A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages

Abstract

Background: Computer clinical decision support (CDS) systems are uncommon in the pediatric intensive care unit (PICU), despite evidence suggesting they improve outcomes in adult ICUs. We reasoned that a bedside CDS protocol for intravenous insulin titration, eProtocol-insulin, would be feasible and safe in critically ill children. Methods: We retrospectively reviewed data from non-diabetic children admitted to the PICU with blood glucose (BG) ‡140 mg/dL who were managed with intravenous insulin by either unaided clinician titration or eProtocol-insulin. Primary outcomes were BG measurements in target range (80-110 mg/dL) and severe hypoglycemia (BG £40 mg/dL); secondary outcomes were 60-day mortality and PICU length of stay. We assessed bedside nurse satisfaction with the eProtocol-insulin protocol by using a 5-point Likert scale and measured clinician compliance with eProtocol-insulin recommendations. Results: Over 5 years, 69 children were titrated with eProtocol-insulin versus 104 by unaided clinicians. eProtocol-insulin achieved target range more frequently than clinician titration (41% vs. 32%, P < 0.001). Severe hypoglycemia was uncommon in both groups (4.3% of patients in eProtocol-insulin, 8.7% in clinician titration, P = 0.37). There were no differences in mean time to BG target or median BG between the groups. Mortality was 23% in both groups. Clinician compliance with eProtocol-insulin recommendations was 89%. Nurses believed that eProtocol-insulin was easy to understand and safer than clinician titration. Conclusions: eProtocol-insulin is safe for titration of intravenous insulin in critically ill children. Clinical research protocols and quality improvement initiatives aimed at optimizing BG control should utilize detailed computer protocols that enable replicable clinician decisions.

Use of a Risk Analytic Algorithm to Inform Weaning From Vasoactive Medication in Patients Following Pediatric Cardiac Surgery

“…This clinical decision support tool has the potential to deliver relevant higher-order information on patient stability. When incorporated into a robust clinical decision support protocol, ID o 2 may be able to inform earlier weaning decisions and therefore improve on the accuracy and efficiency of care de-escalation ( 12 , 13 , 21 , 23 , 24 ). Future studies should aim to assess the clinical relevance of risk analytic algorithms during the de-escalation phases of care.…”

Performance of an Electronic Decision Support System as a Therapeutic Intervention During a Multicenter PICU Clinical Trial

“… 1 Additionally, the use of CDS systems for multicenter research trials are often underutilized. 2 , 3 , 4 With the use of an electronic CDS system, Children’s Hospital Euglycemia for Kids Spreadsheet (CHECKS), the National Institutes of Health-funded Heart and Lung Failure-Pediatric Insulin Titration (HALF-PINT) trial demonstrated that blood glucose control to a target of 80 to 110 mg/dL with IV insulin was associated with increased hypoglycemia and conferred no advantage compared with a blood glucose target of 150 to 180 mg/dL. 5 Large multicenter trials provide the highest quality evidence that indicates the optimal approach to blood glucose control with IV insulin.…”