title: A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages.
abstract: Computer clinical decision support (CDS) systems are uncommon in the pediatric intensive care unit (PICU), despite evidence suggesting they improve outcomes in adult ICUs. We reasoned that a bedside CDS protocol for intravenous insulin titration, eProtocol-insulin, would be feasible and safe in critically ill children.
  
  
  
  We retrospectively reviewed data from non-diabetic children admitted to the PICU with blood glucose (BG) ≥140 mg/dL who were managed with intravenous insulin by either unaided clinician titration or eProtocol-insulin. Primary outcomes were BG measurements in target range (80-110 mg/dL) and severe hypoglycemia (BG ≤40 mg/dL); secondary outcomes were 60-day mortality and PICU length of stay. We assessed bedside nurse satisfaction with the eProtocol-insulin protocol by using a 5-point Likert scale and measured clinician compliance with eProtocol-insulin recommendations.
  
  
  
  Over 5 years, 69 children were titrated with eProtocol-insulin versus 104 by unaided clinicians. eProtocol-insulin achieved target range more frequently than clinician titration (41% vs. 32%, P < 0.001). Severe hypoglycemia was uncommon in both groups (4.3% of patients in eProtocol-insulin, 8.7% in clinician titration, P = 0.37). There were no differences in mean time to BG target or median BG between the groups. Mortality was 23% in both groups. Clinician compliance with eProtocol-insulin recommendations was 89%. Nurses believed that eProtocol-insulin was easy to understand and safer than clinician titration.
  
  
  
  eProtocol-insulin is safe for titration of intravenous insulin in critically ill children. Clinical research protocols and quality improvement initiatives aimed at optimizing BG control should utilize detailed computer protocols that enable replicable clinician decisions.
authors.affiliation: 1 Pulmonary and Critical Care Division, Intermountain Medical Center , Murray, Utah.|2 Center for Humanizing Critical Care, Intermountain Medical Center , Murray, Utah.|3 Pulmonary and Critical Care Medicine, University of Utah School of Medicine , Salt Lake City, Utah.|4 Pediatric Critical Care, University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Eliotte L
authors.initials: EL
authors.lastname: Hirshberg
authors.affiliation: 1 Pulmonary and Critical Care Division, Intermountain Medical Center , Murray, Utah.|3 Pulmonary and Critical Care Medicine, University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Lanspa
authors.affiliation: 1 Pulmonary and Critical Care Division, Intermountain Medical Center , Murray, Utah.|2 Center for Humanizing Critical Care, Intermountain Medical Center , Murray, Utah.
authors.forename: Emily L
authors.initials: EL
authors.lastname: Wilson
authors.affiliation: 5 Department of Biomedical Informatics, University of Utah School of Medicine , Salt Lake City, Utah.|6 University of Utah School of Nursing , Salt Lake City, Utah.
authors.forename: Katherine A
authors.initials: KA
authors.lastname: Sward
authors.affiliation: 1 Pulmonary and Critical Care Division, Intermountain Medical Center , Murray, Utah.
authors.forename: Al
authors.initials: A
authors.lastname: Jephson
authors.affiliation: 4 Pediatric Critical Care, University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Gitte Y
authors.initials: GY
authors.lastname: Larsen
authors.affiliation: 1 Pulmonary and Critical Care Division, Intermountain Medical Center , Murray, Utah.|3 Pulmonary and Critical Care Medicine, University of Utah School of Medicine , Salt Lake City, Utah.|5 Department of Biomedical Informatics, University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Alan H
authors.initials: AH
authors.lastname: Morris
mesh_terms: D000293:Adolescent; D001786:Blood Glucose / Q000032:analysis*; D002648:Child; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D007223:Infant; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use*; D015278:Intensive Care Units, Pediatric; D008297:Male; D019095:Point-of-Care Systems
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin
keywords: Computer; Decision support; Glucose; Hyperglycemia; Pediatric; Protocol