The evolution of eProtocols that enable reproducible clinical research and care methods

Abstract

Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation. Our eProtocols have progressed from a locally developed mainframe computer application in one clinical site (LDS Hospital) to web-based applications available in multiple languages and used internationally. We use eProtocol-insulin as an example to illustrate this evolution. We initially developed eProtocol-insulin as a local quality improvement effort to manage stress hyperglycemia in the adult intensive care unit (ICU). We extended eProtocol-insulin use to translate our quality improvement results into usual clinical care at Intermountain Healthcare ICUs. We exported eProtocol-insulin to support research in other US and international institutions, and extended our work to the pediatric ICU. We iteratively refined eProtocol-insulin throughout these transitions, and incorporated new knowledge about managing stress hyperglycemia in the ICU. Based on our experience in the development and clinical use of eProtocols, we outline remaining challenges to eProtocol development, widespread distribution and use, and suggest a process for eProtocol development. Technical and regulatory issues, as well as standardization of protocol development, validation and maintenance, need to be addressed. Resolution of these issues should facilitate general use of eProtocols to improve patient care.

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*

“…An accepted ventilator management protocol(20) might encourage less variability and more systematic decisions about reductions in pressures and volumes. However, a randomized, controlled trial is needed to determine if adherence to such a protocol leads to a better outcome.…”

The European Society for Computing and Technology in Anaesthesia and Intensive Care (ESCTAIC): a special issue of full papers (Amsterdam meeting 2010) and conference abstracts (Erlangen meeting 2011)

“…Eight full papers [3][4][5][6][7][8][9][10] were accepted following peer review for publication in this issue, and these reflect the activities of ESCTAIC meeting participants. Three of the papers [3][4][5] deal with monitoring of oxygenation and perfusion covering a spectrum of topics from basic physiological principles to the state of the art in monitoring technologies.…”

“…Hurrell et al [7] describe a strategy and progress toward defining a standards-based anaesthesia record using a consistent model and vocabulary and using international standards. The effective use of clinical data is highlighted by two papers looking at clinical decision support [8,9]. Blagev et al [8] present a summary of the large quantity of work that has taken place over several decades at the University of Utah and collaborative partners, in the field of clinical decision support based upon automated protocols.…”

“…The effective use of clinical data is highlighted by two papers looking at clinical decision support [8,9]. Blagev et al [8] present a summary of the large quantity of work that has taken place over several decades at the University of Utah and collaborative partners, in the field of clinical decision support based upon automated protocols. Medical applications areas range from fluid administration, to glucose regulation and mechanical ventilator control, with protocols implemented locally and over many institutions, using various platforms including web-based browsers.…”

Protocols and Hospital Mortality in Critically Ill Patients

“…The use of clinical protocols that target specific clinical syndromes is one method to decrease unnecessary variation in care and improve compliance with desired therapies 4-6 . Clinical protocols are prevalent in academic hospitals in the United States 7 , and have been shown to be associated with desired treatments in patients with acute lung injury, ventilator weaning and sedation management 2,8-10 .…”