title: Characteristics and effects of nurse dosing over-rides on computer-based intensive insulin therapy protocol performance.
abstract: OBJECTIVE
  To determine characteristics and effects of nurse dosing over-rides of a clinical decision support system (CDSS) for intensive insulin therapy (IIT) in critical care units.
  
  
  METHODS
  Retrospective analysis of patient database records and ethnographic study of nurses using IIT CDSS.
  
  
  METHODS
  The authors determined the frequency, direction-greater than recommended (GTR) and less than recommended (LTR)- and magnitude of over-rides, and then compared recommended and over-ride doses' blood glucose (BG) variability and insulin resistance, two measures of IIT CDSS associated with mortality. The authors hypothesized that rates of hypoglycemia and hyperglycemia would be greater for recommended than over-ride doses. Finally, the authors observed and interviewed nurse users.
  
  
  RESULTS
  5.1% (9075) of 179,452 IIT CDSS doses were over-rides. 83.4% of over-ride doses were LTR, and 45.5% of these were ≥ 50% lower than recommended. In contrast, 78.9% of GTR doses were ≤ 25% higher than recommended. When recommended doses were administered, the rate of hypoglycemia was higher than the rate for GTR (p = 0.257) and LTR (p = 0.033) doses. When recommended doses were administered, the rate of hyperglycemia was lower than the rate for GTR (p = 0.003) and LTR (p < 0.001) doses. Estimates of patients' insulin requirements were higher for LTR doses than recommended and GTR doses. Nurses reported trusting IIT CDSS overall but appeared concerned about recommendations when administering LTR doses.
  
  
  CONCLUSIONS
  When over-riding IIT CDSS recommendations, nurses overwhelmingly administered LTR doses, which emphasized prevention of hypoglycemia but interfered with hyperglycemia control, especially when BG was >150 mg/dl. Nurses appeared to consider the amount of a recommended insulin dose, not a patient's trend of insulin resistance, when administering LTR doses overall. Over-rides affected IIT CDSS protocol performance.
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA. thc2015@med.cornell.edu
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Campion
authors.forename: Addison K
authors.initials: AK
authors.lastname: May
authors.forename: Lemuel R
authors.initials: LR
authors.lastname: Waitman
authors.forename: Asli
authors.initials: A
authors.lastname: Ozdas
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Lorenzi
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Gadd
mesh_terms: D000328:Adult; D001292:Attitude to Computers; D020000:Decision Support Systems, Clinical; D054796:Drug Dosage Calculations; D004360:Drug Therapy, Computer-Assisted; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007003:Hypoglycemia / Q000517:prevention & control; D007328:Insulin / Q000008:administration & dosage*; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D057184:Practice Patterns, Nurses'; D012189:Retrospective Studies; D013714:Tennessee
chemical_list: D007328:Insulin