Skip to 0 minutes and 5 secondsPhysicians in the case scenario ignored the advice of the ID consultant. While ID consultants-- consultations have been associated with improved patient outcomes, at least for some infections, such as Staph aureus bacteremia they are time-consuming, and much of the time is dedicated to the assessment and collection of information. Nowadays, at least in theory, this information should be available in the electronic health record, and hence the interest to use computerised decisions support systems to guide the physician to make the correct treatment and diagnostic decisions. The computerised decision support systems are designed to provide the physician, at the time when he or she needs it, with the relevant information.
Skip to 0 minutes and 49 secondsDespite the great promise the system holds also for antibiotic stewardship, the results of studies so far examining the impact on appropriate antibiotic use have been relatively disappointing for several reasons that we will discuss later.
Computerised systems to aid decision-making
In this video Dr Benedikt Huttner discusses how information should be held on computerised systems to aid decision-making.
Watch the video and then read this extract from the Nachtigall et al paper and consider the following questions:
- What are the advantages of the described system?
- What are its limitations?
- What would be obstacles to the implementation of the system in your setting?
- How do you think the system could be improved?
The full paper contains screen shots of the CDSS which are omitted from this extract.
….a CDSS for antibiotic therapy was designed as a tool to provide clinicians with essential guideline-based information concerning the treatment of infections, the use of antibiotic agents and microbiological diagnostics in the ICU. The CDSS could be accessed from every computer in the hospital, including all computers used to document electronic patient files. The CDSS contains algorithms and pathways for most infections occurring in patients in surgical ICUs. For every infection included in the CDSS, there is one main five step algorithm. This algorithm leads the user to the first interface to reassess infection signs to evaluate whether diagnosis of an infection is plausible. Next, the user is guided to a page where the suspected infection focus has to be identified. Then, there is a request for differential diagnoses and focus specifications, followed by a fourth page showing diagnostic procedures that are needed for the specific focus. In the fifth step there is a page where suggestions are made for empiric therapy (compare figure 1A). Additionally, the CDSS includes links to references and background information focusing on the infections covered and also points out the tools required, for example, calculators for renal creatinine clearance. Local resistance patterns of bacterial pathogens were included for every study ward (compare figure 1B–C). Each algorithm was developed by a multidisciplinary team of ICU experts from the fields of microbiology, infectious diseases, surgery, pharmacology and specialists for each focus of the algorithms. The team also included front-line providers of patient care and those with less professional experience (residents and medical students).
The CDSS also contains a section for bacterial pathogens and their targeted treatment (compare figure 1B). In patients with microbiological pathogen identification the CDSS can be used to guide choice of targeted antibiotic therapy as well. In summary, the programme was initially developed to support empiric antibiotic therapy but also addressed de-escalation strategies and targeted antibiotic therapy when pathogens were identified in microbiological diagnostics. The programme also incorporates educational aspects with tools and evidence from the current medical literature to support recommendations given. After the programme was finished and released, it was introduced in every ICU of the department, giving every staff member the opportunity to be trained in the applications. The programme included a contact link to communicate with the team responsible for drafting the CDSS. Furthermore, one physician provided telephone support. All queries were immediately discussed in the team and, if deemed relevant, incorporated into the decision pathways. One full-time physician was responsible for changing the programme, for example, if new drugs were available or locally updated resistance was available during the course of the study….