The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

BACKGROUND: Drug-drug interactions (DDIs) can harm patients admitted to the intensive care unit (ICU). Yet, clinical decision support systems (CDSSs) aimed at helping physicians prevent DDIs are plagued by low-yield alerts, causing alert fatigue and compromising patient safety. The aim of this multicentre study was to evaluate the effect of tailoring potential DDI alerts to the ICU setting on the frequency of administered high-risk drug combinations. METHODS: We implemented a cluster randomised stepped-wedge trial in nine ICUs in the Netherlands. Five ICUs already used potential DDI alerts. Patients aged 18 years or older admitted to the ICU with at least two drugs administered were included. Our intervention was an adapted CDSS, only providing alerts for potential DDIs considered as high risk. The intervention was delivered at the ICU level and targeted physicians. We hypothesised that showing only relevant alerts would improve CDSS effectiveness and lead to a decreased number of administered high-risk drug combinations. The order in which the intervention was implemented in the ICUs was randomised by an independent researcher. The primary outcome was the number of administered high-risk drug combinations per 1000 drug administrations per patient and was assessed in all included patients. This trial was registered in the Netherlands Trial Register (identifier NL6762) on Nov 26, 2018, and is now closed. FINDINGS: In total, 10 423 patients admitted to the ICU between Sept 1, 2018, and Sept 1, 2019, were assessed and 9887 patients were included. The mean number of administered high-risk drug combinations per 1000 drug administrations per patient was 26·2 (SD 53·4) in the intervention group (n=5534), compared with 35·6 (65·0) in the control group (n=4353). Tailoring potential DDI alerts to the ICU led to a 12% decrease (95% CI 5-18%; p=0·0008) in the number of administered high-risk drug combinations per 1000 drug administrations per patient, after adjusting for clustering and prognostic factors. INTERPRETATION: This cluster randomised stepped-wedge trial showed that tailoring potential DDI alerts to the ICU setting significantly reduced the number of administered high-risk drug combinations. Our list of high-risk drug combinations can be used in other ICUs, and our strategy of tailoring alerts based on clinical relevance could be applied to other clinical settings. FUNDING: ZonMw.

Prevalence and management of delirium in intensive care units in the Netherlands: An observational multicentre study.

OBJECTIVES: This study aimed to determine the prevalence, risk factors of delirium and current practice of delirium management in intensive care units of various levels of care. RESEARCH METHODOLOGY/DESIGN: Prospective multicentre cohort study. SETTING: In all adult patients admitted to one of the participating intensive care units on World Delirium Awareness Day 2018, delirium point and period prevalence rates were measured between ICU admission and seven days after the index day. RESULTS: In total, 28 (33%) Dutch intensive care units participated in this study. Point-prevalence was 23% (range 41), and period-prevalence was 42% (range 70). University intensive care units had a significantly higher delirium point-prevalence compared with non-university units (26% vs.15%, p = 0.02). No significant difference were found in period prevalence (50% vs. 39%, p = 0.09). Precipitating risk factors, infection and mechanical ventilation differed significantly between delirium and non-delirium patients. No differences were observed for predisposing risk factors. A delirium protocol was present in 89% of the ICUs. Mean delirium assessment compliance measured was 84% (±19) in 14 units and estimated 59% (±29) in the other 14. CONCLUSION: Delirium prevalence in Dutch intensive care units is substantial and occurs with a large variation, with the highest prevalence in university units. Precipitating risk factors were more frequent in patients with delirium. In the majority of units a delirium management protocol is in place.

Direct complications and routine ICU admission after total laryngectomy.

BACKGROUND: In the Netherlands Cancer Institute (NCI), patients are admitted to the Intensive Care Unit (ICU) after total laryngectomy (TL). AIMS/OBJECTIVES: To assess direct complications and the need for ICU admission after TL. MATERIAL AND METHODS: Patients who underwent a TL in the NCI were reviewed on the occurrence of an event requiring ICU treatment within the first 24 hours postoperatively. The predictive value of predetermined risk factors was assessed with multivariable logistic analysis. The optimal threshold of the risk score assigned by the resulting model was determined. RESULTS: An event occurred in 25 of the 113 patients (22%) of which 72% included norepinephrine dependence. Risk analysis showed that patients with either CRT prior to TL or a procedure including pharynx reconstruction, or both, should be indicated for ICU stay. Applying the rule on this cohort, 57 patients (50%) would have been sent to the ward postoperatively of which seven (12%) developed an event requiring ICU treatment. CONCLUSIONS: A substantial proportion of the patients developed an event within the first 24 hours after TL. Our risk stratification of patients based on the mentioned risk factors is insufficiently accurate. SIGNIFICANCE: The study provides an overview of direct postoperative complications after TL.

A comparison of postoperative throat and neck complaints after the use of the i-gel and the La Premiere disposable laryngeal mask: a double-blinded, randomized, controlled trial.

BACKGROUND: Many supralaryngeal airway devices are available. Because of the absence of an inflatable cuff, we hypothesized that use of the i-gel should produce fewer postoperative throat and neck complaints compared with a standard disposable laryngeal mask (LM). METHODS: Two hundred eighteen patients were randomized to have either an i-gel or La Premiere LM airway placed for airway management. Patients were interviewed postoperatively for throat and neck complaints at 1, 24, and 48 h. Interviewers and patients were blinded to the device used. RESULTS: One hundred nine patients had an i-gel and 103 had a La Premiere supraglottic device inserted. The incidence of sore throat was significantly lower with the i-gel than with LM at 1 (6 vs 32), 24 (7 vs 48), and 48 h (5 vs 25). Similar results were seen for dysphagia. The incidence of neck pain was also lower for the i-gel at 24 (1 vs 7) and 48 h (1 vs 7). CONCLUSION: In this randomized study, the i-gel supraglottic device resulted in a lower incidence of throat and neck complaints than the La Premiere LM airway.