Page 84 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

52 PART 1: An Overview of the Approach to and Organization of Critical Care

■ COMPUTERIZED PHYSICIAN ORDER ENTRY • Closed-loop control: Based on expert systems, this type of CDDS

Computerized physician order entry (CPOE) can be used to order includes a computer linked directly to a technical device, with
the capability to adjust that device without human intervention.
medications, laboratory tests, radiologic investigations, and consultation
services. In many instances, CPOE has been demonstrated to decrease Mechanical ventilators and automated target control drug deliv-
ery are examples of closed-loop control devices that are equipped
the time taken to complete an order, decrease associated complications
(handwriting identification and medication errors), and improve billing with the capability to automatically adjust one parameter based on
another.
management. One of the major reported effects of CPOE is a 55%
medication errors is almost twice that found in other hospital settings. ■ BEDSIDE MONITORING
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decrease in serious medication errors. In the ICU, the rate of preventable
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Earlier study in 1993 found that CPOE implementation lowered costs per Bedside monitors are an essential part of the ICU electronic environment
admission by $887 and length of stay decreased by 0.89 days. Advanced and generate a large quantity of data. Bedside monitoring is a specific
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CPOE systems can also utilize elements of CDSS. part of device technology that is a subset of biomedical technology.
More widespread use of CPOE has, however, uncovered some new errors The development of bedside monitors correlates with advances in
and underlines the importance of post adoption safety surveillance and hardware and software technology. Gradual incorporation of microcom-
adverse event reporting, a provision that is currently being debated as part puters and sophisticated algorithms has increased the ability of monitors
of the ongoing discussion about meaningful use. The problem with CPOE to calculate and display meaningful clinical parameters. Modern moni-
deployments can be overcome by systematically developing and applying tors can communicate with EHR and archive data. The rate of change
human-centered design, implementation, and evaluation methods led by of patient monitors is now limited by the rate of advance in sensor
practitioners experienced in medical informatics. In addition to concerns technology. The future generation of medical sensors should be wire-
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about increased complexity and the potential negative impact on patient- less, portable, durable, noninvasive, and especially for military medicine
centered outcomes, implementation of CPOE can be slow, resource inten- cheap and disposable.
sive, and costly. Indeed the cost of implementation has emerged as a critical The rationale for current use of physiological monitoring in the ICU
barrier to providers working in smaller group practices. is to facilitate the detection (and prediction) of physiological instabil-
■ CLINICAL DECISION SUPPORT SYSTEM ity. Reliance on physiologic data alone to trigger alerts about complex
disease states such as sepsis has led to poor specificity. Monitoring
The US Office of the National Coordinator for Health Information data needs to be integrated with other patient-related information.
Technology (ONC) defines Clinical Decision Support System (CDSS) For example, arterial blood pressure should be evaluated together with
as providing “clinicians, staff, patients, or other individuals with knowl- information about vasoactive drugs administration. Modern ICUs have
edge and person-specific information, intelligently filtered or presented multiple monitoring devices that display and archive data through
at appropriate times, to enhance health and health care. CDSS encom- charting programs linked to the EHR. This capability facilitates the
passes a variety of tools to enhance decision making in the clinical development of algorithms that combine information contained within
workflow. These tools include computerized alerts and reminders to the EHR (ventilator settings, laboratory values, or imaging reports) with
care providers and patients, clinical guidelines, condition-specific order vital signs data (heart rate, respiratory rate, temperature, pulse oximetry)
sets, focused patient data reports and summaries, documentation from a bedside monitor and form the basis of smart alerts. 21
templates, diagnostic support, and contextually relevant reference infor- ■
mation, among other tools.” TELEMEDICINE
Computer technologies should facilitate and enhance the clinician’s The ICU manpower shortage and lack of on-site expertise has created
ability to make decisions for the benefit of the patient. A classical a demand for remote consultations and monitoring. Surprisingly, back
example of a successful CDSS is the Health Evaluation Through Logical in 1997, only 27% of ICU patients were treated by intensivists. One of
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Processing (HELP) system. 18 the emerging technologies that may help deal with this problem is tele-
CDSS can support clinical decision making in a number of ways. medicine (Fig. 8-3). The American Telemedicine Association defines
telemedicine as “the use of medical information, exchanged from one
• Alert: Notification about an event or inaction. Examples include
drug-drug interactions, allergy, dosing errors, or blood transfusion site to another via electronic communications, to improve patients’
ordering. There are two modes of interaction: passive guidance health status”. The first reported use of telemedicine (intermittent con-
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when notification is delivered in a way that does not interrupt work- sultative advice) was published in 1982. Until recently, technological
flow, and active alerting, which forces clinicians to take action and issues represented the major barrier to widespread implementation of
potentially interrupt workflow. telemanagement in the ICU. While these technological barriers have
been overcome and several companies offer commercial packages for
• Critique the decision and propose alternatives: Computer ICU telemedicine, the evidence supporting their ability to add value to
system analyze the decision and suggest alternative solutions if the care of ICU patients is conflicting. In addition, the start-up costs,
needed. Guidance for blood transfusion is an example of such a estimated at up to $50,000 per ICU bed, and ongoing staffing expenses
system. 20 have emerged as the key barriers to more widespread adoption.
• Expert systems: Developed in medicine for over 40 years. In general,
expert systems can be classified into two categories: diagnostic or ■ MOBILE COMPUTING
therapeutic. Most use Bayesian probability to generate a recommen- The development of mobile networks and hardware opens up exciting
dation but systems have been developed which utilize fuzzy logic,
neural networks, pattern matching, and machine learning. possibilities for the future of the EMR. Wi-Fi networks and high-speed
cellular networks (3G and 4G) allow access to data from remote loca-
• Retrospective quality assurance: This is a post hoc analysis of prior tions. The most recent generation of handheld devices offer very high
decisions and suggestions for better future solutions. screen resolution comparable with desktop monitors, intuitive gesture-
• Reference links to online guidelines and training materials based interactions, and integration with desktop applications. Tablet
(Infobuttons): During the examination of the patient’s EMR, a clini- computers are becoming lightweight (~2 lb) with unprecedented battery
cian has access to content dependent references for data interpreta- life (~10 hours) and no boot time compared to laptops. These features
tion and potential therapeutic options. Examples of such Infobutons have made them popular with health care providers. According to
includes: UpToDate, Isabel, Epocrates, Micromedex, and InfoButton Manhattan Research, “Physicians in 2012: The Outlook for on Demand,
Access from Thomson Reuters. Mobile, and Social Digital Media,” the number of physicians who own

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