Impact of Computerised Information Systems (CIS) on Nutritional Support
(Eighth World Congress of Intensive and Critical Care Medicine, Oct. 28 - Nov. 1 2001, Sydney, Australia)

MM Berger1, JP Revelly1, JB Wasserfallen2, E Benbasat3, S Bouvry3, A Schmidt1, M. Musset1, P. Maravic1, R Chiolero1
1Surgical ICU, 2Medical Admin, & 3Clinical Nutrition, CHUV, 1011 Lausanne, Switzerland

Introduction

The impact of CIS on quality of ICU care remains largely unknown. Introducing CIS requires structured therapeutic protocols. Patient outcome largely depends on quality of nutritional support, which requires strict protocols. Nutrition was therefore chosen to study the influence of CIS on nutrient prescription and delivery, comparing 2 ICU subunits equipped or not with CIS.

Methods

The study consisted in 2 parts:

Part 1:

Compared the 2 subunits of a single ICU equipped or not with CIS.

A 2 weeks prospective survey was carried out in the 2 surgical ICU subunit: unit A has 11 beds-without CIS, and B has 4 beds admits surgical and burned ICU -with CIS.

Nurses and doctors in units A and B belong to the same ICU team: procedures are identical. The difference between A and B is the presence of burned patients in B, with slightly longer mean ICU stays for that reason. During the study period, a new prescription sheet was introduced in unit B, adapted to computer prescription (Fig 1).
A computer page was configured to retrieve the variables in 24hr intervals in the CIS (Application: MetaVision, iMDsoft, Tel-Aviv). Patient weight, nutritional category, delay from admission to nutrition, route of nutritional support, prescribed and delivered nutrients (target 25 kcal/kg), and calculated energy intakes retrieved Figure 2).

Part 2:

As the presence of burned patients may influence nutritional support, this part analyzed the nutritional support before and after introduction of CIS in the unit admitting burned patients.

· Comparison of nutritional management during 2 consecutive periods of 2 years in unit B: 1997-98 before CIS, 1999-2000 with CIS. During the first period, the data were collected manually, while they were retrieved from the computer thereafter.
Nutritional support was assessed using predefined criteria (Table 1).
Results

· Patients demographic data did not differ significantly between units A and B (Part 1) or between periods (Part 2)
· Nutritional support was required in 60% of ICU days by consensus definition (Part 1) and in all burned patients (Part 2)
Part 1:

· Nutritional follow up differed in both units. The nutritional data were frequently missing from the charts in A (weight, energy intake).

· Calculation of the derived variables (energy delivery) was time consuming (per patient: 10-15 min vs 1-2 min in B: p = ), due to automatic computing in B (integration of energy from all sources including drugs like propofol, calculation of energy deficit).
· Energy delivery was below target in both units (Part 1) but significantly closer to target in B with CIS
· Nutritional support was better in Unit B with CIS than in A, as shown by
o Prescription closer to optimal energy target
o Higher mean energy delivery
o Energy delivery was 77% of prescription in B versus 29% in A
o Low number of missing data (Structured prescription)
Part 2:

· Nutritional improved after introduction of CIS in burned patients (Fig 3)
There was no case of TPN and enteral route was always used (gastric or jejunal)

Conclusions

· Nutritional support differed in both units, being standardised in B. The change is not due to the burn specificity of the unit, since an improved nutritional support was observable in unit B after the introduction of CIS in the burn unit.

· CIS facilitates nutritional follow-up: gain on time on energy calculation, structured prescription, easy observation of delivered nutrients.
· And eased its monitoring. This has reduced time required for calculations and writing. The CIS has increased quality of nutritional care, by forcing standardisation of prescription, changes are associated with a better follow up, and nutrient delivery closer to energy target.