Computer decision support software safely improves glycemic control in the burn intensive care unit: a randomized controlled clinical study. J Burn Care Res. 2011;32:246-255. [PMID: 21240001 DOI: 10.1097/bcr.0b013e31820aaebf]

Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024

RATIONALE

Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods.

OBJECTIVES

The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians.

PANEL DESIGN

The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting.

METHODS

We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research.

RESULTS

This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available.

CONCLUSIONS

The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.

The effects of computerised decision support systems on nursing and allied health professional performance and patient outcomes: a systematic review and user contextualisation

Background

Computerised decision support systems (CDSS) are widely used by nurses and allied health professionals but their effect on clinical performance and patient outcomes is uncertain.

Objectives

Evaluate the effects of clinical decision support systems use on nurses', midwives' and allied health professionals' performance and patient outcomes and sense-check the results with developers and users.

Eligibility criteria

Comparative studies (randomised controlled trials (RCTs), non-randomised trials, controlled before-and-after (CBA) studies, interrupted time series (ITS) and repeated measures studies comparing) of CDSS versus usual care from nurses, midwives or other allied health professionals.

Information sources

Nineteen bibliographic databases searched October 2019 and February 2021.

Risk of bias

Assessed using structured risk of bias guidelines; almost all included studies were at high risk of bias.

Synthesis of results

Heterogeneity between interventions and outcomes necessitated narrative synthesis and grouping by: similarity in focus or CDSS-type, targeted health professionals, patient group, outcomes reported and study design.

Included studies

Of 36,106 initial records, 262 studies were assessed for eligibility, with 35 included: 28 RCTs (80%), 3 CBA studies (8.6%), 3 ITS (8.6%) and 1 non-randomised trial, a total of 1318 health professionals and 67,595 patient participants. Few studies were multi-site and most focused on decision-making by nurses (71%) or paramedics (5.7%). Standalone, computer-based CDSS featured in 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile or handheld technology. Care processes - including adherence to guidance - were positively influenced in 47% of the measures adopted. For example, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling, and documenting care were improved if they used CDSS. Patient care outcomes were statistically - if not always clinically - significantly improved in 40.7% of indicators. For example, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity, and accurate triaging were features of professionals using CDSS compared to those who were not.

Evidence limitations

Allied health professionals (AHPs) were underrepresented compared to nurses; systems, studies and outcomes were heterogeneous, preventing statistical aggregation; very wide confidence intervals around effects meant clinical significance was questionable; decision and implementation theory that would have helped interpret effects - including null effects - was largely absent; economic data were scant and diverse, preventing estimation of overall cost-effectiveness.

Interpretation

CDSS can positively influence selected aspects of nurses', midwives' and AHPs' performance and care outcomes. Comparative research is generally of low quality and outcomes wide ranging and heterogeneous. After more than a decade of synthesised research into CDSS in healthcare professions other than medicine, the effect on processes and outcomes remains uncertain. Higher-quality, theoretically informed, evaluative research that addresses the economics of CDSS development and implementation is still required.

Future work

Developing nursing CDSS and primary research evaluation.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in Health and Social Care Delivery Research; 2023. See the NIHR Journals Library website for further project information.

Registration

PROSPERO [number: CRD42019147773].

Effects of computerised clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes: a systematic review of experimental and observational studies

OBJECTIVE

Computerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals' performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this.

MATERIALS AND METHODS

The following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion.

RESULTS

A total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile/handheld-technology.

DISCUSSION

CDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness.

CONCLUSION

CDSS may have a positive impact on selected aspects of nurses' and AHPs' performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing.

Digital interventions to improve safety and quality of inpatient diabetes management: A systematic review

IMPORTANCE

Diabetes is common amongst hospitalised patients and contributes to increased length of stay and poorer outcomes. Digital transformation, particularly the implementation of electronic medical records (EMRs), is rapidly occurring across the healthcare sector and provides an opportunity to improve the safety and quality of inpatient diabetes care. Alongside this revolution has been a considerable and ongoing evolution of digital interventions to optimise care of inpatients with diabetes including optimisation of EMRs, digital clinical decision support systems (CDSS) and solutions utilising data visibility to allow targeted patient review.

OBJECTIVE

To systematically appraise the recent literature to determine which digitally-enabled interventions including EMR, CDSS and data visibility solutions improve the safety and quality of non-critical care inpatient diabetes management.

METHODS

Pubmed, Embase and Cochrane databases were searched for suitable articles. Selected articles underwent quality assessment and analysis with results grouped by intervention type.

RESULTS

1202 articles were identified with 42 meeting inclusion criteria. Four key interventions were identified; computerised physician order entry (n = 4), clinician decision support systems (n = 21), EMR driven active case finding (data visibility solutions) and targeted patient review (n = 10) and multicomponent system interventions (n = 7). Studies reported on glucometric outcomes, evidence-based medication ordering including medication errors, and patient and user outcomes. An improvement in glucometric measures particularly mean blood glucose and proportion of target range blood glucose levels and rates of evidence-based insulin prescribing were consistently demonstrated.

CONCLUSION

Digitally-enabled interventions utilised to improve quality and safety of inpatient diabetes care were heterogenous in design. The majority of studies across all intervention types reported positive effects for evidence-based prescribing and glucometric outcomes. There was less evidence for digital interventions reducing diabetes medication administration errors or impacting patient outcomes (length of stay).

Performance of an Electronic Decision Support System as a Therapeutic Intervention During a Multicenter PICU Clinical Trial: Heart and Lung Failure-Pediatric Insulin Titration trial (HALF-PINT)

Background

The use of electronic clinical decision support (CDS) systems for pediatric critical care trials is rare. We sought to describe in detail the use of a CDS tool (Children’s Hospital Euglycemia for Kids Spreadsheet [CHECKS]), for the management of hyperglycemia during the 32 multicenter Heart And Lung Failure-Pediatric Insulin Titration trial.

Research Question

In critically ill pediatric patients who were treated with CHECKS, how was user compliance associated with outcomes; and what patient and clinician factors might account for the observed differences in CHECKS compliance?

Study Design and Methods

During an observational retrospective study of compliance with a CDS tool used during a prospective randomized controlled trial, we compared patients with high and low CHECKS compliance. We investigated the association between compliance and blood glucose metrics. We describe CHECKS and use a computer interface analysis framework (the user, function, representation, and task analysis framework) to categorize user interactions. We discuss implications for future randomized controlled trials.

Results

Over a 4.5-year period, 658 of 698 children were treated with the CHECKS protocol for ≥24 hours with a median of 119 recommendations per patient. Compliance per patient was high (median, 99.5%), with only 30 patients having low compliance (<90%). Patients with low compliance were from 16 of 32 sites, younger (P = .02), and less likely to be on inotropic support (P = .04). They were more likely to be have been assigned randomly to the lower blood glucose target (80% vs 48%; P < .001) and to have spent a shorter time (53% vs 75%; P < .001) at the blood glucose target. Overrides (classified by the user, function, representation, and task analysis framework), were largely (89%) due to the user with patient factors contributing 29% of the time.

Interpretation

The use of CHECKS for the Heart And Lung Failure-Pediatric Insulin Titration trial resulted in a highly reproducible and explicit method for the management of hyperglycemia in critically ill children across varied environments. CDS systems represent an important mechanism for conducting explicit complex pediatric critical care trials.

Clinical Trial Registration

ClinicalTrials.gov Identifier: NCT01565941, registered March 29 2012; https://clinicaltrials.gov/ct2/show/NCT01565941?term=HALF-PINT&draw=2&rank=1

Inpatient and Outpatient Technologies to Assist in the Management of Insulin Dosing

Several new technologies use computer algorithms to analyze a person's blood glucose response to insulin treatment, calculate the person's next recommended insulin dose, advise the person regarding when to check blood glucose next, and provide alerts regarding glucose control for the individual patient or across a hospital system. This article reviews U.S. Food and Drug Administration (FDA)-approved products designed to help manage insulin dosing for inpatients, as well as those available to provide people with insulin-requiring diabetes support in making adjustments to their basal and/or mealtime insulin doses. Many of these products have a provider interface that allows for remote monitoring of patients' glucose readings and insulin doses. By alleviating some of the burdens of insulin initiation and dose adjustment, these products may facilitate improved glycemic management and patient outcomes.

Review of Intravenous and Subcutaneous Electronic Glucose Management Systems for Inpatient Glycemic Control

PURPOSE OF REVIEW

The goal of this review is to summarize current literature on electronic glucose management systems (eGMS) and discuss their benefits and disadvantages in the inpatient setting.

RECENT FINDINGS

We review different versions of commercially available eGMS: Glucommander™ (Glytec, Greenville, SC), EndoTool^R (MD Scientific LLC, Charlotte, NC), GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA), GlucoCare™ (Pronia Medical Systems, KY), and discuss advantages such as reducing rates of hypoglycemia, hyperglycemia, and glycemic variability. In addition, eCGMs offer a uniform standard of care and may improve workflows across institutions as well reduce barriers. Despite ample literature on intravenous (IV) versions of eGMS, there is little published research on subcutaneous (SQ) insulin guidance. Although use of eGMS requires extensive training and institution-wide adoption, time spent on diabetes management is better facilitated by their use.

The effects of clinical decision support systems on insulin use: A systematic review

BACKGROUND

A clinical decision support system (CDSS) is a computerized system using case-based reasoning to assist clinicians in assessing disease status, in selecting appropriate therapy or in making other clinical decisions. Previous randomized controlled trials (RCTs or trials) have shown that CDSSs have the potential to improve the insulin use, but the evidence was conflicting and uncertain. The purpose of our study was to determine whether a CDSS improves the use of insulin.

METHOD

PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from their inception to October 2018. The quality assessment was based on the risk of bias criteria of the Cochrane Handbook.

RESULTS

Twenty-four RCTs, involving 7653 participants, were included. Thirteen of those trials (54.2%) used a computerized algorithm or a computer-assisted insulin protocol for insulin dose and therapy adjustment, of which 30.8% (four of 13) found significant changes. Of 10 trials that measured mean blood glucose levels and the 11 trials reported HbA1c, the computerized insulin dose adjustment resulted in lower mean blood glucose levels in 70.0% (seven of 10) and 36.4% (four of 11) of RCTs, respectively. Additionally, a significant reduction of hyperglycaemia events was reported in three of six RCTs. The evidence in a majority of the 24 RCTs was of moderate quality.

CONCLUSIONS

CDSSs have the potential to improve the insulin use and blood glucose control in a clinical setting. The methodologies in these studies were of mixed quality. Better designed and longer-term studies are required to ensure a larger and more reliable evidence base on the effects of CDSS intervention on insulin use.

Performance of a closed-loop glucose control system, comprising a continuous glucose monitoring system and an AI-based controller in swine during severe hypo- and hyperglycemic provocations

Intensive care unit (ICU) patients develop stress induced insulin resistance causing hyperglycemia, large glucose variability and hypoglycemia. These glucose metrics have all been associated with increased rates of morbidity and mortality. The only way to achieve safe glucose control at a lower glucose range (e.g., 4.4–6.6 mmol/L) will be through use of an autonomous closed loop glucose control system (artificial pancreas). Our goal with the present study was to assess the safety and performance of an artificial pancreas system, composed of the EIRUS (Maquet Critical Care AB) continuous glucose monitor (CGM) and novel artificial intelligence-based glucose control software, in a swine model using unannounced hypo- and hyperglycemia challenges. Fourteen piglets (6 control, 8 treated) underwent sequential unannounced hypoglycemic and hyperglycemic challenges with 3 IU of NovoRapid and a glucose infusion at 17 mg/kg/min over the course of 5 h. In the Control animals an experienced ICU physician used every 30-min blood glucose values to maintain control to a range of 4.4–9 mmol/L. In the Treated group the artificial pancreas system attempted to maintain blood glucose control to a range of 4.4–6.6 mmol/L. Five of six Control animals and none of eight Treated animals experienced severe hypoglycemia (< 2.22 mmol/L). The area under the curve 3.5 mmol/L was 28.9 (21.1–54.2) for Control and 4.8 (3.1–5.2) for the Treated animals. The total percent time within tight glucose control range, 4.4–6.6 mmol/L, was 32.8% (32.4–47.1) for Controls and 55.4% (52.9–59.4) for Treated (p < 0.034). Data are median and quartiles. The artificial pancreas system abolished severe hypoglycemia and outperformed the experienced ICU physician in avoiding clinically significant hypoglycemic excursions.

Effect of Electronic Prescribing Strategies on Medication Error and Harm in Hospital: a Systematic Review and Meta-analysis

BACKGROUND

Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients.

METHODS

MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I² 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I² 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I² 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I² 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I² 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I² 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I² 74%, n = 9). The quality of evidence was rated very low.

DISCUSSION

Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.

Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review

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.

A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages

BACKGROUND

Computer clinical decision support (CDS) systems are uncommon in the pediatric intensive care unit (PICU), despite evidence suggesting they improve outcomes in adult ICUs. We reasoned that a bedside CDS protocol for intravenous insulin titration, eProtocol-insulin, would be feasible and safe in critically ill children.

METHODS

We retrospectively reviewed data from non-diabetic children admitted to the PICU with blood glucose (BG) ≥140 mg/dL who were managed with intravenous insulin by either unaided clinician titration or eProtocol-insulin. Primary outcomes were BG measurements in target range (80-110 mg/dL) and severe hypoglycemia (BG ≤40 mg/dL); secondary outcomes were 60-day mortality and PICU length of stay. We assessed bedside nurse satisfaction with the eProtocol-insulin protocol by using a 5-point Likert scale and measured clinician compliance with eProtocol-insulin recommendations.

RESULTS

Over 5 years, 69 children were titrated with eProtocol-insulin versus 104 by unaided clinicians. eProtocol-insulin achieved target range more frequently than clinician titration (41% vs. 32%, P < 0.001). Severe hypoglycemia was uncommon in both groups (4.3% of patients in eProtocol-insulin, 8.7% in clinician titration, P = 0.37). There were no differences in mean time to BG target or median BG between the groups. Mortality was 23% in both groups. Clinician compliance with eProtocol-insulin recommendations was 89%. Nurses believed that eProtocol-insulin was easy to understand and safer than clinician titration.

CONCLUSIONS

eProtocol-insulin is safe for titration of intravenous insulin in critically ill children. Clinical research protocols and quality improvement initiatives aimed at optimizing BG control should utilize detailed computer protocols that enable replicable clinician decisions.

On the horizon: research priorities in burns for the next decade

This review demonstrates that many advances have been made in burn care that have made dramatic differences in mortality, clinical outcomes, and quality of life in burn survivors; however, much work remains. In reality, the current standard of care is insufficient and we cannot be satisfied with the status quo. We must strive for the following goals: no deaths due to burn, no scarring, and no pain. These particular goals have only begun to be confronted.

The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis

BACKGROUND

Inadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable.

OBJECTIVES

To determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes.

DATA SOURCES

Citations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013.

STUDY SELECTION

Randomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility.

DATA ABSTRACTION

A single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains.

DATA SYNTHESIS

Thirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79-1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI -0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31-5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21-2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12-1.94) in accordance with the alert.

CONCLUSIONS

There is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions).

Systematic review of clinical decision support interventions with potential for inpatient cost reduction

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.

Computerized decision support in adult and pediatric critical care

Computerized decision support (CDS) is the most advanced form of clinical decision support available and has evolved with innovative technologies to provide meaningful assistance to medical professionals. Critical care clinicians are in unique environments where vast amounts of data are collected on individual patients, and where expedient and accurate decisions are paramount to the delivery of quality healthcare. Many CDS tools are in use today among adult and pediatric intensive care units as diagnostic aides, safety alerts, computerized protocols, and automated recommendations for management. Some CDS use have significantly decreased adverse events and improved costs when carefully implemented and properly operated. CDS tools integrated into electronic health records are also valuable to researchers providing rapid identification of eligible patients, streamlining data-gathering and analysis, and providing cohorts for study of rare and chronic diseases through data-warehousing. Although the need for human judgment in the daily care of critically ill patients has limited the study and realization of meaningful improvements in overall patient outcomes, CDS tools continue to evolve and integrate into the daily workflow of clinicians, and will likely provide advancements over time. Through novel technologies, CDS tools have vast potential for progression and will significantly impact the field of critical care and clinical research in the future.

Review of burn research for the year 2011

The year 2011 was another robust year for burn research. Over 1100 articles were published on a wide range of burn injury and treatment topics. In this review, we highlight some of the interesting and potentially influential research in the following areas: critical care, infection, inhalation injury, epidemiology, wound characterization and treatment, nutrition and metabolism, pain management, burn reconstruction, psychology, and rehabilitation. As in years past, burn injury research reflects the multidisciplinary and holistic care that is needed to treat this challenging injury condition.

The effectiveness of a computerized IV infusion protocol to treat hyperglycemia in burn patients

Tight glucose control (TGC) in critical care settings is becoming increasingly the standard of care. However, TGC comes with the risk of hypoglycemia, as highlighted by some recent studies. Our aim was to establish TGC in burn patients without increasing rates of hypoglycemia. The authors used a computer-driven glucose control program (CGS) to achieve this goal. The computer program calculates insulin drip rates by using a multiplier that changes according to blood glucose (BG) values as well as trends and keeps a record of BG data and insulin infusion rates for future quality control analysis. CGS is also a useful adjunct in transitioning patients from an IV insulin drip to subcutaneous insulin. A retrospective review of the glucose control program database was performed to obtain information on length of time to goal glucose levels (set at 100-150 mg/dl), glucose level trends, and incidence of hypoglycemia when using the computer program. Over 18 months, we used CGS on 94 critical and noncritical burn patients. Mean time to target BG was 5.1 hours. Glucose levels of 100 to 150 mg/dl were maintained 63.3% of the time, and values within the wider range of 70 to 150 mg/dl were maintained 80.8% of the time. The incidence of hypoglycemia, defined as BG level below 70 mg/dl, was only 1.66% and was treated without any adverse sequelae. Hyperglycemic episodes were directly correlated with surgical interventions during which time the CGS was not utilized in the operating room. CGS offers a safe and effective means of rapidly achieving and maintaining glucose targets in burn patients. Further analysis of the data needs to be conducted to determine whether the BG targets used in our study offer a morbidity benefit to burn patients.

Intravenous insulin infusions: what nurses need to know

Glucose control in the acute setting has long been a debate among leaders in the fields of diabetes and acute care. Providers struggle to maintain euglycemia in critically ill patients and simultaneously prevent hypoglycemia. Intravenous insulin infusions are frequently preferred in the critical care setting to control glucose, because they can be titrated for changing insulin requirements and can be cleared from the system rapidly. This article discusses the basics of the insulin drip, common insulin drips, and the role of the nurse in managing an insulin drip.

The year in burns 2011

For 2011, approximately 1746 original research articles in burns were published in English in scientific journals. This article reviews those with the most potential impact on for burn therapeutics and outcomes according to the Editor of one of the major journals (Burns) and his colleague. As done previously, articles were found and divided into these topic areas: epidemiology of injury and burn prevention, wound and scar characterisation, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. Each selected article is mentioned briefly with editorial comment.

Evolving changes in the management of burns and environmental injuries

Burns and environmental injuries are common as primary or secondary problems in survivors of natural disasters, terrorist incidents, and combat operations. In recent years, intensive military medical experience has resulted in substantial progress in treatment of these important problems. This article reviews practical applications of this new knowledge.

Computerized insulin infusion programs are safe and effective in the burn intensive care unit

Glucose control has repeatedly been shown to influence favorable outcomes in the surgical intensive care unit (ICU). Intensive insulin therapy has recently been associated with reduced infections complications in burn patients. However, traditional protocols are associated with rates of severe hypoglycemia as high as 19%. Two commercial computer glucose control programs have reported rates of severe hypoglycemia (glucose <50 mg/dl) of 0.6 and 0.4%. Recently, the authors' burn ICU adopted an intensive insulin computer-based protocol created at their institution and already successfully in use in their surgical ICU. The authors hypothesized that their protocol can be used effectively in the burn patient population without an increase risk of severe hypoglycemia. All patients admitted to the burn ICU have blood glucose (BG) values checked routinely. With two consecutive hyperglycemic values >200 mg/dl, patients are placed on a computer-based protocol intravenous insulin drip. Once initiated, BGs are tested hourly with adjustments made according to the computer protocol. Values recorded from January to December 2008 were abstracted from the database and analyzed. Thirty-one patients were treated using the computer glucose control protocol and 12,699 measurements were performed. There were eight measurements <50 mg/dl (0.07%). Seventy-six percent of values were within the target range of 90 to 150 mg/dl. Few patients had severe hyperglycemia with BG >300 mg/dl (0.2%). There were no adverse events associated with the hypoglycemic episode. The computer-based protocol is more effective than those previously used at the institution and provides safe, reliable results in the burn patients.

Examining the evidence of the impact of health information technology in primary care: an argument for participatory research with health professionals and patients

PURPOSE

Health information technology represents a promising avenue to improve health care delivery. How can we use lessons learnt from existing health information technologies in primary care to inform the optimal design of newer developments such as personal health records?

METHODS

The results of systematic literature reviews about the impact of different information systems on health outcomes in primary care are critically discussed in a narrative synthesis, with a focus on their implications for the development of personal health records.

RESULTS

Given the proliferation of systematic reviews and randomized controlled trials, high quality evidence for health information technology in primary care is accumulating with mixed results. The heterogeneity of systems being compared and the quality of research can no longer account for these findings. One potential explanation may be that systems originally designed for acute care settings are being implemented in primary care. Early studies evaluating personal health records suggest that targeting patient outcomes directly and adapting systems to patients' needs may be part of the solution.

CONCLUSION

In order to develop personal health records for primary care, studies are needed that involve the users, namely patients and primary care health professionals, in the design and evaluation of these systems from their inception. Participatory research is a recommended methodological approach.

Clinician satisfaction with computer decision support in the intensive care unit

The purpose of this study was to determine baseline user satisfaction for 2 computer decision support systems (DSSs) with demonstrated improvement in patient outcome used in a burn intensive care unit. We conducted a survey of staff members of a 16-bed burn intensive care unit (n = 82) using a written, anonymous questionnaire to determine satisfaction for 2 DSSs: a commercial glycemic management system and software program to guide initial burn fluid resuscitation. Staff members are not yet convinced of a positive correlation between DSS technology and patient outcomes. We suggest user satisfaction may be generally improved for DSS with concentration in the areas of interface, information, and communication.

The effects of on-screen, point of care computer reminders on processes and outcomes of care

BACKGROUND

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'.

OBJECTIVES

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

SEARCH STRATEGY

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

SELECTION CRITERIA

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

MAIN RESULTS

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

AUTHORS' CONCLUSIONS

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.