Submission to AIME 2009
- 1. Implementing a Clinical Decision Support System for Glucose Control for the Intensive Cardiac Care Rogier Barendse, Jonathan Lipton, Maarten van Ettinger, Stefan Nelwan, Niek van der Putten Erasmus MC, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands r.barendse@erasmusmc.nl Abstract. Adherence to guidelines and protocols in clinical practice can be difficult to achieve. We describe the implementation of a Clinical Decision Support System (CDSS) for glucose control on the Intensive Cardiac Care Unit (ICCU) of the Erasmus MC. An existing paper protocol for glucose control was used for the CDSS rule set. In the first phase we implemented a proof of concept of a CDSS: a web 2.0 AJAX-driven web screen, which resulted in an improved adherence to the glucose guideline. This paper will reflect on the technical implementations and challenges of our experience with this process. The end product will allow: storage of guidelines in a shareable and uniform matter, presentation of guidelines in a more clear way to physicians, a more flexible platform to maintain guidelines, the ability to adjust guidelines to incorporate changes based on collected evidence from the CDSS and/or literature review, and be able to better review the outcome. Keywords: Glucose management, CDSS, ICCU, CCU, cardiology, nurse- driven guideline, web 2.0, guideline implementation 1 Introduction The use and effects of CDSS systems in clinical practice have been studied extensively and have shown to be an effective mean to improve healthcare 1,2 . At the Thoraxcentre of the Erasmus MC we have started to implement CDSS by automating the glucose protocol of the ICCU. Glucose regulation is difficult to achieve and may have significant implications for clinical outcome3. Though the clinical problem is complex, the nature of the paper protocol was very straightforward and therefore a good starting point. The ICCU of the Thoraxcentre treats cardiology patients who require intensive care. These patients have continuous monitoring of vital signs which are registered, along with other clinical data in a Patient Data Management System (PDMS), Innovian4. 1.1 Paper protocol A simple, rule based, sliding scale glucose protocol was used and was available at each patient bedside. The protocol was nurse-driven and dependent on glucose
- 2. 2 Rogier Barendse, Jonathan Lipton, Maarten van Ettinger, Stefan Nelwan, Niek van der Putten measurements determined by the laboratory. Compliance was low regarding advised insulin dosage and timing of measurements: there was a lack of notification when new lab results were available and there was no reminder on when to re-determine glucose values. These factors were given as the main reasons for not adhering to the protocol. The paper protocol uses the most recent glucose measurement to advise an action of starting, adjusting or stopping insulin pump, and advises to measure glucose again within a certain amount of time. The lab results are sent to the patient monitor, the PDMS and the Electronic Patient Record (EPR). A retrospective study of the data in the PDMS system revealed low compliance the protocol5. The protocol rules could not be defined as a gold standard: users suggested that the protocol could be improved with regard to certain points. 2 Methods To achieve higher protocol compliance we decided to implant a CDSS that would resolve some of the previously mentioned problems. We deployed a medical touch screen computer at the nurse desk which displays the 8 beds of the ICCU with patient characteristics, previous glucose measurements and insulin pump settings (Figure 1). When a new glucose measurement for a patient arrives, a popup appears on the “bed” of the corresponding patient. The popup displays the glucose value, time of measurement, generated advice regarding insulin treatment and advised time for the next glucose measurement. Fig. 1. Screen shot of the Glucose Screen with explanation. Fig 1 shows the Glucose Screen. This is a web 2.0 Ajax-driven web interface that polls the glucose web service every 10 seconds using SOAP. The web service
- 3. Implementing a Clinical Decision Support System for Glucose Control for the Intensive Cardiac Care 3 component runs on a web server and caches the lab values, the insulin pump settings and the generated decision of each lab value, every minute. The database runs on SQL Server 2000 and is a real-time replicated database of the PDMS database. The database has extra tables for the glucose lab values, the generated advice and audit information. Figure 2 shows the dataflow of the application. The guideline engine consists of an if-else structure, hard coded into the web service. The values needed for calculation of the generated advice are entered into the decision tree and a corresponding advice is returned. We collected the data, the glucose value, the time of measurement, time of display and the time of reaction into this database. Fig. 2. Dataflow schema of the Glucose Screen 3 Results In our setup the nurse no longer is required to actively look in the PDMS or EPR system to retrieve the latest measurement. The nurse can now easily discover new measurements and the generated advice by glancing at a fixed screen at the nursing station of the ward. After implementation of the CDSS adherence to the glucose protocol increased when compared to baseline5. During a 4 month period we collected 3418 glucose measurements. Retrospectively we analyzed 15360 glucose measurements from the same ICCU from 18 months before the implementation of the CDSS. Patients that had less than 2 glucose measurements were not included in the analyses. The percentage of glucose measurements performed on time (next measurement not later than the advised time + 10%) increased after implementation from 41% to 55%, an increase of 13.2% (95%CI 11.4% to 15.1% P<0.001). Compliance with advised insulin dosage also improved from 48% to 58%, increase of 9.8% (95% CI 7.9% to 11.6% P<0.001).
- 4. 4 Rogier Barendse, Jonathan Lipton, Maarten van Ettinger, Stefan Nelwan, Niek van der Putten 4 Future work One of the challenges in generating this application was retrieving the necessary data. Several sources, such as the hospital information system (HIS), the EPR built on the HIS and the PDMS provide the necessary data elements. The PDMS in itself receives data from the HIS (lab and patient demographics). Getting the necessary data from 3 rd party applications can be challenging. Currently we are extending the project with a third-party commercial decision support tool Gaston6. The tool consists of a guideline executer and an interface to visually design guidelines. Also it has built-in support for data acquisition and several other features. Figure 3 shows the guideline editor. In this program physicians can specify the guidelines themselves. These guidelines are immediately available from a web service when published. This gives us a clear distinction between guidelines and corresponding advice and the display of these guidelines on the screen. With this extension we can focus our research more on implementation of CDSS and on how we can deliver the generated guidelines to the nurse or physician in the most efficient way possible. We want to extend the current application with this rule engine in our webservice. In a later phase we plan to implement a framework for transporting guidelines to other screens, applications and devices. Many aspects of the implementation would be facilitated by an improved data integration of the different products and/or systems. A data warehouse solution would not work in the current setup, since the extraction would only be daily at most and not continuously. At the moment we are implementing HL7 to receive the lab data to be less dependent on the lab data in the PDMS. The new improvements, Gaston and HL7 lab will facilitate and speed up the implementation of new guidelines in a faster and more flexible fashion. Fig. 3. A screenshot of the KA-tool of Gaston with Glucose Decision Tree
- 5. Implementing a Clinical Decision Support System for Glucose Control for the Intensive Cardiac Care 5 5 Discussion We would like to expand CDSS into our organization. This will consist of working with 3-party software vendors that are capable of integrating CDSS into their application. Also we want to be able to extend CDSS to other platforms at the point of care e.g. PDA’s. Validating the outcome of our research is challenging as it is an iterative process with many different alterations: we have been upgrading software periodically on one side and also been improving the guideline on the other side. Each change has been documented and data has been collected until each point of the update. We chose to use different outcome measures for evaluating technical aspects, protocol compliance and clinical outcomes to be able to investigate the effect of each of these changes we made. When interpreting the results it is important to consider that it is possible that changes to the guideline may result in increased adherence, but not always in improved clinical measures, and that technical improvements may lead to improved outcomes as well, irrespective of guideline adherence (e.g. a better graphical display of certain laboratory values may lead to earlier detection of abnormal values). Finally one must always be on the lookout for „bugs‟ (both technical as inconsistencies in guidelines) that can adversely affect patient care. 6 References 1. Garg AX, Adhikari NKJ, McDonald H, et al. Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review. JAMA. 2005;293(10):1223-1238. 2. Kaplan B. Evaluating informatics applications--clinical decision support systems literature review. International Journal of Medical Informatics. 2001;64(1):15-37. 3. Weston C, Walker L, Birkhead J, National Audit of Myocardial Infarction Project NIFCOR. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart. 2007;93(12):1542-1546. 4. Nelwan S, van Dam T, Meij S, van der Putten N. Implementation and use of a patient data management system in the intensive care unit: A two-year experience. In: Computers in Cardiology, 2007.; 2007:221-224. 5. Lipton J, Barendse R, Eenkhoorn E, et al. Glucose Control as a Model for Implementation of a Clinical Decision Support System. In: CIC Proceedings.Vol 35. Bolonga; 2008:661-664. 6. de Clercq PA, Hasman A, Blom JA, Korsten HHM. Design and implementation of a framework to support the development of clinical guidelines. International Journal of Medical Informatics. 2001;64(2-3):285-318.