A strategy for development of computerized critical care decision support systems

Abstract

It is not enough to merely manage medical information. It is difficult to justify the cost of hospital information systems (HIS) or intensive care unit (ICU) patient data management systems (PDMS) on this basis alone. The real benefit of an integrated HIS or PDMS is in decision support. Although there are a variety of HIS and ICU PDMS systems available there are few that provide ICU decision support. The HELP system at the LDS Hospital is an example of a HIS which provides decision support on many different levels. In the ICU there are decision support tools for antibiotic therapy, nutritional management, and management of mechanical ventilation. Computer protocols for the management of mechanical ventilation (respiratory evaluation, ventilation, oxygenation, weaning and extubation) in patients with adult respiratory distress syndrome ((ARDS) have already been developed and clinically validated at the LDS Hospital. These protocols utilize the bedside intensive care unit (ICU) computer terminal to prompt the clinical care team with therapeutic and diagnostic suggestions. The protocols (in paper flow diagram and computerized form) have been used for over 40,000 hours in more than 125 adult respiratory distress syndrome (ARDS) patients. The protocols controlled care for 94% of the time. The remainder of the time patient care was not protocol controlled was a result of the patient being in states not covered by current protocollogic (e.g. hemodynamic instability, or transport for X-Ray studies). 52 of these ARDS patients met extra corporal membrane oxygenation (ECMO) criteria. The survival of the ECMO criteria ARDS patients was 41%, four times that expected (9%) from historical data (p<0.0002). The success of these computer protocols and their acceptance by the clinical staff clearly establishes the feasibility of controlling the therapy of severely ill patients.

Over the last four years we have refined the process which we use for generating computerized protocols. The purpose of this paper is to present the six step development strategy which we are successfully using to produce computerized critical care protocols.