The rise, fall, and future direction of computer-assisted personalized sedation.

PURPOSE OF REVIEW: The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. RECENT FINDINGS: CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. SUMMARY: Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model.

On medical application of neural networks trained with various types of data.

Neural networks have garnered attention over the past few years. A neural network is a typical model of machine learning that is used to identify visual patterns. Neural networks are used to solve a wide variety of problems, including image recognition problems and time series prediction problems. In addition, neural networks have been applied to medicine over the past few years. This paper classifies the ways in which neural networks have been applied to medicine based on the type of data used to train those networks. Applications of neural networks to medicine can be categorized two types: automated diagnosis and physician aids. Considering the number of patients per physician, neural networks could be used to diagnose diseases related to the vascular system, heart, brain, spinal column, head, neck, and tumors/cancer in three fields: vascular and interventional radiology, interventional cardiology, and neuroradiology. Lastly, this paper also considers areas of medicine where neural networks can be effectively applied in the future.

Newer propofol, ketamine, and etomidate derivatives and delivery systems relevant to anesthesia practice.

Drug discovery is the cornerstone of developments in the field of anesthesia. Each year, new drugs enter the market and possibly change clinical practice. The development of new anesthetics can be divided into two groups. One strategy is the discovery of a new type of drug with unique molecular structure, better clinical properties, and lesser side effects than the already existing drugs. Another strategy is changing the molecular structure of current clinically available anesthetics to create new drugs with better pharmacokinetic and pharmacodynamic properties. In this review, we describe the current developments of frequently used anesthetics, namely, propofol, etomidate, and ketamine. Alfaxalone is an old anesthetic with favorable properties such as hemodynamic and respiratory stability but lacks appropriate vehicle. New formulations with recently developed solvents together with this old anesthetic are created. Next to drug development, there is also a constant search for better delivery systems for the already available anesthetics. Following open-loop systems like TIVA, new closed-loop systems have entered the market. We also discuss about SEDASYS®-Computer-Assisted Personalized Sedation System, an automatic closed-loop delivery system that provides propofol sedation for endoscopic procedures.

Developing an electronic system to manage and track emergency medications.

PURPOSE: The development of a Web-based program to track and manage emergency medications with radio frequency identification (RFID) is described. SUMMARY: At the Cleveland Clinic, medication kit restocking records and dispense locations were historically documented using a paper record-keeping system. The Cleveland Clinic investigated options to replace the paper-based tracking logs with a Web-based program that could track the real-time location and inventory of emergency medication kits. Vendor collaboration with a board of pharmacy (BOP) compliance inspector and pharmacy personnel resulted in the creation of a dual barcoding system using medication and pocket labels. The Web-based program was integrated with a Cleveland Clinic-developed asset tracking system using active RFID tags to give the real-time location of the medication kit. The Web-based program and the asset tracking system allowed identification of kits nearing expiration or containing recalled medications. Conversion from a paper-based system to a Web-based program began in October 2013. After 119 days, data were evaluated to assess the success of the conversion. Pharmacists spent an average of 27 minutes per day approving medication kits during the postimplementation period versus 102 minutes daily using the paper-based system, representing a 74% decrease in pharmacist time spent on this task. Prospective reports are generated monthly to allow the manager to assess the expected workload and adjust staffing for the next month. CONCLUSION: Implementation of a BOP-approved Web-based system for managing and tracking emergency medications with RFID integration decreased pharmacist review time, minimized compliance risk, and increased access to real-time data.

[ Preventing adverse drug events using clinical decision support systems]. / Verhindern von unerwünschten Arzneimittelereignissen mit Hilfe von elektronischen Entscheidungsunterstützungssystemen.

Adverse drug events pose a great risk to patients, are an everyday clinical problem and can have potential/ega/ consequences. Computerized physician order entry or computerized provider order entry (CPOE} in combination with clinical decision support systems {CDSS) are popular and aim to reduce prescribing errors as well as identifying potentially harmful drug drug interactions. The quantifiable benejit these systems bring to patients, has however, yet to be definitively proven. This article focusses on the current standpoint of CPOE-/CDSS, their risks and benefits, the potential for improvement and their perspectives for the future.

[New technologies in diabetology. How far are we from a closed loop?]. / Neue Technologien in der Diabetologie. Wie weit ist es noch bis zum Closed-loop-System?

Today, assistive technologies are highly important in the treatment of diabetes, especially in the therapy of type 1 diabetes. The use of insulin pumps, for example, has become an established form of treatment. Modern insulin pumps offer various functions, such as different basal rate profiles, split delivery of the meal bolus, and integrated bolus calculators. Some pumps are additionally connected to a blood glucose meter or a continuous glucose-monitoring sensor. Several minimally invasive needle-type sensor systems for continuous tissue glucose monitoring are already available. Recent developments aim at increasing the functionality of insulin pumps and the improvements of sensors for continuous glucose monitoring. In addition, many research groups are working on closing the loop between these two components and thus developing an artificial pancreas, which automatically regulates insulin delivery. The first steps have already been taken and bolus calculators or sensor-augmented insulin pumps with suspension of insulin delivery are now available. Many experimental models show promising results. Prior to the implementation of a fully automated system for everyday use, however, partially automated systems that require user input are to be expected. This article aims at giving an overview of the current state of development in the field of diabetes technology.

Factors associated with medication warning acceptance for hospitalized adults.

BACKGROUND: Computerized provider order entry (CPOE) systems can warn clinicians ordering medications about potential allergic or adverse reactions, duplicate therapy, and interactions with other medications. Clinicians frequently override these warnings. Understanding the factors associated with warning acceptance should guide revisions to these systems. OBJECTIVE: Increase understanding of the factors associated with medication warning acceptance. DESIGN: Retrospective study of all single-medication warnings generated in a CPOE system from October 2009 through April 2010. SETTING: Academic medical center. PATIENTS: All adult non-intensive care unit patients hospitalized during the study period. RESULTS: A total of 40,391 medication orders generated a single-medication warning during the 7-month study period. Of these warnings, 47% were duplicate warnings, 47% interaction warnings, 6% allergy warnings, 0.1% adverse reaction warnings, and 9.8% were repeated for the same patient, medication, and provider. Only 4% of warnings were accepted. In multivariate analysis, warning acceptance was positively associated with male patient gender, admission to a service other than internal medicine, caregiver status other than resident, parenteral medications, lower numbers of warnings, and allergy or adverse reaction warning types. Older patient age, longer length of stay, inclusion on the Institute for Safe Medication Practice's List of High Alert Medications, and interaction warning type were all negatively associated with warning acceptance. CONCLUSIONS: Medication warnings are rarely accepted. Acceptance is more likely when the warning is infrequently encountered, and least likely when it is potentially most important. Warning systems should be redesigned to increase their effectiveness for the sickest patients, the least experienced physicians, and the medications with the greatest potential to cause harm.

Automatic control of the NMB level in general anaesthesia with a switching total system mass control strategy.

This paper presents a model based switching control strategy to drive the neuromuscular blockade (NMB) level of patients undergoing general anesthesia to a predefined reference. A single-input single-output Wiener system with only two parameters is used to model the effect of two different muscle relaxants, atracurium and rocuronium, and a switching controller is designed based on a bank of total system mass control laws. Each of such laws is tuned for an individual model from a bank chosen to represent the behavior of the whole population. The control law to be applied at each instant corresponds to the model whose NMB response is closer to the patient's response. Moreover a scheme to improve the reference tracking quality based on the analysis of the patient's response, as well as, a comparison between the switching strategy and the Extended Kalman Kilter (EKF) technique are presented. The results are illustrated by means of several simulations, where switching shows to provide good results, both in theory and in practice, with a desirable reference tracking. The reference tracking improvement technique is able to produce a better reference tracking. Also, this technique showed a better performance than the (EKF). Based on these results, the switching control strategy with a bank of total system mass control laws proved to be robust enough to be used as an automatic control system for the NMB level.

Evaluation of medication dose alerts in pediatric inpatients.

OBJECTIVE: This study evaluates the impact of 12,093 consecutive dose alerts generated by a computerized provider order entry system on pediatric medication ordering. PATIENTS AND METHODS: All medication orders entered and all resulting medication dose alerts at the Johns Hopkins Children's Medical and Surgical Center in 2010, were retrospectively evaluated. Inclusion criteria were hospitalized patients less than 21 years old. There were no exclusion criteria. RESULTS: During 2010, there were 7738 admissions for 5553 unique patients. A total of 182,308 medication orders for 1092 unique medications were submitted by providers. Six percent (11,155) of orders or order attempts generated alerts for 2046 patients and 524 medications. Two categories of alerts were analyzed: dose range alerts and informational alerts. 73.4% (8187) of all alerts were dose range alerts, with a compliance rate of 8.5% (694); 26.6% (2968) were informational alerts, with a compliance rate of 5.5% (163). CONCLUSIONS: We found that underdosing alerts provide less value to providers than overdosing alerts. However, the low compliance with the alerts should trigger the evaluation of clinical practice behavior and the existing alert thresholds. Informational alerts noting the absence of established dosing guidelines had little effect on provider behavior and should be avoided when building a dose range alert system.

21st century diabetes care: a marriage between humans and technology.

Technological advances in the management of diabetes have been described as a stepping stone in the journey towards a cure. These include continuous glucose monitoring, insulin pumps, computerised mathematical algorithms, and closed-loop artificial pancreas systems. The approaches offer the tantalising promise of near-normal glucose control to people with diabetes. However, as is often the case with human/technological interactions, we have the technology but we do not have all the answers.

La prescripción electrónica asistida: instrumento clave para la disminución de los problemas relacionados con los medicamentos en el hospital / Computerized physician order entry: a key instrument for reducing drug-related problems in hospitals

Objetivo: Evaluar el efecto de la implantación de la prescripción electrónica asistida (PEA) en una unidad clínica sobre los problemas relacionados con los medicamentos (PRM) y sobre el grado de aceptación de las intervenciones farmacéuticas. Métodos: Estudio prospectivo, casi experimental. Se revisaron las prescripciones farmacológicas de un servicio de medicina interna durante dos periodos secuenciales de 3,5 meses cada uno (antes y después de la implantación de la PEA). Se registraron todos los PRM detectados en ambas fases. Se analizó también la aceptación de la intervención farmacéutica ante cada error. Resultados: Durante los 7 meses del estudio se detectaron un total de 4.023 PRM, 3.785 en la fase de prescripción manual (PM) y 238 en la fase de PEA; la tasa de PRM por paciente ingresado era de 16,9 en PM y de 1,07 en PEA, lo que supone una reducción estadísticamente significativa del 93,67%. Si omitimos los PRM de identificación de la orden médica, se obtiene una reducción del 43,21%. Con la introducción de la PEA, desaparecieron los PRM de identificación de la orden médica y de transcripción en farmacia, disminuyeron los de dosis no adecuada, duración no adecuada e interacciones, y aumentaron los de error en la identificación del medicamento. Conclusiones: La implantación de la PEA ha disminuido de forma significativa la tasa total de PRM y la de PRM de importancia mayor. La proporción de intervenciones farmacéuticas no contestadas por el médico ha disminuido significativamente (AU)

Objective: To evaluate the effect of the implementation of computerized physician order entry (CPOE) in a clinical unit on drug related problems (DRP) and on the degree of acceptance of the pharmaceutical interventions. Methods: In this prospective, quasi-experimental study, the drug prescriptions of an internal medicine service were revised over two sequential periods of 3.5 months each (before and after the implementation of the CPOE). All the DRP detected in both phases were recorded. The acceptance of the pharmaceutical intervention in each error was also analysed. Results: In the 7 months of the study, a total of 4,023 DRP were detected, 3,785 in the manual prescription (MP) phase and 238 in the CPOE phase, the rate of DRP per patient admitted being 16.9 in MP and 1.07 in CPOE. This constitutes a statistically significant reduction of 93.67%. If we omit the DRP in the identification of the physician’s order, we obtain a reduction of 43.21%. With the introduction of CPOE, the DRP in the identifi cation of the physician’s order and of transcription in the pharmacy disappeared, those pertaining to unsuitable dose and unsuitable duration and interactions fell, and those involving an error in the identification of the medicinal product increased. Conclusions: The implementation of the CPOE significantly reduced the total rate of DRP and the rate of DRP of major importance. The proportion of pharmaceutical interventions unanswered by the physician has been reduced significantly (AU)

Interacciones farmacológicas en pacientes que acuden a una farmacia comunitaria con receta electrónica / Assessment of drug interactions in patients of a Spanish community pharmacy with electronic prescription

Introducción: El estudio de interacciones farmacológicas en la farmacia comunitaria no está integrado en el día a día del profesional farmacéutico. Una de las principales barreras para lograrlo ha sido la falta de un historial farmacoterapéutico único. Se sabe que este tipo de problema relacionado con los medicamentos tiene un elevado impacto sobre la salud de los pacientes, asociado a la efectividad o seguridad de éstos, así como un gran coste económico para el sistema sanitario. Objetivos: Calcular la prevalencia de interacciones farmacológicas en usuarios de receta electrónica; clasificar las interacciones según su gravedad, según su evidencia y por su recomendación en la intervención; buscar factores asociados a la aparición de interacciones farmacológicas. Material y métodos: Se incluyó a todos los pacientes con dos o más medicamentos distintos prescritos con receta electrónica. Se evaluaron las interacciones de la receta electrónica utilizando la base de datos Bot PLUS y Medinteract. Resultados: Entre los 285 pacientes incluidos, 38 presentan una o más interacciones de carácter grave, cuya prevalencia fue del 13,3% (intervalo de confianza del 95%: 13,3-19,8). El 87,8% de las interacciones graves estaban documentadas. La interacción grave más frecuente fue la asociación de antiinflamatorios no esteroideos y ácido acetilsalicílico. Conclusiones: La prevalencia de interacciones farmacológicas graves es elevada. El uso de la receta electrónica agiliza y facilita su identificación (AU)

Introduction: The identification of pharmacological drug-interactions is not integrated in the daily practice of the community pharmacy. The main barrier has always been the lack of a complete patient medication record. It is known that this drug-related problem has a great economic and social impact. Objectives: To know the potential drug interactions in a community pharmacy on patients using electronic prescription. To assess their severity, recommendations and the clinical evidence. Methods: Prevalence study. The study took place in a community pharmacy with patients who acquires two or more electronic prescriptions. Potential drug interactions were checked by two database, Bot PLUS and Medinteract. Main results: 285 patients were included. Among these patiens 38 had one or more fatal interactions. The prevalence of these fatal interactions was 13.3% (95%CI: 13.3-19.8). 87.8% of the fatal interactions were documented. Interaction between antiinflamatory drugs and salycilic acid was of high prevalence. Conclusions: There is a high prevalence of fatal drug interactions between patients using electronical prescription. The use of this system makes easy the identification and prevention of interactions by the pharmacists (AU)

Desarrollo, implantación y evaluación de un programa de prescripción electrónica asistida de medicamentos en un hospital / Development, implementation and evaluation of an electronic drug prescribing program in a hospital

Objetivo: Desarrollar e implantar herramientas seguras y eficaces para la prescripción electrónica de los tratamientos farmacológicos. Material y método: Se realizó una revisión bibliográfica para cada medicamento o principio activo incluido en la Guía Farmacoterapéutica del Hospital para recoger información acerca de sus interacciones y ajustes posológicos en insuficiencia renal. Se elaboró una base de datos con 62 interacciones clínicamente relevantes y otra de 531 fármacos con recomendaciones posológicas o de monitorización en función del grado de insuficiencia renal (IR). Resultados: La integración de la base de datos de IR permite que desde el Servicio de Farmacia se pueda seleccionar a los pacientes con alteración en la función renal que tienen prescritos medicamentos que requieren ajuste posológico y asesorar sobre las recomendaciones individualizadamente, incorporando esta información a la historia clínica electrónica. Conclusión: esta herramienta, ha mejorado el programa de prescripción electrónica, convirtiéndolo en una prescripción electrónica asistida (AU)

Objetive: Develop and implement safe and effective tools for computer provider order entry to serve as clinical decision support. Material and methods: A literature review was performed for each drug included in the Hospital's pharmaceutical guide for collecting information on clinically relevant drug interactions and dose adjustments in renal failure Results: A database with 62 clinically relevant interactions was developed and integrated into the hospital information program. When an interaction is detected at the time of prescribing an alert is generated to report on its consequences and alternatives. Another database with 531 drugs with dosing or monitoring recommendations specific to the degree of renal failure in each patient was developed and integrated into the hospital information system, so that from the Pharmacy Department we can select patients with impaired renal function who have been prescribed drugs that require dose adjustment and advise on the dosage recommendations for each patient. Conclusion: Due to the development and implementation of these tools, we have improved our computer provider order entry with a clinical decision support system (AU)

Mejora de la calidad de la especificación de la inclusión en ensayo clínico sobre prescripciones en quimioterapia / Improving the specification quality of inclusion criteria of patients in chemotherapy clinical trials

Objetivos: Evaluar la mejora de la calidad de las prescripciones de quimioterapia para pacientes en ensayo clínico (EC) y analizar si en la orden médica se especifica la participación en el ensayo tras determinar los principales factores de riesgo y mediante la aplicación de medidas correctoras. Método: Estudio retrospectivo de omisiones recogidas durante 2006 y 2007. Con los datos del 2006 se analizaron los factores de riesgo y se implantaron medidas de mejora (información a prescriptores e inicio de prescripción electrónica). Posteriormente, se evaluaron los datos del 2007. Variables analizadas: EC, número de prescripciones, investigador principal, prescriptor, servicio, antineoplásicos y enfermedad. Resultados: Los servicios de Oncología y Hematología realizaron el 57,1% de los ensayos del hospital. En 2006 se recibieron 1.625 prescripciones y se detectaron 151 incorrectas (9,3%), y en 2007 se recibieron 1.858 prescripciones y se detectaron 65 incorrectas (3,5%). En 2006 se observó mayor frecuencia de prescripciones incorrectas en Hematología (34,1%) que en Oncología (8,6%). En 2007 Hematología apenas tuvo omisiones (1,8%) y en Oncología disminuyeron al 3,6%. Respecto a la enfermedad, la tasa de error desapareció prácticamente en mieloma múltiple (del 34,1 al 2,2%) y disminuyó en mama (del 10,8 al 4,4%). El incumplimiento siempre fue mayor cuando el prescriptor difería del investigador principal. Conclusiones: La frecuencia de las prescripciones con error se redujo (pasó del 9,3 al 3,5%). Destaca la reducción extraordinaria en Hematología relacionada con ensayos en mieloma múltiple. Las medidas correctoras han resultado útiles en la mejora de la calidad (AU)

Objectives: To assess the quality improvement of chemotherapy prescriptions for patients included in clinical trials (CT) analyzing whether the prescription is specified for patient participation, after having identified the major risks factors and the appropriate corrective measures are applied. Methods: Retrospective study of omissions collected during 2006 and 2007. After collecting all the information, we analyzed the risks factors and introduced improvement measures (information to prescribers and the beginning of electronic prescription). The 2007 data were then evaluated. Variables analyzed: CT, number of prescriptions, principal investigator, prescriber, department, anti-neoplastic involved and pathology. Results: Oncology and Haematology make up 57.1% of hospital trials. In 2006, 1625 chemotherapy prescriptions were received and there were 151 incorrect prescriptions (9.3%), and in 2007, 1858 prescriptions with 65 (3.5%) incorrect. In 2006, there was a higher frequency of incorrect prescriptions in Haematology (34.1%) and (Oncology (8.6%)). In 2007 Hematology had just 1.8% of omissions and in Oncology it decreased to 3.6%. As regards the pathology, the error rate has virtually disappeared in multiple myeloma prescriptions (34.1 to 2.2%) and decreased in breast cancer (10.8 to 4.4%). The non-fulfilment rate is higher when the prescriber is not the principal investigator. Conclusions: The overall frequency of prescriptions with errors decreased significantly from 9.3% to 3.5%, with an extraordinary reduction in Haematology (34.1% to 1.8%) related to the multiple myeloma trials. The corrective measures implemented have proved to be useful in CT (AU)

Calidad de las recomendaciones farmacoterapéuticas de los procesos asistenciales integrados en Andalucía / Quality of the pharmacotherapeutic recommendations for the integrated care procedures in Andalusia

Objetivos: Evaluar, a través del diseño y la validación de una herramienta, la calidad de las recomendaciones farmacoterapéuticas incluidas en los Procesos Asistenciales Integrados (PAI) de la Consejería de Salud de la Junta de Andalucía, publicados hasta marzo de 2008. Métodos: La herramienta de evaluación se diseñó a partir de instrumentos similares, fundamentalmente el Appraisal of Guidelines for Research and Evaluation. Otros criterios incluidos provenían de diversas fuentes bibliográficas o fueron de elaboración propia. Previamente a su utilización, la herramienta fue validada. Tras la aplicación a todos los PAI, se analizó el grado de cumplimiento de estos criterios farmacoterapéuticos globalmente y por subgrupos de PAI. Resultados: La herramienta elaborada consiste en un cuestionario de 20 ítems dividido en 4 bloques. El primer bloque corresponde a criterios esenciales, el resto hace referencia a criterios más específicos y considerados no esenciales: definición del nivel de evidencia, exhaustividad de la información y definición de indicadores. De los 60 PAI, 4 no contienen ningún tipo de recomendación terapéutica. Ningún PAI cumple el total de ítems recogidos en la herramienta; no obstante, un 70 % de ellos cumple los criterios esenciales de calidad establecidos. Conclusiones: Hay una gran variabilidad en cuanto al contenido de recomendaciones farmacoterapéuticas de cada PAI. Una vez demostrada la validez de la herramienta diseñada, podría utilizarse para valorar la calidad de las recomendaciones terapéuticas en guías de práctica clínica (AU)

Objectives: To evaluate the quality of the pharmacotherapeutic recommendations included in the Integrated Care Procedures (PAIs regarding its initials in Spanish) of the Andalusian Ministry of Health, published up to March 2008, through the design and validation of a tool. Methods: The assessment tool was designed based on similar instruments, specifically the AGREE. Other criteria included were taken from various literature sources or were devised by ourselves. The tool was validated prior to being used. After applying it to all the PAIs, we examined the degree of compliance with these pharmacotherapeutic criteria, both as a whole and by PAIs subgroups. Results: The developed tool is a questionnaire of 20 items, divided into 4 sections. The first section consists of the essential criteria, and the rest make reference to more specific, non essential criteria: definition of the level of evidence, thoroughness of information and definition of indicators. It was found that 4 of the 60 PAIs do not contain any type of therapeutic recommendation. No PAI fulfils all the items listed in the tool, however, 70 % of them fulfil the essential quality criteria established. Conclusions: There is a great variability in the content of pharmacotherapeutic recommendations for each PAI. Once the validity of the tool has been proved, it could be used to assess the quality of the therapeutic recommendations in clinical practice guidelines (AU)