Discussion: Clinical Decision Making
Discussion: Clinical Decision Making ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Clinical Decision Making Use your understanding of informatics based clinical decision making to post a discussion that answers the following questions: What clinical decision making tools have you used or seen used in nursing? How do these tools affect outcomes? What are the assets and barriers to the use of these tools? Discussion: Clinical Decision Making Should be APA style and have a reference page I Attached a few articles to help View lectures: Clinical Support Systems https://www.youtube.com/watch?v=o6-Ejw9vet8 Electronic Health Records Benefits for Practice https://www.youtube.com/watch?v=Z84fL4HzBmw Websites to View: https://n415son01.wordpress.com/2014/04/08/the-electronic-health-record-and-nursing-care/ clinical_decision_support_for_nursing_practice.pdf evaluating_informatics_applications.pdf informatics_solutions_for_decision_making.pdf CIN: Computers, Informatics, Nursing & Vol. 31, No. 10, 477495 & Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins C O N T I N U I N G E D U C A T I O N 2.4 ANCC Contact Hours Features of Computerized Clinical Decision Support Systems Supportive of Nursing Practice A Literature Review SEONAH LEE, PhD, MSN, RN According to the Institute of Medicine,1 the development and implementation of more sophisticated information systems are essential not only to enhance quality and efficiency of patient care but also to support clinical decision making.
Clinical decision support becomes more and more a core function of health information systems to eliminate preventable medical errors,2 and the investments in decision support technologies targeted at nursing practice have increased.3 A computerized clinical decision support system (CDSS) refers to any electronic system designed to aid directly in clinical decision making. To generate patientspecific recommendations, CDSSs use the characteristics of individual patients; these recommendations are then presented to nurses for consideration.4,5 The knowledge base embedded in CDSSs contains the rules and logic statements that encapsulate knowledge required for clinical decisions so that it generates tailored recommendations for individual patients.6 With this, CDSSs assist nurses in completing the knowledge base ruledriven decision making or standardized rule-driven decision making,7 instead of using their own biases and intuition.810 On the one hand, CDSSs applied to nursing care are an expansion of the CDSS prototype defined above. For example, CDSSs for nursing care provide prebuilt forms for data entry of patient assessment, care plans, or outcome evaluation on given nursing interventions.8 Although it is not the case of recommendations automatically generated by the algorithm, the predesigned forms help decision making for nurses because these present the full scope of components that should be included for This study aimed to organize the system features of decision support technologies targeted at nursing practice into assessment, problem identification, care plans, implementation, and outcome evaluation.
Discussion: Clinical Decision Making It also aimed to identify the range of the five stage-related sequential decision supports that computerized clinical decision support systems provided. MEDLINE, CINAHL, and EMBASE were searched. A total of 27 studies were reviewed. The system features collected represented the characteristics of each category from patient assessment to outcome evaluation. Several features were common across the reviewed systems. For the sequential decision support, all of the reviewed systems provided decision support in sequence for patient assessment and care plans. Fewer than half of the systems included problem identification. There were only three systems operating in an implementation stage and four systems in outcome evaluation. Consequently, the key steps for sequential decision support functions were initial patient assessment, problem identification, care plan, and outcome evaluation. Providing decision support in such a full scope will effectively help nurses clinical decision making.
By organizing the system features, a comprehensive picture of nursing practice oriented computerized decision support systems was obtained; however, the development of a guideline for better systems should go beyond the scope of a literature review. KEY WORDS Computerized clinical decision support systems & Features & Nursing care & Sequential decision support related nursing care activities. Thus, CDSSs for nursing care in this study include all the CDSS prototypes and the expanded versions. Author Affiliation: College of Nursing, University of Missouri-St. Louis, Missouri. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Seonah Lee, PhD, MSN, RN, College of Nursing, University of Missouri-St. Louis, One University Boulevard, St. Louis, MO 63121 ([email protected]). DOI: 10.1097/01.NCN.0000432127.99644.25 CIN: Computers, Informatics, Nursing & October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 477 Because using CDSSs to support nurses decision making is widespread, it is worth capturing which features of CDSSs were empirically effective for optimum decision support for frontline nurses. Currently, there are studies on CDSSs used to improve the clinical practice of nurses; however, system features addressing particular nursing care activities have been dispersed in individual reports. Nursing does not have the well-organized knowledge base on the features of nursing practiceoriented CDSSs in real practice settings.
Discussion: Clinical Decision Making The purpose of this study was to organize the features of CDSSs useful for nursing practice through a literature review, especially using the categories of assessment, problem identification (ie, diagnosis), care plans, implementation, and outcome evaluation. The current decision support technologies typically operate in these five stages. A certain CDSS helps decision making in a single stage, while other CDSSs help decision making in two or more stages. However, because of a lack of empirical investigations, it has not been clear whether a CDSS providing decision support in all the stages from assessment to outcome evaluation was more clinically useful than a CDSS operating, for example, in only a single stage of assessment. If there are evidential data to answer this question, the evidence should be included as an important feature for better decision support. As a preliminary to conducting an empirical study to address the question above, the first priority was in conducting a literature review to identify to the extent of sequential decision support provided by CDSSs in the stages from assessment to outcome evaluation. In this study, the sequential decision support, which is another important concept, is one of the CDSS features. METHODS Studies Eligible for Review To obtain the most relevant studies, studies eligible for inclusion were primary studies on CDSSs used for nursing practice and designed to contain at least two aspects of assessment, problem identification, care plans, implementation, and outcome evaluation.
Studies published in peerreviewed journals and in English were included. On the other hand, studies were excluded if they were studies on a nonelectronic decision support system such as a paperbased system, studies not providing a description on a CDSS, and studies providing only a technical description of a CDSS application (ie, testing algorithms of an application). Review studies on CDSSs were also excluded. Data Sources Databases of MEDLINE, CINAHL, and EMBASE were searched up to 2012 by using the search terms computer478 assisted decision support system, automated decision support, computerized evidence-based decision making, computerized evidence-based practice, and evidence, decision support system, having nursing in common. Conference proceedings and the reference lists of all included articles were reviewed to identify additional primary studies.Discussion: Clinical Decision Making Study Selection The author reviewed titles and abstracts of identified references and rated each article as potentially relevant or not relevant by using the inclusion and exclusion criteria. The author reviewed the full texts of potentially relevant primary studies and again rated each article as potentially relevant or not relevant using a screening checklist. Thus, the final selection of studies for review was made. A screening checklist was to check the presence or absence of and appropriateness of data that should be extracted from studies. Its content is identical to a data extraction form for double-checking (see Data Extraction section).
Use of the checklist prevented important data from inadvertently being omitted. Before actual use of the checklist, the author piloted it on a sample of three articles to address the issues of arranging the checklist items in user-friendly sequence and completing the checklist.11 Data Extraction The author extracted necessary information from each of the finally selected articles by using a data extraction form. The form was to record study purpose, study design, data collection methods, study settings and participants, nursing care areas addressed by the use of a CDSS, functions of a CDSS, study results, and features of a CDSS. The functions of a CDSS were categorized into assessment, problem identification, care plans, implementation, and outcome evaluation. A CDSS was considered having the functions of the stages from assessment to outcome evaluation: when a CDSS had preformulated forms for data entry that are embedding evidence to support clinical decision making relating from assessment to outcome evaluation, when the rule engine of a CDSS automatically generated recommendations or instructions for a next action based on data entered in a prior step, or when the sections from assessment to outcome evaluation were automatically linked to each other for a logical continuity of clinical decision making and then relevant data have to be entered in a prebuilt form or selected from a prebuilt list. For example, if an assessment entry form existed, the CDSS had the function for patient assessment.
If care plans were automatically generated based on assessment data entered, the CDSS had the functions of assessment and care plans.Discussion: Clinical Decision Making When a set of care plans was linked to patient outcome evaluation and then an outcome measurement CIN: Computers, Informatics, Nursing & October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. form should be filled out, the CDSS had the functions of care plans and outcome evaluation. Study results are any changes by the use of a CDSS. These would include improvement or nonimprovement in terms of, but not limited to, nurses decision making, nurse performance, and patient outcomes. As the features of CDSSs, components of CDSSs that improved nurses decision making, nurse performance, or patient outcomes were extracted. If some components deteriorated them (eg, the need to devise care plans made nurses spend much time), the author treated the logically opposite component as a potential improvement component (eg, removing the need to devise care plans made nurses save time).12,13 In addition, if authors of studies mentioned important features of their CDSS, the features were also included here. The functions of CDSSs mentioned above were integrated as part of the features of CDSSs. The author recorded extracted information on the data extraction form and also double-checked extracted information with original articles for accuracy.
Data Analysis The extracted data, including study purpose, design, data collection methods, settings and participants, nursing care areas addressed by the use of a CDSS, functions of a CDSS, and study results, were organized in tables. To synthesize CDSS features across the reviewed studies, the author carefully read and compared the features extracted from each study and divided them into meaning units. The meaning units were assessment, problem identification, care plans, implementation, and outcome evaluation. Discussion: Clinical Decision Making The author integrated or separately organized the features into key words and phrases capturing core content of each unit. The synthesized results were organized in a separate table. RESULTS Of 681 potentially relevant studies published from 1990 to 2012, 27 studies met the eligibility criteria and the items on the screening checklist. The study description in Table 1 combines study purpose, design, data collection methods, settings, and participants. Table 2 presents a summary of Table 1, which includes study purpose, design, data collection methods, CDSS-applied nursing care areas, and sequential decision support functions of CDSSs. Of the 27 studies reviewed, 17 were system development, and eight of the 17 studies piloted their system immediately after system development (Table 2). In the study purpose of Table 2, others included two studies examining barriers to use of computerized advice6,26 and a study evaluating completeness of nursing documentation.
19 The designs of 20 studies that conducted system evaluation or pilot test, except for seven studies of system development only, varied (Table 2). When considering the presence of a CDSS as the given intervention, 15 studies, which were mostly pilot tests, were posttest studies without a control group. Two pretest-posttest studies used different groups for comparison before and after system use. Four studies used a one-group pretest-posttest format. Also included were a quasi-experimental study with two nonrandomized control groups and a randomized controlled trial. Three studies used two different designs for their system evaluation or pilot test7,25,34; thus, they were counted twice in the design. Data collection methods used in the 20 studies for system evaluation or pilot test were individual interviews, focus group interviews, observations, chart review, analysis of screen usage, questionnaires for nurses and other healthcare providers, and questionnaires for patients. Eight studies collected data by mixed methods; three studies, by quantitative methods; and nine studies, by qualitative methods. Nursing care areas addressed by the use of a CDSS varied; however, fall, pressure ulcer, pain, blood glucose control, and patient referral overlapped, as shown in Tables 1 and 2. Eighteen studies targeted a single area of nursing care, while nine studies covered multiple areas of nursing care.Discussion: Clinical Decision Making Two mobile-based decision support systems targeted multiple areas of nursing care (Table 2). Table 1 presents the functions of CDSSs that provided decision support in the stages available from assessment to outcome evaluation.
The reviewed CDSSs showed the diverse ranges of sequential decision support functions. Sequential decision support for patient assessment and care plans existed in all of the reviewed CDSSs (Table 2). With reference to the sequence, movement to a next stage such as from assessment to problem identification or to care plans occurred as a next screen automatically showed up or was clicked after completion of a prior stage; a nurse was forced to implement the movement. Two studies assessment entry forms were to assess patients responses to treatments (ie, patient outcomes),34,35 instead of initial assessment for patients (Table 1). Most CDSSs started their function for patient assessment with a nurses entry in an electronic assessment form (Table 2). Five CDSSs started their function as they automatically retrieved necessary data from hospital databases or other connected information systems and a nurse inputs additional information. Three CDSSs were a real-time system for patient assessment,23,29,37 and two of them were tele-advice systems.29,37 Two CDSSs automatically assessed patients without input of a nurse (Table 2).23,29 For the details of CDSS functions from problem identification to outcome evaluation, see Table 1. Table 1 presents the study results on patient outcomes, nurse performance, and nurses decision making by the use of CDSSs.
The CDSSs were of benefit to patients and nurses as they improved patient status in the CIN: Computers, Informatics, Nursing & October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 479 480 CIN: Computers, Informatics, Nursing & October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Bakken et al (2007)16 Fall-injury management Browne et al (2004)15 Single nursing care area Delirium care Fick et al (2011)14 Study System development at the Columbia University Medical Center campus of Presbyterian Hospital in New York System development System evaluation by chart review after system use in all units at the Methodist Healthcare System of San Antonio in Texas Pilot study for feasibility (1) using questionnaires for 15 patients and their caregivers in a medical-surgical unit and (2) by analysis of screen uses and 34 nurses feedback at an acute care hospital in the central Pennsylvania region Study Description Characteristics of the 27 Studies ReviewedPart 1 T a b l e 1 A fall-injury risk management system within the hospital-wide information system A computerized documentation system for fall risk stand-alone). Discussion: Clinical Decision Making A decision support system for delirium superimposed on dementia within the electronic medical record (EMR) CDSS C: Problem-specific care plans are generated by the system. Fall risk information is integrated into an interdisciplinary communication network including report sheets, care conferences, and audits until solved. A: Fall-injury risk is assessed by the system with a nurses input.
The system rates a risk score. C: Institution-specific standard care plans are preselected and a nurse selects care plans from a drop-down box, based on a risk score. A: Fall risk is assessed by the system with a nurses input. The system rates a risk score. P: Fall risk categoryspecific problems are generated by the system. P: Presence of delirium is triggered by the system.a C: Individualized nonpharmacological care plans for the management and prevention of delirium are generated by the system. A: Delirium is assessed by the system with a nurses input and delirium-associated data automatically pulled from other electronic records. CDSS Functions of Assessment (A), Problem Identification (P), Care Plans (C), Implementation (I), and Outcome Evaluation (E) (continues) Fall and injury rates decreased but were not statistically significant at 6 mo after system use. 93% of patients improved or stayed the same on their mental health scores from admission to discharge.
Overall, nurses did not have problems in using the system. Study Results on Patient Outcomes and Nurses Performance and Decision Making CIN: Computers, Informatics, Nursing & October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 481 Gunningberg et al (2009)19 Clarke et al (2005)18 Pressure ulcer management Quaglini et al (2000)17 Study System development Pilot study for feasibility using questionnaires and qualitative data for nurses, mentors, experts in seven healthcare organizations (acute, home, intermediate, and extended care) in a Canadian urban health region A study examining the quality and comprehensiveness of nursing documentation by chart review before and after system use in a surgical, medical, and geriatric unit at the Swedish University Hospital System development Pilot study of feasibility by chart review for 40 patients in a general medicine ward Study Description CDSS A nursing documentation system for pressure ulcer within the electronic health record A decision support system for pressure ulcer prevention and treatment (stand-alone).
Discussion: Clinical Decision Making A system for pressure ulcer prevention and treatment within the electronic patient record (EPR) Characteristics of the 27 Studies ReviewedPart 1, Continued T a b l e 1 A: Pressure ulcer is assessed by the system with a nurses input. The system rates a risk score. C: Standard care plans are generated by the system. In addition, nurses were required to record nursing diagnosis, implementation of care plans, and evaluation of care. It was not part of the system. A: Pressure ulcer risk is assessed by the system with a nurses input and dat Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10