Objective: To determine characteristics and effects of nurse dosing over-rides of a clinical decision support system (CDSS) for intensive insulin therapy (IIT) in critical care units.
Design: Retrospective analysis of patient database records and ethnographic study of nurses using IIT CDSS.
Measurements: The authors determined the frequency, direction-greater than recommended (GTR) and less than recommended (LTR)- and magnitude of over-rides, and then compared recommended and over-ride doses' blood glucose (BG) variability and insulin resistance, two measures of IIT CDSS associated with mortality. The authors hypothesized that rates of hypoglycemia and hyperglycemia would be greater for recommended than over-ride doses. Finally, the authors observed and interviewed nurse users.
Results: 5.1% (9075) of 179,452 IIT CDSS doses were over-rides. 83.4% of over-ride doses were LTR, and 45.5% of these were ≥ 50% lower than recommended. In contrast, 78.9% of GTR doses were ≤ 25% higher than recommended. When recommended doses were administered, the rate of hypoglycemia was higher than the rate for GTR (p = 0.257) and LTR (p = 0.033) doses. When recommended doses were administered, the rate of hyperglycemia was lower than the rate for GTR (p = 0.003) and LTR (p < 0.001) doses. Estimates of patients' insulin requirements were higher for LTR doses than recommended and GTR doses. Nurses reported trusting IIT CDSS overall but appeared concerned about recommendations when administering LTR doses.
Conclusion: When over-riding IIT CDSS recommendations, nurses overwhelmingly administered LTR doses, which emphasized prevention of hypoglycemia but interfered with hyperglycemia control, especially when BG was >150 mg/dl. Nurses appeared to consider the amount of a recommended insulin dose, not a patient's trend of insulin resistance, when administering LTR doses overall. Over-rides affected IIT CDSS protocol performance.
Download full-text PDF |
Source |
|---|---|
| http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3078667 | PMC |
| http://dx.doi.org/10.1136/amiajnl-2011-000129 | DOI Listing |
Publication Analysis
Top Keywords
Similar Publications
Barriers and facilitators to the use of computer-based intensive insulin therapy.
Int J Med Inform
December 2011
Department of Biomedical Informatics, Vanderbilt University School of Medicine, United States.
Purpose: Computerized clinical decision support systems (CDSSs) for intensive insulin therapy (IIT) are increasingly common. However, recent studies question IIT's safety and mortality benefit. Researchers have identified factors influencing IIT performance, but little is known about how workflow affects computer-based IIT.
View Article and Find Full Text PDFCharacteristics and effects of nurse dosing over-rides on computer-based intensive insulin therapy protocol performance.
J Am Med Inform Assoc
May 2011
Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
Objective: To determine characteristics and effects of nurse dosing over-rides of a clinical decision support system (CDSS) for intensive insulin therapy (IIT) in critical care units.
Design: Retrospective analysis of patient database records and ethnographic study of nurses using IIT CDSS.
Measurements: The authors determined the frequency, direction-greater than recommended (GTR) and less than recommended (LTR)- and magnitude of over-rides, and then compared recommended and over-ride doses' blood glucose (BG) variability and insulin resistance, two measures of IIT CDSS associated with mortality.
Effects of blood glucose transcription mismatches on a computer-based intensive insulin therapy protocol.
Intensive Care Med
September 2010
Department of Biomedical Informatics, Vanderbilt University School of Medicine, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA.
Purpose: Computerized clinical decision support systems (CDSS) for intensive insulin therapy (IIT) generate recommendations using blood glucose (BG) values manually transcribed from testing devices to computers, a potential source of error. We quantified the frequency and effect of blood glucose transcription mismatches on IIT protocol performance.
Methods: We examined 38 months of retrospective data for patients treated with CDSS IIT in two intensive care units at one teaching hospital.
Social, organizational, and contextual characteristics of clinical decision support systems for intensive insulin therapy: a literature review and case study.
Int J Med Inform
January 2010
Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA.
Introduction: Evaluations of computerized clinical decision support systems (CDSS) typically focus on clinical performance changes and do not include social, organizational, and contextual characteristics explaining use and effectiveness. Studies of CDSS for intensive insulin therapy (IIT) are no exception, and the literature lacks an understanding of effective computer-based IIT implementation and operation.
Results: This paper presents (1) a literature review of computer-based IIT evaluations through the lens of institutional theory, a discipline from sociology and organization studies, to demonstrate the inconsistent reporting of workflow and care process execution and (2) a single-site case study to illustrate how computer-based IIT requires substantial organizational change and creates additional complexity with unintended consequences including error.
Want AI Summaries of new PubMed Abstracts delivered to your In-box?
Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!