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Submitted on April 4, 2004
Accepted on November 12, 2004
Affiliation of the authors: 1 Department of Intensive Care, Amsterdam, The Netherlands; 2 CHIME UCL, London, England
* To whom correspondence should be addressed.
Objective To measure the impact of a computerized guideline for glucose regulation in an ICU.
Design A randomized, controlled trial with an off-on-off design.
Methods We implemented a glucose regulation guideline in an intensive care unit in paper form during the first study period. During the second period, the guideline was randomly applied in either paper or computerized form. In the third period the guideline was available only in paper form.
Measurements and Results We analyzed data for 484 patients. During the intervention period, the control group included 54 patients and the computerized intervention group included 66 patients. The two guideline-related outcome measures, consisted of compliance with: (a) glucose measurement timing recommendations, and (b) insulin dosage advice. We measured clinical impact as the proportion of time that glucose levels fell within target range. In the first (paper-based) study period, 29.0% of samples occurred with optimal timing; during the second period, this increased to 35.5% for paper-based and to 40.2% for computerized protocols. Third study period timeliness scores reverted to the first period rates. Late (sub-optimal) sampling occurred for 66% of glucose measurements in the first study period; for 42% of paper-based and 28% of computer-based protocol samples in the second period; and, for 50.0% of samples in the third study period In the first study period, insulin-dosing guideline compliance was 56.3%; in the second period, 64.2% for paper-based and 77.3% for computer-based protocols; and, it fell to 42.4% in the third period. For the second study period, the time that a patient's glucose values fell within target range improved for both the control (52.9%) and the computerized groups (54.2%) compared to the first study period (44.3%) and the third period (42.3%).
Conclusion Implementing a computerized version of a guideline significantly improved timeliness of measurements and glucose level regulation for critically ill patients compared with implementing a paper-based version of the guideline.
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