Performance of a computerized protocol for trauma shock resuscitation.
BACKGROUND
A computerized protocol was developed and used to standardize bedside clinician decision making for resuscitation of shock due to severe trauma during the first day in the intensive care unit (ICU) at a metropolitan Level I trauma center. We report overall performance of a computerized protocol for resuscitation of shock due to severe trauma, incorporating two options for resuscitation monitoring and intervention intensity, according to: (1) duration of use and (2) acceptance of computerized protocol-generated instructions.


METHODS
A computerized protocol operated by clinicians, using a personal computer (PC) at the bedside, was used to guide clinical decision making for resuscitation of patients meeting specific injury and shock criteria. The protocol generated instructions that could be accepted or declined. Clinician acceptance of the protocol instructions was stored by the PC software in a database for each patient. A rule-based, data-driven protocol was developed using literature evidence, expert opinion, and ongoing protocol performance analysis. Logic-flow diagrams were used to facilitate communication among multidisciplinary protocol development team members. The protocol was computerized using standard programming methods and implemented using cart-mounted PCs with a touch screen and keyboard interfaces. Protocol progression began with patient demographic data and criteria entry, confirmation of hemodynamic monitor instrumentation, request for specific hemodynamic performance data, and instructions for specific interventions (or no intervention). Use and performance of the computerized protocol was recorded in a protocol execution database. The protocol was continuously maintained with new literature evidence and database performance analysis findings. Initially implemented in 2000, the computerized protocol was refined in 2004 with two options for resuscitation intensity: pulmonary artery catheter- and central venous pressure-directed resuscitation.


RESULTS
Over 2 years ending at August 2006, a total of 193 trauma patients (mean Injury Severity Score was 27, survival rate 89%) were resuscitated using the computerized protocol. Protocol duration was 4400 hours or 22.7 +/- 0.4 hours per patient. The computerized protocol generated 3724 instructions (19 +/- 1 per patient) that required a bedside clinician response. In all, 94% of these instructions were accepted by the bedside clinician users.


CONCLUSIONS
A computerized protocol to guide decision making for trauma shock resuscitation in a Level 1 trauma center surgical ICU was developed and used as standard of care. During 2 years ending at August 2006, 94% of computer-generated instructions for specific interventions or measurements of hemodynamic performance were accepted by bedside clinicians, indicating appropriate, useful design and reliance on the computerized protocol system.
Sucher
Joseph F
JF
Department of Surgery, The Methodist Hospital, 6550 Fannin Street, Smith Tower 1661A, Houston, TX 77030, USA. jfsucher@tmhs.org
Moore
Frederick A
FA
Sailors
R Matthew
RM
Gonzalez
Ernest A
EA
McKinley
Bruce A
BA
D000328:Adult; D002985:Clinical Protocols; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008838:Microcomputers; D008991:Monitoring, Physiologic; D019095:Point-of-Care Systems; D012151:Resuscitation / Q000379:methods*; D012774:Shock, Traumatic / Q000628:therapy*; D015996:Survival Rate; D014193:Trauma Centers; D015599:Trauma Severity Indices; D016896:Treatment Outcome