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      Rational use of computerized protocols in the intensive care unit

      , 1

      Critical Care

      BioMed Central

      decision-support, intensive care, protocols, research, safety

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          Abstract

          Excess information in complex ICU environments exceeds human decision making limits, increasing the likelihood of clinical errors. Explicit decision-support tools have favorable effects on clinician and patient outcomes and can reduce the variation in clinical practice that persists even when guidelines based on reputable evidence are available. Computerized protocols used for complex clinical problems generate, at the point-of-care, patient-specific evidence-based therapy instructions that can be carried out by different clinicians with almost no inter-clinician variability. Individualization of patient therapy is preserved by these explicit protocols since they are driven by patient data. Computerized protocols that aid ICU decision-makers should be more widely distributed.

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          Most cited references 73

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          Human error: models and management.

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            The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.

            Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice. We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean-contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative. Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who received the antibiotics perioperatively, 4 (1.4 percent) had such infections (P = 0.12; relative risk as compared with the preoperatively treated group, 2.4; 95 percent confidence interval, 0.9 to 7.9). Of 488 patients who received the antibiotics postoperatively, 16 (3.3 percent) had wound infections (P less than 0.0001; relative risk, 5.8; 95 percent confidence interval, 2.6 to 12.3). Finally, of 369 patients who had antibiotics administered early, 14 (3.8 percent) had wound infections (P less than 0.0001; relative risk, 6.7; 95 percent confidence interval, 2.9 to 14.7). Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection. We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection.
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              Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality.

              To determine the excess length of stay, extra costs, and mortality attributable to adverse drug events (ADEs) in hospitalized patients. Matched case-control study. The LDS Hospital, a tertiary care health care institution. All patients admitted to LDS Hospital from January 1, 1990, to December 31, 1993, were eligible. Cases were defined as patients with ADEs that occurred during hospitalization; controls were selected according to matching variables in a stepwise fashion. Controls were matched to cases on primary discharge diagnosis related group (DRG), age, sex, acuity, and year of admission; varying numbers of controls were matched to each case. Matching was successful for 71% of the cases, leading to 1580 cases and 20,197 controls. Crude and attributable mortality, crude and attributable length of stay, and cost of hospitalization. ADEs complicated 2.43 per 100 admissions to the LDS Hospital during the study period. The crude mortality rates for the cases and matched controls were 3.5% and 1.05%, respectively (P<.001). The mean length of hospital stay significantly differed between the cases and matched controls (7.69 vs 4.46 days; P<.001) as did the mean cost of hospitalization ($10,010 vs $5355; P<.001). The extra length of hospital stay attributable to an ADE was 1.74 days (P<.001). The excess cost of hospitalization attributable to an ADE was $2013 (P<.001). A linear regression analysis for length of stay and cost controlling for all matching variables revealed that the occurrence of an ADE was associated with increased length of stay of 1.91 days and an increased cost of $2262 (P<.001). In a similar logistic regression analysis for mortality, the increased risk of death among patients experiencing an ADE was 1.88 (95% confidence interval, 1.54-2.22; P<.001). The attributable lengths of stay and costs of hospitalization for ADEs are substantial. An ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.
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                Author and article information

                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                2001
                13 September 2001
                : 5
                : 5
                : 249-254
                Affiliations
                [1 ]LDS Hospital and University of Utah School of Medicine, Salt Lake City, USA
                Article
                cc1041
                10.1186/cc1041
                137284
                11737899
                Copyright © 2001 BioMed Central Ltd
                Categories
                Review

                Emergency medicine & Trauma

                decision-support, protocols, intensive care, safety, research

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