Computerized clinical decision support: a technology to implement and validate evidence based guidelines

TraumaFlow-development of a workflow-based clinical decision support system for the management of severe trauma cases

PURPOSE

The treatment of severely injured patients in the resuscitation room of an emergency department requires numerous critical decisions, often under immense time pressure, which places very high demands on the facility and the interdisciplinary team. Computer-based cognitive aids are a valuable tool, especially in education and training of medical professionals. For the management of polytrauma cases, TraumaFlow, a workflow management-based clinical decision support system, was developed. The system supports the registration and coordination of activities in the resuscitation room and actively recommends diagnosis and treatment actions.

METHODS

Based on medical guidelines, a resuscitation room algorithm was developed according to the cABCDE scheme. The algorithm was then modeled using the process description language BPMN 2.0 and implemented in a workflow management system. In addition, a web-based user interface that provides assistance functions was developed. An evaluation study was conducted with 11 final-year medical students and three residents to assess the applicability of TraumaFlow in a case-based training scenario.

RESULTS

TraumaFlow significantly improved guideline-based decision-making, provided more complete therapy, and reduced treatment errors. The system was shown to be beneficial not only for the education of low- and medium-experienced users but also for the training of highly experienced physicians. 92% of the participants felt more confident with computer-aided decision support and considered TraumaFlow useful for the training of polytrauma treatment. In addition, 62% acknowledged a higher training effect.

CONCLUSION

TraumaFlow enables real-time decision support for the treatment of polytrauma patients. It improves guideline-based decision-making in complex and critical situations and reduces treatment errors. Supporting functions, such as the automatic treatment documentation and the calculation of medical scores, enable the trauma team to focus on the primary task. TraumaFlow was developed to support the training of medical students and experienced professionals. Each training session is documented and can be objectively and qualitatively evaluated.

Effectiveness and cost-effectiveness of a web-based routine assessment with integrated recommendations for action for depression and anxiety (RehaCAT+): protocol for a cluster randomised controlled trial for patients with elevated depressive symptoms in rehabilitation facilities

INTRODUCTION

The integration of a web-based computer-adaptive patient-reported outcome test (CAT) platform with persuasive design optimised features including recommendations for action into routine healthcare could provide a promising way to translate reliable diagnostic results into action. This study aims to evaluate the effectiveness and cost-effectiveness of such a platform for depression and anxiety (RehaCAT+) compared with the standard diagnostic system (RehaCAT) in cardiological and orthopaedic health clinics in routine care.

METHODS AND ANALYSIS

A two-arm, pragmatic, cluster-randomised controlled trial will be conducted. Twelve participating rehabilitation clinics in Germany will be randomly assigned to a control (RehaCAT) or experimental group (RehaCAT+) in a 1:1 design. A total sample of 1848 participants will be recruited across all clinics. The primary outcome, depression severity at 12 months follow-up (T3), will be assessed using the CAT Patient-Reported Outcome Measurement Information System Emotional Distress-Depression Item set. Secondary outcomes are depression at discharge (T1) and 6 months follow-up (T2) as well as anxiety, satisfaction with participation in social roles and activities, pain impairment, fatigue, sleep, health-related quality of life, self-efficacy, physical functioning, alcohol, personality and health economic-specific general quality of life and socioeconomic cost and benefits at T1-3. User behaviour, acceptance, facilitating and hindering factors will be assessed with semistructured qualitative interviews. Additionally, a smart sensing substudy will be conducted, with daily ecological momentary assessments and passive collection of smartphone usage variables. Data analysis will follow the intention-to-treat principle with additional per-protocol analyses. Cost-effectiveness analyses will be conducted from a societal perspective and the perspective of the statutory pension insurance.

ETHICS AND DISSEMINATION

The study will be conducted according to the Declaration of Helsinki. The Ethics Committee of Ulm University, has approved the study (on 24 February 2021 ref. 509/20). Written informed consent will be obtained for all participants. Results will be published via peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00027447.

Impact of an electronic medical record-based automated screening program for critical congenital heart disease: Emirates Health Services, United Arab Emirates

Background

Almost eight children per 1000 live births are expected to have a congenital heart defect globally. The seven most critical congenital heart conditions that cause severe compromise on the patient’s quality and duration of life are collectively referred to as the Critical Congenital Heart Diseases (CCHD). CCHD is a critical condition that requires prompt detection and intervention as a life-saving measure. Pulse oximetry is a non-invasive, highly specific, and moderately sensitive method that can be used for screening new-borns for CCHD. The Emirates Health Services (EHS), UAE, adopted a strategy of developing a stringent program for newborn screening of Critical Congenital Heart disease, which would help in the early diagnosis and treatment of CCHD patients. An automated EMR (Wareed) driven solution was introduced to enhance this program as part of the routine workflow for the nurse care providers.

Methods

Our study is a retrospective observational study that aims to understand: the prevalence of CCHD in our target population and to study the impact of an automated program on screening compliance and its implications for early diagnosis of CCHD.

Results

We found that an EMR-driven automated screening program was highly effective in achieving high compliance (98.9%). It created a (statistically significant) improvement in the disease identification for CCHD in live births at EHS facilities.

Conclusion

We conclude that implementing an automated protocol through the EMR can effectively improve new-born screening coverage. It reduces the days to CCHD diagnosis, which would improve health outcomes in neonates.

Optimizing a decision support system for damage-control resuscitation using mixed methods human factors analysis

BACKGROUND

Damage-control resuscitation (DCR) improves trauma survival; however, consistent adherence to DCR principles through multiple phases of care has proven challenging. Clinical decision support may improve adherence to DCR principles. In this study, we designed and evaluated a DCR decision support system using an iterative development and human factors testing approach.

METHODS

The phases of analysis included initial needs assessment and prototype design (Phase 0), testing in a multidimensional simulation (Phase 1), and testing during initial clinical use (Phase 2). Phase 1 and Phase 2 included hands-on use of the decision support system in the trauma bay, operating room, and intensive care unit. Participants included trauma surgeons, trauma fellows, anesthesia providers, and trauma bay and intensive care unit nurses who provided both qualitative and quantitative feedback on the initial prototype and all subsequent iterations.

RESULTS

In Phase 0, 14 (87.5%) of 16 participants noted that they would use the decisions support system in a clinical setting. Twenty-four trauma team members then participated in simulated resuscitations with decision support where 178 (78.1%) of 228 of tasks were passed and 27 (11.8%) were passed with difficulty. Twenty-three (95.8%) completed a postsimulation survey. Following iterative improvements in system design, Phase 2 evaluation included 21 trauma team members during multiple real-world trauma resuscitations. Of these, 15 (71.4%) completed a formal postresuscitation survey. Device-level feedback on a Likert scale (range, 0-4) confirmed overall ease of use (median score, 4; interquartile range, 4-4) and indicated the system integrated well into their workflow (median score, 3; interquartile range, 2-4). Final refinements were then completed in preparation for a pilot clinical study using the decision support system.

CONCLUSIONS

An iterative development and human factors testing approach resulted in a clinically useable DCR decision support system. Further analysis will determine its applicability in military and civilian trauma care.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level V.

Improving adherence to cardiovascular guidelines: realistic transition from paper to patient

Introduction: The emphasis on clinical trials to inform evidence-based medicine remains paramount within the cardiovascular community. Although such high-quality evidence is often translated into national and international guidelines, there exists a large gap between guideline development and guideline implementation into daily clinical practice.Areas covered: This article outlines barriers that impede guideline adherence and possible strategies to overcome such barriers. Barriers intrinsic and extrinsic to clinicians are discussed. The structured process of guideline implementation including guideline adoption, diffusion, and dissemination is discussed. Lastly, the authors review in detail the current and potential future elements of guideline diffusion and dissemination.Expert opinion: Improving guideline adherence remains challenging as it requires understanding of and navigation through various barriers. However, further research specific to cardiovascular medicine guidelines is necessary to better understand the objective effectiveness of various strategies employed by guideline writers and medical societies to improve adherence. The cost-effectiveness of nationwide dissemination strategies in improving guideline adherence and patient outcomes is also necessary but is largely unknown.

An Interactive Website for Whiplash Management (My Whiplash Navigator): Process Evaluation of Design and Implementation

Background

Whiplash is a health and economic burden worldwide. Contributing to this burden is poor guideline adherence and variable management by health care professionals (HCPs). Web-based tools that facilitate clinical pathways of care are an innovative solution to improve management.

Objective

The study aimed to develop, implement, and evaluate a Web-based tool to support whiplash management following a robust process.

Methods

This study followed the first 3 processes of a research translation framework (idea generation, feasibility, and efficacy) to inform the development, implementation, and evaluation of a website that supports HCPs in whiplash management. Development followed the idea generation and feasibility processes to inform the content, design, features, and functionality of the website. This involved stakeholder (eg, industry partners, website developers, and HCPs) consultations through face-to-face meetings, surveys, and focus group discussions. Implementation followed the feasibility process to determine the practicality of the website for clinical use and the most effective strategy to promote wider uptake. Implementation strategies included classroom education, educational meetings, educational outreach, reminders, and direct phone contact. The analysis of website use and practicality of implementation involved collection of website metrics. Evaluation followed the feasibility and efficacy processes to investigate the acceptability and extent to which the website assisted HCPs in gaining knowledge about whiplash management. Surveys were conducted among student, primary, and specialist HCPs to explore ease of access, use, and satisfaction with the website, as well as self-rated improvements in knowledge of risk assessment, management, and communication between HCPs. Website logs of specialist management decisions (eg, shared care, specialist care, and referred care) were also obtained to determine actual practice.

Results

The development process delivered an interactive, user-friendly, and acceptable website, My Whiplash Navigator, tailored to the needs of HCPs. A total of 260 registrations were recorded from June 2016 to March 2018, including 175 student, 65 primary, and 20 specialist HCPs. The most effective implementation strategies were classroom education for students (81% uptake, 175/215) and educational meetings for primary HCPs (43% uptake, 47/110). Popular pages visited included advice and exercises and risk assessment. Most HCPs agreed that their knowledge about risk management (79/97, 81%) and exercises (85/97, 88%) improved. The specialists’ most common management decision was shared care, an improvement from a previous cohort. Areas to improve were navigation and access to outcome measures.

Conclusions

A robust process resulted in an innovative, interactive, user-friendly, and acceptable website, the My Whiplash Navigator. Implementation with HCPs was best achieved through classroom education and educational meetings. Evaluation of the website showed improved knowledge and practice to be more consistent with a risk-based clinical care pathway for whiplash. The positive results provide sufficient evidence to scale implementation nationally and involve other target markets such as people with whiplash, insurers, and insurance regulators.

Evaluation of User-Interface Alert Displays for Clinical Decision Support Systems for Sepsis

BACKGROUND

Hospitals are increasingly turning to clinical decision support systems for sepsis, a life-threatening illness, to provide patient-specific assessments and recommendations to aid in evidence-based clinical decision-making. Lack of guidelines on how to present alerts has impeded optimization of alerts, specifically, effective ways to differentiate alerts while highlighting important pieces of information to create a universal standard for health care providers.

OBJECTIVE

To gain insight into clinical decision support systems-based alerts, specifically targeting nursing interventions for sepsis, with a focus on behaviors associated with and perceptions of alerts, as well as visual preferences.

METHODS

An interactive survey to display a novel user interface for clinical decision support systems for sepsis was developed and then administered to members of the nursing staff.

RESULTS

A total of 43 nurses participated in 2 interactive survey sessions. Participants preferred alerts that were based on an established treatment protocol, were presented in a pop-up format, and addressed the patient's clinical condition rather than regulatory guidelines.

CONCLUSIONS

The results can be used in future research to optimize electronic medical record alerting and clinical practice workflow to support the efficient, effective, and timely delivery of high-quality care to patients with sepsis. The research also may advance the knowledge base of what information health care providers want and need to improve the health and safety of their patients.

Rapid Adjustment of Clinical Decision Support in Response to Updated Recommendations for Palivizumab Eligibility

Background: Palivizumab is effective at reducing hospitalizations due to respiratory syncytial virus among high-risk children, but is indicated for a small population. Identification of patients eligible to receive palivizumab is labor-intensive and error-prone. To support patient identification we developed Clinical Decision Support (CDS) based on published recommendations in 2012. This CDS was developed using a systematic process, which directly linked computer code to a recommendation’s narrative text. In 2014, updated recommendations were published, which changed several key criteria used to determine eligible patients.

Objective: Assess the effort required to update CDS in response to new palivizumab recommendations and identify factors that impacted these efforts.

Methods: We reviewed the updated American Academy of Pediatrics (AAP) policy statement from Aug 2014 and identified areas of divergence from the prior publication. We modified the CDS to account for each difference. We recorded time spent on each activity to approximate the total effort required to update the CDS.

Results: Of the 15 recommendations in the initial policy statement, 7 required updating. The CDS update was completed in 11 person-hours. Comparison of old and new recommendations was facilitated by the AAP policy statement structure and required 3 hours. Validation of the revised logic required 2 hours by a clinical domain expert. An informaticist required 3 hours to update and test the CDS. This included adding 24 lines and deleting 37 lines of code. Updating relevant data queries took an additional 3 hours and involved 10 edits.

Conclusion: We quickly adapted CDS in response to changes in recommendations for palivizumab administration. The consistent AAP policy statement structure and the link we developed between these statements and the CDS rules facilitated our efforts. We recommend that CDS implementers establish linkages between published narrative recommendations and their executable rules to facilitate maintenance efforts.

Citation: Michel J, Utidjian LH, Karavite D, Hogan A, Ramos MJ, Miller J, Shiffman RN, Grundmeier RW. Rapid adjustment of clinical decision support in response to updated recommendations for palivizumab eligibility. Appl Clin Inform 2017; 8: 581–592 https://doi.org/10.4338/ACI-2016-10-RA-0173

COMBAT study - Computer based assessment and treatment - A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients

BACKGROUND AND AIMS

The prevalence of pain in cancer patients are relatively high and indicate inadequate pain management strategies. Therefore, it is necessary to develop new methods and to improve implementation of guidelines to assess and treat pain. The vast improvement in information technology facilitated development of a computerized symptom assessment and decision support system (CCDS) - the Combat system - which was implemented in an outpatient cancer clinic to evaluate improvement in pain management.

METHODS

We conducted a controlled before-and-after study between patient cohorts in two consecutive study periods: before (n=80) and after (n=134) implementation of the Combat system. Patients in the first cohort completed questionnaires with the paper-and-pencil method and this data was not shown to physicians. Patients in the latter cohort completed an electronic questionnaire by using an iPad and the data were automatically transferred and presented to physicians at point of care. Additionally, the system provided computerized decision support at point of care for the physician based on the electronic questionnaires completed by the patients, an electronic CRF completed by physicians and clinical guidelines.

RESULTS

The Combat system did not improve pain intensity and there were no significant alterations in the prescribed dose of opiates compared to the cohort of patients managed without the Combat system.

CONCLUSION

The Combat system did not improve pain management. This may be explained by several factors, however, we consider lack of proper implementation of the CCDS in the clinic to be the most important factor. As a result, we did not manage to change the behaviour of the physicians in the clinic.

IMPLICATIONS

There is a need to conduct larger prospective studies to evaluate the efficacy of modern information technology to improve pain management in cancer patients. Before introducing new information technology in the clinics, it is important to have a well thought out implementation strategy. The trial is registered at Clinialtrials.gov, number NCT01795157.

Sepsis and Critical Illness Research Center investigators: protocols and standard operating procedures for a prospective cohort study of sepsis in critically ill surgical patients

INTRODUCTION

Sepsis is a common, costly and morbid cause of critical illness in trauma and surgical patients. Ongoing advances in sepsis resuscitation and critical care support strategies have led to improved in-hospital mortality. However, these patients now survive to enter state of chronic critical illness (CCI), persistent low-grade organ dysfunction and poor long-term outcomes driven by the persistent inflammation, immunosuppression and catabolism syndrome (PICS). The Sepsis and Critical Illness Research Center (SCIRC) was created to provide a platform by which the prevalence and pathogenesis of CCI and PICS may be understood at a mechanistic level across multiple medical disciplines, leading to the development of novel management strategies and targeted therapies.

METHODS

Here, we describe the design, study cohort and standard operating procedures used in the prospective study of human sepsis at a level 1 trauma centre and tertiary care hospital providing care for over 2600 critically ill patients annually. These procedures include implementation of an automated sepsis surveillance initiative, augmentation of clinical decisions with a computerised sepsis protocol, strategies for direct exportation of quality-filtered data from the electronic medical record to a research database and robust long-term follow-up.

ETHICS AND DISSEMINATION

This study has been registered at ClinicalTrials.gov, approved by the University of Florida Institutional Review Board and is actively enrolling subjects. Dissemination of results is forthcoming.

Impact of a Sequential Intervention on Albumin Utilization in Critical Care

OBJECTIVES

Literature generally finds no advantages in mortality risk for albumin over cheaper alternatives in many settings. Few studies have combined financial and nonfinancial strategies to reduce albumin overuse. We evaluated the effect of a sequential multifaceted intervention on decreasing albumin use in ICU and explore the effects of different strategies.

DESIGN

Prospective prepost cohort study.

SETTING

Eight ICUs at two hospitals in an academic healthcare system.

PATIENTS

Adult patients admitted to study ICUs from September 2011 to August 2014 (n = 22,004).

INTERVENTIONS

Over 2 years, providers in study ICUs participated in an intervention to reduce albumin use involving monthly feedback and explicit financial incentives in the first year and internal guidelines and order process changes in the second year.

MEASUREMENTS AND MAIN RESULTS

Outcomes measured were albumin orders per ICU admission, direct albumin costs, and mortality. Mean (SD) utilization decreased 37% from 2.7 orders (6.8) per admission during the baseline to 1.7 orders (4.6) during the intervention (p < 0.001). Regression analysis revealed that the intervention was independently associated with 0.9 fewer orders per admission, a 42% relative decrease. This adjusted effect consisted of an 18% reduction in the probability of using any albumin (p < 0.001) and a 29% reduction in the number of orders per admission among patients receiving any (p < 0.001). Secondary analysis revealed that probability reductions were concurrent with internal guidelines and order process modification while reductions in quantity occurred largely during the financial incentives and feedback period. Estimated cost savings totaled $2.5M during the 2-year intervention. There was no significant difference in ICU or hospital mortality between baseline and intervention.

CONCLUSIONS

A sequential intervention achieved significant reductions in ICU albumin use and cost savings without changes in patient outcomes, supporting the combination of financial and nonfinancial strategies to align providers with evidence-based practices.

Computerized Decision Support Systems for Mechanical Ventilation in Children

Mechanical ventilation is an effective treatment in the ICU but can have significant adverse effects. Approaches from adult research have been adopted in pediatric critical care despite known differences in respiratory physiology and ICU processes. There continues to be considerable variation in how ventilators are managed. Computerized decision support systems implement explicit protocols, and are designed to make mechanical ventilation management safer, more consistent, and more lung protective. Variable results and low or unknown compliance with protocols and CDSS tools have been reported. To date, there has been limited research regarding CDSS for mechanical ventilation in children.

Perioperative fluid therapy: a statement from the international Fluid Optimization Group

BACKGROUND

Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered.

METHODS

Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them.

RESULTS

The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration.

CONCLUSIONS

We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.

Computer versus paper system for recognition and management of sepsis in surgical intensive care

BACKGROUND

A system to provide surveillance, diagnosis, and protocolized management of surgical intensive care unit (SICU) sepsis was undertaken as a performance improvement project. A system for sepsis management was implemented for SICU patients using paper followed by a computerized system. The hypothesis was that the computerized system would be associated with improved process and outcomes.

METHODS

A system was designed to provide early recognition and guide patient-specific management of sepsis including (1) modified early warning signs-sepsis recognition score (MEWS-SRS; summative point score of ranges of vital signs, mental status, white blood cell count; after every 4 hours) by bedside nurse; (2) suspected site assessment (vascular access, lung, abdomen, urinary tract, soft tissue, other) at bedside by physician or extender; (3) sepsis management protocol (replicable, point-of-care decisions) at bedside by nurse, physician, and extender. The system was implemented first using paper and then a computerized system. Sepsis severity was defined using standard criteria.

RESULTS

In January to May 2012, a paper system was used to manage 77 consecutive sepsis encounters (3.9 ± 0.5 cases per week) in 65 patients (77% male; age, 53 ± 2 years). In June to December 2012, a computerized system was used to manage 132 consecutive sepsis encounters (4.4 ± 0.4 cases per week) in 119 patients (63% male; age, 58 ± 2 years). MEWS-SRS elicited 683 site assessments, and 201 had sepsis diagnosis and protocol management. The predominant site of infection was abdomen (paper, 58%; computer, 53%). Recognition of early sepsis tended to occur more using the computerized system (paper, 23%; computer, 35%). Hospital mortality rate for surgical ICU sepsis (paper, 20%; computer, 14%) was less with the computerized system.

CONCLUSION

A computerized sepsis management system improves care process and outcome. Early sepsis is recognized and managed with greater frequency compared with severe sepsis or septic shock. The system has a beneficial effect as a clinical standard of care for SICU patients.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries

OBJECT

Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome.

METHODS

This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity.

RESULTS

The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005).

CONCLUSIONS

Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

Human Factors in Critical Care Medical Environments

The purpose of this chapter on human factors in critical care medical environments is to provide a systematic review of the human factors and ergonomics contributions that led to significant improvements in patient safety over the last five decades. The review will focus on issues that contributed to patient injury and fatalities and how human factors and ergonomics can improve performance of providers in critical care. Given the complexity of critical care delivery, a review needs to cover a wide range of subjects. In this review, I take a sociotechnical systems perspective on critical care and discuss the people, their technical and nontechnical skills, the importance of teamwork, technology, and ergonomics in this complex environment. After a description of the importance of a safety climate, the chapter will conclude with a summary on how human factors and ergonomics can improve quality in critical care delivery.

Surveillance: A strategy for improving patient safety in acute and critical care units

Surveillance is a nursing intervention that has been identified as an important strategy in preventing and identifying medical errors and adverse events. The definition of surveillance proposed by the Nursing Intervention Classification is the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making. The term surveillance is often used interchangeably with the term monitoring, yet surveillance differs significantly from monitoring both in purpose and scope. Monitoring is a key activity in the surveillance process, but monitoring alone is insufficient for conducting effective surveillance. Much of the attention in the bedside patient safety movement has been focused on efforts to implement processes that ultimately improve the surveillance process. These include checklists, interdisciplinary rounds, clinical information systems, and clinical decision support systems. To identify optimal surveillance patterns and to develop and test technologies that assist critical care nurses in performing effective surveillance, more research is needed, particularly with innovative approaches to describe and evaluate the best surveillance practices of bedside nurses.

Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care

Surgical intensive care unit (ICU) stay of longer than 10 days is often described by the experienced intensivist as a "complicated clinical course" and is frequently attributed to persistent immune dysfunction. "Systemic inflammatory response syndrome" (SIRS) followed by "compensatory anti-inflammatory response syndrome" (CARS) is a conceptual framework to explain the immunologic trajectory that ICU patients with severe sepsis, trauma, or emergency surgery for abdominal infection often traverse, but the causes, mechanisms, and reasons for persistent immune dysfunction remain unexplained. Often involving multiple-organ failure (MOF) and death, improvements in surgical intensive care have altered its incidence, phenotype, and frequency and have increased the number of patients who survive initial sepsis or surgical events and progress to a persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Often observed, but rarely reversible, these patients may survive to transfer to a long-term care facility only to return to the ICU, but rarely to self-sufficiency. We propose that PICS is the dominant pathophysiology and phenotype that has replaced late MOF and prolongs surgical ICU stay, usually with poor outcome. This review details the evolving epidemiology of MOF, the clinical presentation of PICS, and our understanding of how persistent inflammation and immunosuppression define the pathobiology of prolonged intensive care. Therapy for PICS will involve innovative interventions for immune system rebalance and nutritional support to regain physical function and well-being.

Early Diagnosis and Evidence-Based Care of Surgical Sepsis

Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.

Computerized clinical decision support improves mortality in intra abdominal surgical sepsis

BACKGROUND

The management of surgical sepsis is challenging because of the complexity of interventions. The authors therefore created a computerized clinical decision support program to facilitate this process, with the goal of improving abdominal sepsis mortality.

METHODS

The authors evaluated a prospective database for all patients requiring surgery for abdominal sepsis. Patient demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained. Observed mortality was compared with predicted mortality using Fisher's exact test.

RESULTS

Eighty-seven patients met the inclusion criteria. The average age was 59 ± 17.0 years, and 39% were men. The most common source of infection was the colon (45%). The average Acute Physiology and Chronic Health Evaluation II score was 27.6 ± 9.72. The overall actual mortality rate for the cohort was 24% compared with a predicted Acute Physiology and Chronic Health Evaluation II mortality of 62.5% (P < .0001).

CONCLUSION

The use of computerized clinical decision support results in significantly improved survival in patients with intra-abdominal surgical sepsis.

Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation

Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.

Performance of a computerized protocol for trauma shock resuscitation

BACKGROUND

A computerized protocol was developed and used to standardize bedside clinician decision making for resuscitation of shock due to severe trauma during the first day in the intensive care unit (ICU) at a metropolitan Level I trauma center. We report overall performance of a computerized protocol for resuscitation of shock due to severe trauma, incorporating two options for resuscitation monitoring and intervention intensity, according to: (1) duration of use and (2) acceptance of computerized protocol-generated instructions.

METHODS

A computerized protocol operated by clinicians, using a personal computer (PC) at the bedside, was used to guide clinical decision making for resuscitation of patients meeting specific injury and shock criteria. The protocol generated instructions that could be accepted or declined. Clinician acceptance of the protocol instructions was stored by the PC software in a database for each patient. A rule-based, data-driven protocol was developed using literature evidence, expert opinion, and ongoing protocol performance analysis. Logic-flow diagrams were used to facilitate communication among multidisciplinary protocol development team members. The protocol was computerized using standard programming methods and implemented using cart-mounted PCs with a touch screen and keyboard interfaces. Protocol progression began with patient demographic data and criteria entry, confirmation of hemodynamic monitor instrumentation, request for specific hemodynamic performance data, and instructions for specific interventions (or no intervention). Use and performance of the computerized protocol was recorded in a protocol execution database. The protocol was continuously maintained with new literature evidence and database performance analysis findings. Initially implemented in 2000, the computerized protocol was refined in 2004 with two options for resuscitation intensity: pulmonary artery catheter- and central venous pressure-directed resuscitation.

RESULTS

Over 2 years ending at August 2006, a total of 193 trauma patients (mean Injury Severity Score was 27, survival rate 89%) were resuscitated using the computerized protocol. Protocol duration was 4400 hours or 22.7 +/- 0.4 hours per patient. The computerized protocol generated 3724 instructions (19 +/- 1 per patient) that required a bedside clinician response. In all, 94% of these instructions were accepted by the bedside clinician users.

CONCLUSIONS

A computerized protocol to guide decision making for trauma shock resuscitation in a Level 1 trauma center surgical ICU was developed and used as standard of care. During 2 years ending at August 2006, 94% of computer-generated instructions for specific interventions or measurements of hemodynamic performance were accepted by bedside clinicians, indicating appropriate, useful design and reliance on the computerized protocol system.

Standardizing care in medical oncology: are Web-based systems the answer?

BACKGROUND

Medical oncology is embracing information technology to standardize care and improve patient outcomes, with a range of Web-based systems used internationally. The authors' aim was to determine the factors affecting the uptake and use of a Web-based protocol system for medical oncology in the Australian setting.

METHODS

The authors conducted 50 interviews and observed medical oncology physicians, nurses, and pharmacists in their treatment setting at 6 hospitals in different geographic locations.

RESULTS

The Web-based system plays a major role in guiding oncology treatment across participating sites. However, its use varies according to hospital location, clinician roles, and experience. A range of issues impact on clinicians' attitudes toward and use of the Web-based system. Important factors are clinician-specific (eg, their need for autonomy and perceptions of lack of time) or environmental (eg, hospital policy on protocol use, endorsement of the system, and the availability of appropriate infrastructure, such as sufficient computers). The level of education received regarding the system was also found to be integral to its ongoing use.

CONCLUSIONS

Although the provision of high-quality evidence-based resources, electronic or otherwise, is essential for standardizing care and improving patient outcomes, the authors' findings demonstrate that this alone does not ensure uptake. It is important to understand end-users, the environment in which they operate, and the basic infrastructure required to implement such a system. Implementation must also be accompanied by continuing education and endorsement to ensure both long-term sustainability and use of the system to its full potential.

Sepsis in general surgery: a deadly complication

BACKGROUND

Sepsis is a deadly and potentially preventable complication. A better understanding of sepsis in general surgery patients is needed to help direct resources to those patients at highest risk for death from sepsis.

METHODS

We identified risk factors for sepsis in general surgery patients by using the National Surgical Quality Improvement Project database.

RESULTS

Analysis of the database identified 3 major risk factors for both the development of sepsis and death from sepsis in general surgery patients. These risk factors are age older than 60 years, need for emergency surgery, and the presence of comorbid conditions.

CONCLUSIONS

Risk factors for death from sepsis or septic shock in general surgery patients include age older than 60 years, need for emergency surgery, and the presence of preexisting comorbidities. These findings emphasize the need for early recognition through aggressive sepsis screening and rapid implementation of evidence-based interventions for sepsis and septic shock in general surgery patients with these risk factors.

Information management to enable personalized medicine: stakeholder roles in building clinical decision support

BACKGROUND

Advances in technology and the scientific understanding of disease processes are presenting new opportunities to improve health through individualized approaches to patient management referred to as personalized medicine. Future health care strategies that deploy genomic technologies and molecular therapies will bring opportunities to prevent, predict, and pre-empt disease processes but will be dependent on knowledge management capabilities for health care providers that are not currently available. A key cornerstone to the potential application of this knowledge will be effective use of electronic health records. In particular, appropriate clinical use of genomic test results and molecularly-targeted therapies present important challenges in patient management that can be effectively addressed using electronic clinical decision support technologies.

DISCUSSION

Approaches to shaping future health information needs for personalized medicine were undertaken by a work group of the American Health Information Community. A needs assessment for clinical decision support in electronic health record systems to support personalized medical practices was conducted to guide health future development activities. Further, a suggested action plan was developed for government, researchers and research institutions, developers of electronic information tools (including clinical guidelines, and quality measures), and standards development organizations to meet the needs for personalized approaches to medical practice. In this article, we focus these activities on stakeholder organizations as an operational framework to help identify and coordinate needs and opportunities for clinical decision support tools to enable personalized medicine.

SUMMARY

This perspective addresses conceptual approaches that can be undertaken to develop and apply clinical decision support in electronic health record systems to achieve personalized medical care. In addition, to represent meaningful benefits to personalized decision-making, a comparison of current and future applications of clinical decision support to enable individualized medical treatment plans is presented. If clinical decision support tools are to impact outcomes in a clear and positive manner, their development and deployment must therefore consider the needs of the providers, including specific practice needs, information workflow, and practice environment.

Automated system to identify Clostridium difficile infection among hospitalised patients

The purpose of this study was to assess whether data on stool frequency collected electronically could identify patients at high risk for Clostridium difficile infection (CDI). All patients with reports of diarrhoea were assessed prospectively for number of stools per day and number of diarrhoea days. C. difficile testing was requested independently from study investigators. Number of days with diarrhoea and maximum number of unformed stools was assessed as a CDI predictor. A total of 605 patients were identified with active diarrhoea of whom 64 (10.6%) were diagnosed with CDI. In univariate analysis, the maximum number of stools and number of diarrhoea days was associated with increased risk of CDI. Compared to patients with three diarrhoea stools per day (CDI incidence: 6.3%), CDI increased to 13.4% in patients with four or more diarrhoea stools per day [odds ratio (OR): 2.3; 95% confidence interval (CI): 1.3-4.2; P=0.0054]. Compared to patients with one day of diarrhoea (CDI incidence: 6.3%), CDI increased to 17.4% in patients with two diarrhoea days (OR: 3.1; 95% CI: 1.7-5.6) and to 27.1% in patients with three or more diarrhoea days (OR: 5.5; 95% CI: 2.6-11.7). These results were validated using logistic regression with number of days with diarrhoea identified as the most important predictor. Using an electronic data capture technique, number of days of diarrhoea and maximum number of diarrhoea stools in a 24h time period were able to identify a patient population at high risk for CDI.

Computerized clinical decision support for traumatic shock resuscitation

PURPOSE OF REVIEW

To review what we learned through implementation of computerized decision support for ICU resuscitation of major torso trauma patients who arrive in shock.

RECENT FINDINGS

Overall, these patients respond well to preload-directed goal-orientated ICU resuscitation; however, the subset of patients destined to develop abdominal compartment syndrome do not respond well. In fact, this strategy precipitates the full-blown syndrome that is a new iatrogenic variant of multiple organ failure. The clinical trajectory of abdominal compartment syndrome starts early after emergency department admission and its course is fairly well defined by the time patients reach the ICU. It occurs in patients who arrive with severe bleeding that is not readily controlled. These patients require a very different emergency department management strategy. Hemorrhage control is paramount. Alternative massive transfusion protocols should be used with an emphasis on hemostasis and avoidance of excessive isotonic crystalloids. Finally, near-infrared spectroscopy that measures tissue hemoglobin saturation in skeletal muscle (StO2) is good at identifying high-risk patients. A falling StO2 in the setting of ongoing resuscitation is a harbinger of death from early exsanguination and multiple organ failure.

SUMMARY

Fundamental changes are needed in the care of trauma patients who arrive in shock and require a massive transfusion.