J Am Med Inform Assoc - Characteristics and effects of nurse dosing over-rides on computer-based intensive insulin therapy protocol performance.

Tópicos

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Resumo

JECTIVE: 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.

Resumo Limpo

jectiv determin characterist effect nurs dose overrid clinic decis support system cdss intens insulin therapi iit critic care unitsdesign retrospect analysi patient databas record ethnograph studi nurs use iit cdssmeasur author determin frequenc directiongreat recommend gtr less recommend ltr magnitud overrid compar recommend overrid dose blood glucos bg variabl insulin resist two measur iit cdss associ mortal author hypothes rate hypoglycemia hyperglycemia greater recommend overrid dose final author observ interview nurs usersresult iit cdss dose overrid overrid dose ltr lower recommend contrast gtr dose higher recommend recommend dose administ rate hypoglycemia higher rate gtr p ltr p dose recommend dose administ rate hyperglycemia lower rate gtr p ltr p dose estim patient insulin requir higher ltr dose recommend gtr dose nurs report trust iit cdss overal appear concern recommend administ ltr dosesconclus overrid iit cdss recommend nurs overwhelm administ ltr dose emphas prevent hypoglycemia interf hyperglycemia control especi bg mgdl nurs appear consid amount recommend insulin dose patient trend insulin resist administ ltr dose overal overrid affect iit cdss protocol perform

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