Clinical Decision Support in Nursing
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1 School of Healthcare FACULTY OF MEDICINE AND HEALTH Clinical Decision Support in Nursing Dawn Dowding Professor of Applied Health Research or
2 Overview What is Clinical Decision Support? Considerations for developing Clinical Decision Support
3 What is Decision Support? Integration of evidence with characteristics from individual patients to provide advice or guidance during decision making Can be in a variety of formats Can support different types of decision
4 Examples Diagnosis: (Visualdx
5 Examples Reminder systems for prevention:
6 Examples Management of disease: Mann DM, Lin JJ. Increasing efficacy of primary care-based counseling for diabetes prevention: Rationale and design of the ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial. Implementation Science 2012; 7:6.
7 Examples Medications Management
8 Decision Support in Nursing Nurses tend to make different decisions to doctors Context Often used to support role substitution Used to support nurses with advanced practice Used to support decision related to patient safety For example: Nurses carrying out telephone triage (with the use of decision algorithms) Nurses running anti-coagulation clinics prescribing warfarin (with the support of decision support software) Decision support for nursing assessment and decision making in areas such as fall and pressure ulcer risk prevention
9 Developing Decision Support: What to support? Decision taken vs process of decision making
10 Developing Decision Support: Who is it for?
11 Developing decision support: Organisational issues
12 Developing Decision Support What are you hoping to achieve? Improved documentation Changes to care processes Improvements in patient outcomes Efficiency (time saving) Reduction in adverse events How will you know what the impact is?
13
14 School of Healthcare FACULTY OF MEDICINE AND HEALTH Consequences of Using Clinical Decision Support in Nursing Dawn Dowding Professor of Applied Health Research or
15 Overview What impact does decision support in nursing have on: Care Processes Patient Outcomes How are decision support systems actually used in practice? Experience/expertise and decision support Factors that influence decision support use/effectiveness
16 Impact of decision support in nursing: Systematic Review Search of Literature up to 2005 (currently being updated) Inclusion criteria CDSS used by nurses Study design: Randomised controlled trial, controlled clinical trial, controlled before/after study, interrupted time series Clinical setting Measurable outcomes Randell et al. Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review. Journal of Health Services Research & Policy Vol 12 No 4, 2007:
17 Impact of decision support in nursing: Systematic Review Database searches n=7761 Retrieved articles n=343 Excluded n=7418 Hand searching & contacting experts n=49 Excluded n=383 Articles included in review n=9 8 studies
18 Impact of decision support in nursing: Systematic Review Nurses using CDSS vs Nurses not using CDSS 3 studies Performance Outcomes Patient Outcomes Anticoagulation management Triage for same day appt. requests Glucose management in ICU Not measured Probability of nurse as final contact Number of samples taken on time No significant difference No significant difference No significant difference Nurses using CDSS vs Health Professionals not using CDSS Performance Outcomes Patient Outcomes Anticoagulation Management (3 studies) Telephone triage in first contact care (2 studies) In dose and interval acceptance (1 study) In GP telephone advice/appts. No significant difference 1 study adverse events
19 Impact of decision support in nursing Evidence based on systematic review would suggest: Not clear if using decisions support in nursing improves clinical care processes or patient outcomes Quality of studies poor Evidence from medicine stronger (Garg et al 2005) Improved practitioner performance in 64% of studies Improved outcomes in 13% of trials
20 How are decision support systems used in practice? Unintended consequences More/new work issues Workflow issues Maintenance of knowledge base New kinds of errors Changes in power structures Alert fatigue See Campbell et al Types of unintended consequences related to computerized provider order entry, J. Am. Med. Inform. Assoc. 13 (5) (2006)
21 Experience/expertise and decision support I end up almost engineering the answers, because you think oh I can t put that because it s going to say (CS3 Nurse5 Int) So you ve got an idea how you re going to dose them and you run it through [the system] and you think, oh yeah, that agrees with me and it kind of boosts your confidence to know that you re thinking along the right lines. (CS1 Nurse2 Int) Dowding et al Nurses' use of computerised clinical decision support systems: a case site analysis 2009 Journal of Clinical Nursing, 18,
22 Experience/expertise and decision support when you start doing the job, you do tend to rely on that more for guidance, you know, but as you get more experienced, that lessens. (CS1 Nurse1 Int) But we have to use our clinical judgment because there could be some different reason than what it says on the computer, the software (CS1 Nurse4 Int).
23 Other Impacts
24 Factors that Influence decision support The decision support system*: Automatic decision support as part of the workflow Provision of recommendations Decision support at time and location of decision making Computer based The individual decision maker The organisation Clinician engagement with implementation Resources and training Organisational culture and support for innovation * Kawamoto et al. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ: 330,
25 Conclusions Decision support in nursing has potential to: Improve care processes (help nurses make better decisions) Improve outcomes for patients Reduce adverse events Need to be clear before design and implementation What decision(s) you are supporting Who is the intended user of the system Provide organisational support for design and implementation How you are going to monitor its impact on care
26
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Computerized clinical decision support systems (CCDSS) and patient reported outcomes (PRO) - A systematic literature review
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