Evaluation of consulting and critiquing decision support systems: Effect on adherence to a lower tidal volume mechanical ventilation strategy

Purpose: Our hypothesis was that both styles are effective to decrease tidal volume (V-T) but that critiquing comprises the most effective strategy. The purpose of this study is to test this hypothesis by measuring the effect of an active computerized decision support system, in 2 communication styles, consulting and critiquing, on adherence to V-T recommendations. Materials and Methods: We developed and implemented an active computerized decision support system (CDSS) working in a consulting style that always shows the preferred V-T and in a critiquing style that shows the preferred V-T only if V-T is above the desired threshold. A prospective, off-on-off-on study evaluated the system's performance in a mixed medical-surgical intensive care unit of a university hospital. Results: Four thousand seven hundred sixty-four patient-day mechanical ventilation from 757 patients were analyzed. The percentage of ventilation time in excess of 6 and 8 mL/kg predicted body weight decreased significantly after intervening with the consulting style (12% reduction and P < .001; 22% reduction and P < .001) and again increased after stopping the CDSS (11% increase and P < .001; 29% increase and P < .001). With the critiquing CDSS, the percentage of ventilation time in excess of 6 and 8 mL/kg predicted body weight again decreased significantly (6% reduction and P < .001; 15% reduction and P < .001). Conclusions: The use of a CDSS in both communication styles improved the use of lower V(T)s for ventilated patients. When decision support was not sustained, adherence to low V-T fell back to its original value. Interestingly, the consulting style had a slightly larger effect. This may stem from the high frequency of showing reminders in this style and the relatively simple underlying guideline where its display implies the associated action of lowering V-T. The consulting style, however, was more interruptive for clinicians, calling upon the need to strike a balance between effect and intrusiveness. (C) 2012 Elsevier Inc. All rights reserved.