met our inclusion criteria. These were used to develop two multivariate logistic regressions, modeling sub- and supra-therapeutic activated partial thromboplastin time (aPTT) as a function of clinical features. We combined information from these models to estimate an initial heparin dose that would, on a per-patient basis, maximize the probability of a therapeutic aPTT within 4-8 h of the initial infusion. We tested our model's ability to classifying therapeutic outcomes on a withheld dataset and compared performance to a weight-alone alternative using volume under surface (VUS) (a multiclass version of AUC). RESULTS We observed statistically significant associations between sub- and supra-therapeutic aPTT, race, ICU type, gender, heparin dose, age and Sequential Organ Failure Assessment scores with mean validation AUC of 0.78 and 0.79 respectively. Our final model improved outcome classification over the weight-alone alternative, with VUS values of 0.48 vs. 0.42. CONCLUSIONS This work represents an important step in the secondary use of health data in developing models to optimize drug dosing. The next step would be evaluating whether this approach indeed achieves target aPTT more reliably than the current weight-based heparin dosing in a randomized controlled trial.
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Affiliation(s)
- Mohammad M Ghassemi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, E25-505, 77 Massachusetts Ave, Cambridge, 02139, MA, USA,
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Hyperglycemia, hypoglycemia, and glycemic complexity are associated with worse outcomes after surgery. J Crit Care 2014; 29:611-7. [PMID: 24768531 DOI: 10.1016/j.jcrc.2014.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 02/26/2014] [Accepted: 03/10/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this study was to determine if glycemic complexity, along with hypoglycemia and hyperglycemia, was associated with worse outcomes after cardiac surgery. MATERIALS AND METHODS We conducted a retrospective analysis of 970 patients who had insulin infusions designed to keep blood glucose levels between 80 and 110 mg/dL. Glycemic complexity was calculated using jackknifed approximate entropy. Logistic regression was used to adjust for confounders. RESULTS A total of 495 patients (51%) developed complications, and 32 patients (3.3%) died. Along with older age, comorbidities, and complicated surgeries, any hypoglycemia (glucose<71 mg/dL) and the number of glucose values greater than 140 mg/dL were independent predictors of complications. Increased risk of mortality, after adjusting for other risk factors, was associated with older age, longer perfusion time, receiving intraoperative transfusions, and greater jackknifed approximate entropy of the glucose time series. CONCLUSION We found that hypoglycemia (glucose<71 mg/dL) and hyperglycemia (glucose>140 mg/dL) were associated with increased risk of complications, whereas greater complexity of the glucose time series was associated with mortality.
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Fillmore CL, Bray BE, Kawamoto K. Systematic review of clinical decision support interventions with potential for inpatient cost reduction. BMC Med Inform Decis Mak 2013; 13:135. [PMID: 24344752 PMCID: PMC3878492 DOI: 10.1186/1472-6947-13-135] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 12/04/2013] [Indexed: 11/21/2022] Open
Abstract
Background Healthcare costs are increasing rapidly and at an unsustainable rate in many countries, and inpatient hospitalizations are a significant driver of these costs. Clinical decision support (CDS) represents a promising approach to not only improve care but to reduce costs in the inpatient setting. The purpose of this study was to systematically review trials of CDS interventions with the potential to reduce inpatient costs, so as to identify promising interventions for more widespread implementation and to inform future research in this area. Methods To identify relevant studies, MEDLINE was searched up to July 2013. CDS intervention studies with the potential to reduce inpatient healthcare costs were identified through titles and abstracts, and full text articles were reviewed to make a final determination on inclusion. Relevant characteristics of the studies were extracted and summarized. Results Following a screening of 7,663 articles, 78 manuscripts were included. 78.2% of studies were controlled before-after studies, and 15.4% were randomized controlled trials. 53.8% of the studies were focused on pharmacotherapy. The majority of manuscripts were published during or after 2008. 70.5% of the studies resulted in statistically and clinically significant improvements in an explicit financial measure or a proxy financial measure. Only 12.8% of the studies directly measured the financial impact of an intervention, whereas the financial impact was inferred in the remainder of studies. Data on cost effectiveness was available for only one study. Conclusions Significantly more research is required on the impact of clinical decision support on inpatient costs. In particular, there is a remarkable gap in the availability of cost effectiveness studies required by policy makers and decision makers in healthcare systems.
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Affiliation(s)
- Christopher L Fillmore
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah 84112, USA.
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[Management of glycemia: an audit in 66 ICUs]. ACTA ACUST UNITED AC 2013; 32:84-8. [PMID: 23337340 DOI: 10.1016/j.annfar.2012.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 12/05/2012] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The interest of tight glucose control in ICU is still debated. In France, no data are available regarding this therapy and the implementation of its guidelines. STUDY DESIGN Sub-study of a one-day audit performed between January and May 2009. PATIENTS AND METHODS During a one-day audit performed in 66 ICUs, trained residents collected data regarding the presence of a formal glucose control protocol and its practical application. RESULTS A formalized glucose control protocol was found in 88% of patients. During the day before the audit, 3645 glycemia measurements were performed accounting for six measurements [4-9] per patient with a median higher value of 1.6 [1.4-2.1]. Hypoglycemia (<0.8 g/L) and hyperglycemia (>1.4 g/L in non-diabetic and >1.8 g/L in diabetic patients) were found in 81 (15%) and 326 (58%) patients respectively. Two episodes (0.36%) of severe hypoglycemia (<0.4 g/L) were reported. Factors associated with glucose control protocol application were: a high SOFA score, cardioversion, mechanical ventilation, intracranial pressure monitoring, steroid use and nurse to patient ratio less than 1/2.5. Hepatic failure was the only factor associated with hypoglycemia. DISCUSSION Glucose control protocols are available in more than 80% ICUs but their implementation is still imperfect. However, the median glycemia meets international current recommendations. Severe hypoglycemia is a very rare event in ICU.
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Nakamura M, Oda S, Sadahiro T, Watanabe E, Abe R, Nakada TA, Morita Y, Hirasawa H. Correlation between high blood IL-6 level, hyperglycemia, and glucose control in septic patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R58. [PMID: 22494810 PMCID: PMC3681387 DOI: 10.1186/cc11301] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/10/2012] [Accepted: 04/11/2012] [Indexed: 01/08/2023]
Abstract
Introduction The aim of the present study was to investigate the relationship between the blood IL-6 level, the blood glucose level, and glucose control in septic patients. Methods This retrospective observational study in a general ICU of a university hospital included a total of 153 patients with sepsis, severe sepsis, or septic shock who were admitted to the ICU between 2005 and 2010, stayed in the ICU for 7 days or longer, and did not receive steroid therapy prior to or after ICU admission. The severity of stress hyperglycemia, status of glucose control, and correlation between those two factors in these patients were investigated using the blood IL-6 level as an index of hypercytokinemia. Results A significant positive correlation between blood IL-6 level and blood glucose level on ICU admission was observed in the overall study population (n = 153; r = 0.24, P = 0.01), and was stronger in the nondiabetic subgroup (n = 112; r = 0.42, P < 0.01). The rate of successful glucose control (blood glucose level < 150 mg/dl maintained for 6 days or longer) decreased with increase in blood IL-6 level on ICU admission (P < 0.01). The blood IL-6 level after ICU admission remained significantly higher and the 60-day survival rate was significantly lower in the failed glucose control group than in the successful glucose control group (P < 0.01 and P < 0.01, respectively). Conclusions High blood IL-6 level was correlated with hyperglycemia and with difficulties in glucose control in septic patients. These results suggest the possibility that hypercytokinemia might be involved in the development of hyperglycemia in sepsis, and thereby might affect the success of glucose control.
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Affiliation(s)
- Masataka Nakamura
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana Chuo, Chiba-city 2608677, Japan.
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Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2011: I. Nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals. Intensive Care Med 2012; 38:192-209. [PMID: 22215044 PMCID: PMC3291847 DOI: 10.1007/s00134-011-2447-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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