护士剂量Override 对基于计算机的强化胰岛素治疗方案执行情况的特征和影响。
Characteristics and effects of nurse dosing over-rides on computer-based intensive insulin therapy protocol performance.
机构信息
Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
出版信息
J Am Med Inform Assoc. 2011 May 1;18(3):251-8. doi: 10.1136/amiajnl-2011-000129. Epub 2011 Mar 14.
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.
目的
确定重症监护病房（ICU）中强化胰岛素治疗（IIT）临床决策支持系统（CDSS）的护士剂量Override 的特征和影响。
设计
患者数据库记录的回顾性分析和使用 IIT CDSS 的护士的民族志研究。
测量
作者确定了Override 的频率、方向（大于推荐值（GTR）和小于推荐值（LTR））和幅度，并比较了推荐剂量和Override 剂量的血糖（BG）变异性和胰岛素抵抗，这两个指标与死亡率相关。作者假设推荐剂量的低血糖和高血糖发生率将高于Override 剂量。最后，作者观察并采访了护士用户。
结果
在 179452 次 IIT CDSS 剂量中，有 5.1%（9075）是Override。83.4%的Override 剂量是 LTR，其中 45.5%的剂量比推荐值低≥50%。相比之下，78.9%的 GTR 剂量比推荐值高≤25%。当给予推荐剂量时，低血糖的发生率高于 GTR（p=0.257）和 LTR（p=0.033）剂量。当给予推荐剂量时，高血糖的发生率低于 GTR（p=0.003）和 LTR（p<0.001）剂量。LTR 剂量的患者胰岛素需求量估计值高于推荐值和 GTR 剂量。护士总体上表示信任 IIT CDSS，但在给予 LTR 剂量时似乎对推荐值感到担忧。
结论
当Override IIT CDSS 建议时，护士压倒性地给予 LTR 剂量，这强调了预防低血糖，但干扰了高血糖控制，特别是当 BG>150mg/dl 时。护士在给予 LTR 剂量时，似乎总体上考虑了推荐胰岛素剂量的量，而不是患者的胰岛素抵抗趋势。Override 影响了 IIT CDSS 方案的执行。
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