Study finds automated decision minimizes high-risk medicine combinations in ICU patients

A multicenter study coordinated by Amsterdam UMC and carried out in nine Dutch Intensive Care Units (ICUs) found that customizing a computerized decision support system (CDSS) to the ICU environment dramatically reduced the number of high-risk drug combinations given to ICU patients. It also enhanced monitoring of ICU patients when avoiding such combinations was impossible, as well as shortening patients’ stays in the ICU. This study was published in The Lancet.

“Not more, but fewer and more relevant alerts by a CDSS make such a system more valuable for health care providers and patients,” says Ameen Abu-Hanna, Professor of Medical Informatics at Amsterdam UMC and the study’s primary investigator.

Combining two or more medications at the same time might either raise or decrease the effects of the drugs involved. This could do patients considerable harm. Drug combinations are more common in the ICU because ICU patients are critically ill and frequently treated with many medications at the same time.

Fewer but more significant notifications

CDSSs are used to notify ICU physicians about potentially hazardous drug combinations. These devices provide physicians with alerts during drug prescription. However, these systems are not effectively adapted to the ICU environment, resulting in an excessive number of notifications that are not clinically relevant, causing alert fatigue.

According to research, ICU physicians disregard more than 80% of alerts for potentially harmful medicine combinations, including the most crucial ones. This greatly reduces the utility of CDSS in daily clinical practice and jeopardizes patient safety.

“ICU patients are critically unwell and frequently get concurrent medications. At the same time, ICU patients are closely and constantly watched. As a result, Assistant Professor and co-author Joanna Klopotowska emphasizes the importance of tailoring the CDSS to the ICU setting in order to prevent alert fatigue and increase patient safety.

Shorter stay in the ICU

Unlike the present indiscriminate CDSSs, nine ICUs received a CDSS that was specifically suited to the ICU environment for a length of time. This personalized approach only displayed alerts for drug combinations that were deemed high-risk or required further monitoring, as determined by a national panel of ICU physicians and hospital pharmacists.

The notifications for low-risk medication combinations were disabled. As a result of this change, 12% fewer high-risk medicine combinations were given to ICU patients, and monitoring of potential side effects was improved. Patients’ stays in the ICU were also shortened.

This study found that adapting a CDSS to the ICU environment enhances patient safety in the ICU. The ICU physicians were able to better spot risky medicine combinations by alerting just where it was necessary. This method may also be useful for other patient populations, including neonatology, pediatrics, and oncology.

Currently, many hospitals deploy CDSSs without customizing them for their individual patient populations, and the systems’ effectiveness is rarely evaluated.

“We hope that our research inspires and encourages hospitals to take a closer look at all of the signals that health care practitioners receive via such systems. According to Klopotowska, this will help both patients and health care providers.

Low-hanging fruit

Even ICU departments that did not participate in the study can readily modify their CDSS to make it more effective. These changes can be implemented manually in current systems with minimal effort. To that goal, the researchers issued two lists.

A list of high-risk drug combinations in the ICU that should trigger alarms, as well as a list of low-risk drug combinations that do not require alerts.

“Adapting ICU CDSSs is a low-hanging fruit that all ICUs in the Netherlands and beyond can benefit from; they do not have to reinvent the wheel for themselves,” adds Tinka Bakker, the study’s Ph.D. candidate and co-author. On December 7, 2023, she defended her thesis at the University of Amsterdam on customizing the CDSS for the ICU environment.

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