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The Fifth Toronto Critical Care Medicine
Symposium
Novel technology in the setting of the intensive care unit (ICU) includes biotechnology and information technology. The latter consists of database analyses, medical literature reviews, telecommunication, etc. The promise of new developments in technology is that it will lead to improved patient care and reduced morbidity and mortality. A group of experts in the field discussed several interesting issues related to technology in the ICU, including review of medical errors, simulation systems, patient data management, and expert decision-support systems aimed at improving medical practice.
Dealing With Medical Errors
A recent Institute of Medicine (IOM) report on the quality of care stated that medical errors cause between 44,000 and 98,000 deaths every year in American hospitals.[1] The debate in the United States has been kick-started by this report. Rates of medical errors are not easily comparable between countries due to different definitions. In addition, the errors may be due to the medical systems rather than the medical practitioner. The essential message of the IOM report is that there is considerable room for improving patient safety by reducing medical errors.An official report on Australia's Hospital System estimated that between 10,000 and 14,000 people died of preventable causes in both public and private hospitals in 1992.[2] Interestingly, this study found that communication problems were responsible for adverse outcomes more so than inadequate physician practices.
The session attendees discussed several issues, including evidence-based medicine, telehealth, and electronic decision support aiming at improving patient safety.
Use of Electronic Medical Evidence
The Internet contains a tremendous volume of medical information. Unfortunately, much of it is of low quality. One solution to the issue of quality is to provide users with some sort of quality rating, determined by a trusted third party, such as BMJ Publishing Group.[3,4] D. Hunt, MD, of the Department of Clinical Epidemiology and Biostatistics at McMaster University Faculty of Health Sciences in Hamilton, Ontario, Canada, discussed the issue of electronic medical evidence and techniques for searching the medical literature for the best evidence to solve clinical questions.For researchers, 2 barriers exist that impede the search for the best answers to clinical questions: (1) there is a complicated interface to the literature, and (2) the process is time consuming. Textbooks are helpful for basic questions but may not be ideal for clinical practice, because they are often out of date. The electronic MEDLINE service provided by the National Library of Medicine is very important and free but often gives one too much information from both basic and clinical studies. A prefiltered or preappraised resource that provides specific methodologies and highly relevant clinical practice is needed to solve the above-mentioned problems.
Dr. Hunt recommended several high-quality Web sites to search for electronic medical evidence. The American College of Physicians' (ACP) Journal Club provides Best Evidence features covering more than 1500 evaluations of primary studies and systematic reviews from more than 90 journals with structured abstracts and commentary. Commentary Form Reviews are updated quarterly on the Web site or annually (for the CD-ROM). The strength of Best Evidence is that it is a small, easily accessible provider to search for precise summaries of the best current studies of diagnosis, cause, course, and management of a broad range of clinical disorders.
The Cochrane Library is a medical database and is updated quarterly. The Cochrane Library for Evidence-Based Medicine and Cochrane Database of Systematic Reviews provide systematic reviews of the medical literature, in particular, randomized controlled trials.
Ovid Technologies, a key component in Harvard Medical School's core digital library, consists of (1) Evidence-Based Medicine Reviews (EBMR); (2) Best Evidence, a marriage of ACP Journal Club and Evidence-Base Medicine from the American College of Physicians and the BMJ Publishing Group; and (3) The database of Abstracts of Reviews of Effectiveness, produced by the expert reviewers and information staff of the National Health Service's Center for Reviews and Dissemination (NHS CRD).
UpToDate is composed of thousands of original topic reviews written by a recognized faculty of experts, who address a specific clinical issue and provide detailed recommendations with respect to clinical questions. UpToDate also includes information from updated textbooks.
The pharmaceutical industry eagerly promotes electronic medical information systems. The first e-clinical trials conference has been recently held in Brussels, Belgium. The aims of the meeting were to address Internet security issues, drive the industry toward achieving e-common standards, accelerate e-global patient recruitment, interpret e-regulatory guidelines, speed software validation, and motivate investigators to embrace new technologies.
Utilization of Medical Simulation Systems
Randy S. Wax, MD, of the Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada, proposed that utilization of simulation technology is a useful tool for preventing medical errors and saving lives. Simulator systems can present many scenarios that not only simulate real life disease conditions but also those uncommon but critical situations in which a rapid response is needed. The systems allow users to see results of the participant's decision, actions, and errors and to make conclusions. Simulation systems have been widely used in medical teaching for students, nurses, and respiratory therapists, and training for residents and fellows. There are several commercially available simulator systems to choose from.
Medical Electronic Decision Support
William Sibbald, MD, of Sunnybrook and Women's College Health Sciences Center, University of Toronto, Toronto, Ontario, Canada, discussed decision support systems. Bedside computerized protocols that standardize clinical decisions for mechanical ventilation for acute respiratory distress syndrome (ARDS) patients have been used at the LDS hospital at the University of Utah School of Medicine in Salt Lake City since 1987.[5] A randomized, multicenter clinical trial using the bedside computerized protocols to support ARDS patients has been recently completed. There are currently several computerized protocols under development that standardize clinical decisions for intravenous fluids and drug dosages in support for hemodynamics.Many clinicians are concerned that patient care based on computerized protocols will become "cookbook care," and will be practiced without paying attention to the specific and changing needs of the individual patients. Nonetheless, computerized protocols that are developed by customizing patient data can help physicians to reduce errors in clinical practice and also to reduce medical costs. For example, an antibiotic protocol developed by LDS hospital delivers specific, individualized treatment suggestions or recommendations.[6] Use of the computerized antibiotic-dose monitor appears to help reduce the excessive use and cost of antibiotic therapy as well as decrease the number of adverse effects secondary to antibiotics.
Computerized Reminder System
Dr. Sibbald stated that electronic medical systems also play an important role in reducing laboratory expenses. A prospective, randomized, controlled trial has been recently completed by a group of investigators in Boston. The purpose of the study was to look at the impact of giving computerized reminders to physicians regarding redundant clinical laboratory tests. Fifty-one percent of redundant tests were performed in the control group, but only 27% were performed in the study group. The overall annual savings in laboratory charges was approximately $35,000 in this study.[7]
Telemedicine in ICU
Robert M. Filler, MD, of the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada, introduced a so-called Tele-Health system in the session. This system consists of Medicine at a Distance (Tele-health/Tele-consultation, Tele-radiology, Tele-psychiatry, and Tele-pathology); Information Transfer (between institutions); Education Training; and Monitoring Tele-Care/Triage (at home or elsewhere). The Tele-Health system was used in 780 cases of video consultation between 1996 and 2000 in Ontario. The Tele-Health Links network is now being expanded nationally and worldwide. The Hospital for Sick Children has also developed a Tele-Homecare project to target children with cardiopulmonary problems to integrate home care, community care, and hospital care.It has been reported that exposure to the computer-based patient record is associated with changes in physicians' information-gathering strategies. Paper records usually have a narrative structure, whereas the computer-based records are usually organized into discrete items of information. Technology has a profound influence in shaping cognitive behavior. Several software programs are under development to customize personal requirements for data management and integration.
Stephen Lapinsky, MD, of Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada, presented a handheld computerized communication system that is currently used in their daily clinical practice. The ICU at the Mount Sinai Hospital introduced handheld computers (Palm IIIx) to physicians and evaluated the role of the computers in patient care. The handheld devices were installed with ICU management protocols, pharmacopoeias, and customized calculators. The ICU staff found the patient information entered by the resident on call to be very valuable, particularly for data access when they were outside the hospital. The personal handheld computers also improved patient management as assessed by qualitative feedback using focus group methodology. Although several advantages were noted, the system can be improved to enhance timely data communication between staffs.
Conclusion
Electronic medical information systems can provide contemporary topic reviews by experts who screen top clinical journals on a regular basis and identify studies that are both methodologically sound and clinically relevant. It seems that medical decision support systems improve knowledge, reduce decision conflict, and reduce differences in practice between physicians. Although the effect on outcomes of decisions made with these systems is, as yet, uncertain, telecommunications technology has great potential to meet the needs of physicians in improving patient care.
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