荷兰阿姆斯特丹大学Tinka Bakker团队研究了为重症监护量身定制的计算机化决策支持警报，对高风险药物组合管理的影响及其监测效果。2024年1月20日出版的《柳叶刀》杂志发表该项成果。

药物-药物相互作用（DDI）可能会伤害重症监护室（ICU）患者。然而，旨在帮助医生预防DDI的临床决策支持系统（CDSS）受到低收益警报的困扰，导致警报疲劳并危及患者安全。这项多中心研究旨在评估根据ICU设置调整潜在DDI警报对高风险药物组合给药频率的影响。

研究组在荷兰的九个重症监护室进行了一项集群随机阶梯楔形试验。五个ICU已经使用了潜在的DDI警报。入住ICU且至少服用两种药物的18岁及以上患者也包括在内。研究组的干预措施是经过校正的CDSS，仅为被视为高风险的潜在DDI提供警报。干预措施是在重症监护室级别进行的，并针对医生。他们假设，仅显示相关警报将提高CDSS的有效性，并减少高风险药物组合的使用数量。一名独立研究人员对ICU实施干预的顺序进行了随机分组。主要结局是每位患者每1000次给药中服用的高风险药物组合的数量，并在所有纳入的患者中进行评估。

研究组共对2018年9月1日至2019年9月1日期间入住ICU的10423名患者进行了评估，9887名患者被纳入其中。干预组（n=5534）每1000名患者服用的高风险药物组合的平均数量为26.2（SD 53.4），而对照组（n=4353）为35.6（65.0）。在对聚类和预后因素进行校正后，为ICU量身定制潜在的DDI警报导致每位患者每1000次给药中服用的高危药物组合数量减少12%（95%CI 5-18%；p=0.008）。

这项集群随机阶梯楔形试验表明，根据ICU环境调整潜在的DDI警报可以显著减少高风险药物组合的使用数量。该高风险药物组合列表可用于其他重症监护室，根据临床相关性定制警报的策略可应用于其他临床环境。

附：英文原文

Title: 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

Author: Tinka Bakker, Joanna E Klopotowska, Dave A Dongelmans, Saeid Eslami, Wytze J Vermeijden, Stefaan Hendriks, Julia ten Cate, Attila Karakus, Ilse M Purmer, Sjoerd H W van Bree, Peter E Spronk, Martijn Hoeksema, Evert de Jonge, Nicolette F de Keizer, Ameen Abu-Hanna, Dorieke E.M. van Balen, Peter F. Schutte, Marnix J. Sigtermans, Emile M. Kuck, Erik J.M. van Kan, Marijke S. van der Steen, Liesbeth E. Bosma, Ralph O. Nowitzky, Albertus Beishuizen, Kris L.L. Movig, Elsbeth M. Wesselink, Rick J.W. Lammers, Cedric Lau, Joost B. Masselink, Rob J. Bosman, Dylan W. de Lange, Rob J. van Marum, Heleen van der Sijs, Eric J.F. Franssen, Hans Kieft, Walter M. van den Bergh, Wouter Bult, Maurits H. Renes, Peter W. de Feiter, Evert-Jan Wils, Nicole G.M. Hunfeld, Froukje Mulder, Michiel Duyvendak

Issue&Volume: 2024-01-20

Abstract:

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, 10423 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.

DOI: 10.1016/S0140-6736(23)02465-0

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)02465-0/abstract