Nurses' Use of Computerized Clinical Guidelines to Improve Patient Safety in Hospitals.

577430 research-article2015

WJNXXX10.1177/0193945915577430Western Journal of Nursing ResearchHovde et al.

Article

Nurses’ Use of Computerized Clinical Guidelines to Improve Patient Safety in Hospitals

Western Journal of Nursing Research 2015, Vol. 37(7) 877–898 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945915577430 wjn.sagepub.com

Birgit Hovde1,2, Kari H. Jensen1, Gregory L. Alexander3, and Mariann Fossum1,4

Abstract Computerized clinical guidelines are frequently used to translate research into evidence-based behavioral practices and to improve patient outcomes. The purpose of this integrative review is to summarize the factors influencing nurses’ use of computerized clinical guidelines and the effects of nurses’ use of computerized clinical guidelines on patient safety improvements in hospitals. The Embase, Medline Complete, and Cochrane databases were searched for relevant literature published from 2000 to January 2013. The matrix method was used, and a total of 16 papers were included in the final review. The studies were assessed for quality with the Critical Appraisal Skills Program. The studies focused on nurses’ adherence to guidelines and on improved patient care and patient outcomes as benefits of using computerized clinical guidelines. The nurses’ use of computerized clinical guidelines demonstrated improvements in care processes; however, the evidence for an effect of computerized clinical guidelines on patient safety remains limited.

1University

of Agder, Grimstad, Norway Hospital Trust, Norway 3University of Missouri, Columbia, USA 4Deakin University, Melbourne, Australia 2Innlandet

Corresponding Author: Birgit Hovde, Innlandet Hospital Trust, P.O.Box 104, NO-2381 Brumunddal, Norway. Email: [email protected]

Downloaded from wjn.sagepub.com at UNIV NEBRASKA LIBRARIES on October 12, 2015

878

Western Journal of Nursing Research 37(7)

Keywords clinical guidelines, computerized guidelines, hospital, integrative review, nursing

The occurrence of preventable adverse events during hospital admissions has become a problem over the past two decades due to the complexity of drug policies and advances in diagnostic and treatment procedures (de Vries, Ramrattan, Smorenburg, Gouma, & Boermeester, 2008; Greene & Kesselheim, 2011; Hoonhout et al., 2010). In the United States, the costs of preventable adverse events range from US$17 to US$29 billion in 1999 (E. J. Thomas et al., 1999); furthermore, a systematic review concluded that 1 of every 10 patients is affected by an adverse event during hospital admissions, which constitutes a particularly important time for planning care delivery (de Vries et al., 2008). The implementation of clinical guidelines in hospitals can improve safety and increase the quality of patient care through evidence-based behavioral practices (Middleton et al., 2011). The Safe or Sorry program, designed to test the use of clinical guidelines to prevent medical errors, allows organizations to implement clinical guidelines simultaneously to improve patient safety. After implementing the Safe or Sorry program using guidelines, researchers measured the effects on the occurrence of adverse events related to pressure ulcers, urinary tract infections, and falls. The program effectively reduced the incidence of adverse events. In addition, the researchers found that it was difficult to measure the compliance of nurses’ use of the guidelines, and they suggested that more research was needed on how the guidelines were implemented and on the adoption of guidelines (van Gaal et al., 2011). Guidelines have traditionally been paper based; however, recent developments in technology have provided several new opportunities for sharing and using guidelines (Bates et al., 2003; Jones, Stewart, Darer, & Sittig, 2013). Computerized clinical guidelines (CCGs) are an example of a health care intervention to manage, predict, and prevent adverse events (Damiani et al., 2010). CCGs are used to promote standardized practice, alerts, predictive tools, checklists and electronic prescribing tools (SilowCarroll, Edwards, & Rodin, 2012). The use of CCGs in this study included the use of evidence-based CCGs incorporated into the workflow; however, actual use was not included. Effective use of CCGs requires that the CCGs be incorporated into existing electronic health records (EHRs) and integrated into clinicians’ workflow at the point of care (Jones et al., 2013; Kawamoto, Houlihan, Balas, & Lobach, 2005).


879

Hovde et al.

Increased patient safety is an important benefit of using CCGs (Damiani et al., 2010). Patient safety can be defined as “the prevention of harm to patients” (Aspden, Corrigan, Wolcott, & Erickson, 2004, p. 19). Important features of development activities for effective use of CCGs have been identified, and they include the following: Identify standard data triggers, review access to existing input data, work on increasing the clarity and internal consistency of all clinical logic included in guidelines, suggest appropriate personnel and the best insertion points in the clinical workflow for CCG interventions to be delivered, facilitate selective filtering or tailoring of rules, support the HL7 Infobutton standard, and establish CCG development groups. (Jones et al., 2013, p. 10)

However, there is still a lack of knowledge about the implementation of CCGs in nursing practices and the effects of CCGs on patient safety. This article provides an integrative review of the current literature.

Purpose The aim of this research was to identify the factors influencing nurses’ use of CCGs and the effects of nurses’ use of CCGs in improving patient safety in hospitals.

Method The Matrix Method The matrix method, specifically designed to review health sciences literature, was used in this review (Garrard, 2013). The five basic elements used in the method are (a) identifying the purpose of the review, (b) screening and selecting scientific papers that meet specified criteria, (c) carefully reviewing the selected papers for excellence regarding their scientific methods and statistical procedures and for the validity and reliability of the data collection, (d) summarizing the findings across the studies, and (e) drawing conclusions based on the scientific evidence (Garrard, 2013).

Search Strategy A literature search was performed in the Embase, Medline Complete, and Cochrane databases to identify trials and research papers published between 2000 and January 2013 (Figure 1). This time period was chosen to include all of the papers relevant to the aim. Because the development of CCGs has


880


Figure 1. Literature search.

immensely expanded over the past 10 years, we presumed that there was a lack of literature describing CCGs before 2000 (Bates et al., 2003). The basic keywords identified as MeSH terms were the following: practice guideline, patient safety, computerized, hospitals, nurses, and technology. Various combinations of the basic search words and synonyms were used in the searches. We incorporated Boolean logic, including with, and/or and truncations, to broaden the search results. A Population, Intervention, Comparison, Outcome (PICO) form was created. PICO is a tool used to identify elements in search questions, and it is important for clarifying the elements necessary for a precise literature search and for selecting papers that addresses our research questions (Schardt, Adams, Owens, Keitz, & Fontelo, 2007). Accordingly, PICO provided the structure for the literature search and paper selection. A search “tree” of synonyms was built from the PICO statements and was matched with the MeSH terms to strengthen the search criteria. A word base of synonyms was created to cover the research conducted. Sixtyeight search words were used in various combinations. A medical librarian supervised the search strategy and assisted with the retrieval of papers.

Inclusion and Exclusion Criteria The inclusion criteria were the following: nurses in hospitals, CCGs, patient safety, and patient outcomes. The exclusion criteria were the following: mental health hospitals, incomplete description of the population, failure to


881

Hovde et al.

Figure 2. Papers included and excluded using the matrix method.

describe the location, prescribing systems, medical dispensing systems, and computer physician order entry (CPOE) systems.

Study Selection A total of 5,026 abstracts were reviewed by two of the authors to select the papers that met the inclusion criteria for the integrative review. Papers were included or excluded based on the inclusion and exclusion criteria. A total of 4,488 papers were excluded, and 538 papers were eligible for inclusion. The abstracts were reviewed again, and this step resulted in 116 papers meeting the inclusion criteria. The 116 papers were read, and a total of 30 papers were saved in a folder. These papers were reviewed for quality by two of the authors. The papers were saved in a document folder and were renamed according to the year of publication and authors (Garrard, 2013). An additional 16 papers were excluded based on the exclusion criteria (Figure 2 and Table 1).


882


Table 1. Inclusion and Exclusion Criteria. Selection

Inclusion

P-population

Nurse in hospitals Groups of clinicians in hospitals, where nurses participate in the group

I-intervention

Guidelines Electronic guidelines Clinical information systems (CIS) Patient documentation Electronic health record (EHR) Clinical information records Computerized pathways Computerized care plans Clinical decision support systems (CDSS) Evidence-based practice (EBP)

C-comparing

Paper—electronic Practice variation Before—after

O-outcome

Patient safety Adverse events Quality of care

Design and method

Quantitative design Qualitative design Mixed/combined design

Exclusion Nurse in other health care services. (Home care, hospice etc.) Mental health hospitals Not properly describing population Not properly describing location Barcode and labeling medication systems Barcode blood transfusion systems Warning alarms Prescribing systems Medical dispensing Computer physician order entry (CPOE) Cardiopulmonary resuscitation (CPR) feedback Electronic patient monitoring systems Personal safety guidelines Patient handover guidelines Do-not-resuscitate guidelines Paper guidelines Not properly describing interventions used in study Medical errors, comparing nurses and physicians Gap between guidelines and actual care Not properly describing the comparison of elements used Not describing outcome

Not properly describing design Not properly describing method Population, Intervention, Comparison, Outcome (PICO) not properly described Variables not well described and controlled Systematic bias in selection, performance, detection, attrition, or reporting


883

Hovde et al.

A review matrix, which contained nine topics, was created in a Microsoft Excel (Redmond, WA, USA) spreadsheet. The topics were listed, with the authors, title, and journal listed in the first column. The second column contained the year of publication and the third column listed the purpose of the paper. The following topics were listed in a horizontal manner: purpose, method, location, implications for practice, use of clinical guidelines, patient safety, CCGs, and effects of CCGs. This review emphasized the following topics: clinical guidelines, patient safety, CCGs, and effects of CCGs. The included papers were placed vertically in the matrix and were read, abstracted, and reviewed and their quality appraised (Garrard, 2013). The final results are presented in Table 2.

Quality Appraisal of Included Studies The study designs and methods used in the retrieved studies were examined with the Critical Appraisal Skills Programme (1993), and the studies had to meet standard science research criteria to be included. Non-peer-reviewed research papers were excluded. Systematic reviews were stored in a separate folder and were used to compare with our results, but they were not included in the review. The reference lists of all of the papers were reviewed for potential papers to be included.

Results Study Characteristics The 16 papers included in this review were published between 2003 and 2013. The papers focused on various aspects of CCGs, and the characteristics of the included studies are summarized in Table 2. Seven papers focused on nurses’ adherence to guidelines and changes in clinical practice (Britton, Bloch, Strout, & Baumann, 2013; Diby, Merlani, Garnerin, & Ricou, 2005; Gurses et al., 2008; Hyde & Murphy, 2012; Johansson, Pilhammar, Khalaf, & Willman, 2008; Lee et al., 2010; M. Thomas, Dhanani, Irwin, & Doherty, 2010). Improvements in the quality of care and patient outcomes were the focuses of 3 papers (Andreessen, Wilde, & Herendeen, 2012; De Laat, Schoonhoven, Pickkers, Verbeek, & Van Achterberg, 2006; Sinuff, Cook, Randall, & Allen, 2003), and both changes in clinical practices and patient outcomes after the implementation of CCGs were the focuses of 6 papers (Abbott, Dremsa, Stewart, Mark, & Swift, 2006; Habich et al., 2012; Higuchi, Davies, Edwards, Ploeg, & Virani, 2011; Hoekstra et al., 2010; McMullin et al., 2006; Webb, Flagg, & Fink, 2006).


884


The three groups of caregivers modified their practices differently Significant modifications of practice

VAP rate changed, but not significantly Reduced inconsistent practices; improved patient outcomes related to comfort and enhanced collaboration among health care teams

1,909 arterial blood gases (ABGs)

106 mechanically ventilated patients

Pre–post evaluation design Prospectively explored and analyzed a quality improvement program Arterial blood gas analyses Pre–post evaluation design Implementation of an evidence-based clinical practice guidelines (CPG) to decrease ventilation-associated pneumonia (VAP)

Diby, Merlani, Garnerin, and Ricou (2005)

Abbott, Dremsa, Stewart, Mark, and Swift (2006)

Potassium control improved; hypokalemia and hyperkalemia decreased

Outcomes/Results

Data from 189 patients Pre-guideline phase: 91 Post-guideline phase: 98

Sample Size

Pre–post evaluation design Evaluation of a practice guideline for acute respiratory failure (ARF)

Design and Theme

Sinuff, Cook, Randall, and Allen (2003)

Authors and Year

Table 2. Studies Reviewed.

Not mentioned Could reduce unnecessary practice variability and increase practice based on the best current evidence

(continued)

More patients transferred to ICU; improved monitoring Prevalence of hypo- and hyperkalemia decreased Not mentioned

Effects on Patient Safety

Compliance with guidelines increased; could reduce care variability Computerized protocols are superior to paper protocols Greater adherence to guidelines

Factors Influencing Use of CCGs


885

Pre–post evaluation design Prospective, longitudinal, observational study ICU days during heparin thromboprophylaxis Pre–post evaluation design A multidisciplinary approach to prophylactic antibiotic use

McMullin et al. (2006)

Webb, Flagg, and Fink (2006)

Pre–post evaluation design Implementation of a pressure ulcer guideline

Design and Theme

De Laat, Schoonhoven, Pickkers, Verbeek, and Van Achterberg (2006)

Authors and Year

Table 2. (continued)

Significant decrease in surgical wound infections Timely administration of preoperative antibiotics improved from 51% to 98%

Inadequate prevention decreased Significant decrease in hospital-acquired pressure ulcer frequency Decrease in inadequate treatment Increase in adequate repositioning; changes in behavior and compliance with guidelines Significantly more patients received heparin thromboprophylaxis

657 patients before implementation; 735 patients 4 months after; 755 patients 11 months after

Phase 1: 68 patients Phase 2: 261 patients Phase 3: 101 patients Most surgical patients (90%) were monitored

Outcomes/Results

Sample Size

Not mentioned

Improved patient safety

Not mentioned

Compliance with guidelines increased

Nurses’ adherence to guidelines increased Guideline adherence was maintained 1 year later Compliance increased

(continued)



886


Semistructured interviews using a grounded theory approach Aim was to explore the underlying causes of noncompliance with evidence-based guidelines Structured observational study Nurses’ adherence to clinical guidelines regarding peripheral venous catheters

Gurses et al. (2008)

Johansson, Pilhammar, Khalaf, and Willman (2008)

Design and Theme

Authors and Year


Error reduction Nurses partially adhered to clinical guidelines Differences in guideline adherence were observed between local and national guidelines Differences between specialties Complication feedback should be provided to the staff

Adherence to guidelines is important to reduce errors and to prevent complications

Data of 343 peripheral venous catheters were analyzed

(continued)

Compliance with guidelines important for patient safety

Care providers should be able to access an electronic or manual copy of the guidelines for quick reference



Ambiguities reducing strategies can lead to compliance with evidence-based guidelines and reduce health care– associated infections

Outcomes/Results

20 participants were interviewed

Sample Size


887

Higuchi, Davies, Edwards, Ploeg, and Virani (2011)

M. Thomas, Dhanani, Irwin, and Doherty (2010)

Lee et al. (2010)

Hoekstra et al. (2010)

Authors and Year

Design and Theme

Longitudinal follow-up study Implementing a clinical guideline for adults with asthma and diabetes and evaluating nursing care

Pre–post evaluation design Implementation of a computerized potassium regulation protocol Pre–post evaluation design Crossover simulated control study of tight glycemic control Survey, observation, and focus interviews Implementation of a sedation and analgesic guideline


Fewer errors using a computerized tight glycaemic control (TGC) protocol, less nursing time Improved care; improved sedation and analgesia management Enhanced collaboration; reduced inconsistent practice; improved patient outcomes There was an increase in the “assessment of risk factors for foot ulcers” from the postimplementation period (44%) to 3 years later

620 responses

85 patient charts were reviewed

24 health care providers

Reduced prevalence of hypo- and hyperkalemia Potassium control improved

Outcomes/Results

775 patients before 1,435 patients after

Sample Size

Electronic documentation system increased guideline sustainability

Error reduction

Computerized protocols provided error reduction and ease of use

(continued)

Improved patient outcomes




Computerized protocols appear to be superior to paper protocols


888


Note. CCGs = computerized clinical guidelines.

Britton, Bloch, Strout, and Baumann (2013)

Hyde and Murphy (2012)

Pre–post evaluation design Comparative survey Piloting a strategy to enhance the quality of patient care using computerized clinical pathways Pre–post evaluation design Comparison rate of treatment compliance pre- and postimplementation of guidelines for treatment of sexual assault victims

Pre- and post-evaluation study Prevention of catheterassociated urinary tract infections Pre–post evaluation design Evaluating the effectiveness of pediatric pain management guidelines

Andreessen, Wilde, and Herendeen (2012)

Habich et al. (2012)

Design and Theme

Authors and Year


332 pre-order set and 131 after implementation

Guidelines Electronic order sets can emulate evidencebased practice, decrease prescribing errors, and improve consistency of care

No differences between nurses’ knowledge and attitudes regarding pain before and after implementation Significant increase in pain assessment Useful tool for educating patients, communicating during shifts, and consistent sharing of information with patients and other health disciplines

51 nurses

25 pre-pilot audits 44 post-pilot audits

Reduction of 71% in catheter device days and a 56% reduction in catheter use

Outcomes/Results

114 patient medical charts included and reviewed

Sample Size

Not mentioned

Patient safety increased

The tool must be used correctly to provide pain-reducing effects

Clinical pathways have to be easily accessible and complement dayto-day workflow

Error reduction

Patient safety increased


Electronic reminder system increased use


889

Hovde et al.

Twelve of the studies used the form of a pre- and post-evaluation design (Abbott et al., 2006; Andreessen et al., 2012; Britton et al., 2013; De Laat et al., 2006; Diby et al., 2005; Gurses et al., 2008; Habich et al., 2012; Hyde & Murphy, 2012; Lee et al., 2010; McMullin et al., 2006; Sinuff et al., 2003; Webb et al., 2006). One study used structured observations (Johansson et al., 2008), 1 used semistructured interviews (Gurses et al., 2008), 1 used record audits (Higuchi et al., 2011), and 1 used a combination of surveys, observations, and focus group interviews (M. Thomas et al., 2010). Eight of the papers discussed the implications of CCGs for clinical practice. Primarily, they focused on implementation challenges, finding that additional research examining the facilitators and barriers to implementation (Abbott et al., 2006; Andreessen et al., 2012; Diby et al., 2005; Gurses et al., 2008; Higuchi et al., 2011; Hyde & Murphy, 2012; Johansson et al., 2008; M. Thomas et al., 2010) was required for enabling the sustained implementation of the guidelines (Higuchi et al., 2011). Specifically, two papers described the use of reminders for adopting the new practice of using CCGs (Higuchi et al., 2011; M. Thomas et al., 2010), and one paper described the factors used in strategic planning for best practices with urinary catheters, as well as documentation (Andreessen et al., 2012). The scopes of four of the papers encompassed more than the use of guidelines (Abbott et al., 2006; Hyde & Murphy, 2012; Johansson et al., 2008; Webb et al., 2006). One paper described a pathway to support the routine care of patients, and it included several health professions (Hyde & Murphy, 2012) while two papers described clinical decision support systems. These health care systems contained more than guidelines alone, and they also suggested opportunities for improving care (Johansson et al., 2008; Webb et al., 2006). Another paper described several interventions that were performed, including the implementation of guidelines (Abbott et al., 2006).

Effects on the Process of Care of CCGs To secure the adoption of the CCGs, three of the studies used computerized tools during the implementation phases of the CCGs. These studies did not further describe the use of CCGs in the remainder of the study (Abbott et al., 2006; Habich et al., 2012; Sinuff et al., 2003). Sinuff and colleagues (2003) described the use of an interactive teaching program during the implementation phase of the CCGs. This intervention resulted in a significant change in care processes. The study emphasized the importance of guideline maintenance for sustaining outcome benefits, stating that CCGs are dynamic documents. Interviews with staff members in a study at two different hospitals found that computerized charting, among other factors, improved


890


the adoption of CCGs. To sustain behavioral changes, modifying the work environment, improving systems, decentralizing decision making and implementing adult education were recommended (Abbott et al., 2006). A pre- and post-intervention study in a pediatric intensive care unit used a computerbased testing course to introduce a new CCG. This study emphasized the importance of the use of the frontline nursing staff as opinion leaders in the development and successful implementation of the guidelines (Habich et al., 2012). Three papers describing CCGs were available on the Internet, via the intranet or online (De Laat et al., 2006; Diby et al., 2005; Johansson et al., 2008). One study measured the adherence of three groups of caregivers to an implemented CCG, which was made accessible online. The implementation led to a change in practice, in which requesting arterial blood gas (ABG) analyses without a stated reason was reduced (Diby et al., 2005). One study focused on the effects of implementing a CCG to reduce pressure ulcers in the Netherlands. In this study, the new guideline was published on their intranet and on additional hospital media during the implementation phase. In addition, the authors studied nurses’ compliance with the guideline after implementation, and they found an increasing trend in the adequate treatment of patients and a decreasing trend in the inadequate treatment of patients (De Laat et al., 2006). Another study focused on the adherence of nurses to guidelines in a hospital in Sweden. The guidelines were available on the Internet, and every unit had access to the national guidelines for peripheral venous catheters (Johansson et al., 2008). In two papers, the use of a computerized protocol based on clinical guidelines was studied (Hoekstra et al., 2010; Lee et al., 2010). One of the studies compared the use of computerized and paper protocols and found that the computerized protocol appeared to be superior to the paper protocol (Hoekstra et al., 2010). The other study, on the use of computerized protocols, showed that the protocols resulted in a reduction in errors, and they were easy to use (Lee et al., 2010). In the study, the protocols were converted from paper to computerized versions, which had designs based on research and which were focused on error reduction and ease of use. The underlying algorithm was the same as that with the paper protocol, but special alerts were built into the system, and the system also provided suggestions for care. In addition, the program displayed the patient’s insulin rate and time for the next glucose check (Lee et al., 2010). One paper described the use of mobile workstations on which shortcuts to clinical guidelines were installed on desktop computers. A total of 80 respondents stated that implementation of the guidelines promoted improved care (M. Thomas et al., 2010).


891

Hovde et al.

Seven of the papers studied nurses’ adherence to CCGs (Britton et al., 2013; Diby et al., 2005; Higuchi et al., 2011; Johansson et al., 2008; McMullin et al., 2006; Sinuff et al., 2003; Webb et al., 2006). One study found that the implementation of guidelines increased nurses’ adherence to the guidelines (Britton et al., 2013). Two papers examined nurses’ compliance to the CCGs and found that nurses’ compliance with guidelines was improved (De Laat et al., 2006; Hoekstra et al., 2010). One study showed that reminders increased the use of CCGs (Andreessen et al., 2012), whereas another study found that computerized guidelines offered advantages, such as ease of use (Lee et al., 2010).

Effects on Patient Outcomes of CCGs Several papers described the effects of CCGs on changes in care practices, finding that they led to significant modifications (Andreessen et al., 2012; De Laat et al., 2006; Diby et al., 2005; Habich et al., 2012; McMullin et al., 2006; Sinuff et al., 2003; M. Thomas et al., 2010; Webb et al., 2006). The effects were not inadequate treatment but increased appropriate treatment (De Laat et al., 2006; Diby et al., 2005; McMullin et al., 2006; Sinuff et al., 2003; M. Thomas et al., 2010). There were increased pain assessments (Habich et al., 2012), less catheter use (Andreessen et al., 2012), and more appropriate antibiotic use (Webb et al., 2006). More patients received heparin thromboprophylaxis (McMullin et al., 2006). Other papers reported that guideline implementation led to sustained compliance and adherence to guidelines (Britton et al., 2013; De Laat et al., 2006; McMullin et al., 2006). These effects included changes in behavior and improved medical provider compliance using a pressure ulcer guideline (De Laat et al., 2006), a heparin thromboprophylaxis guideline (McMullin et al., 2006), and a guideline for the treatment of sexual assault victims (Britton et al., 2013). One study was unable to determine the effect of the guideline due to problems with sustained practice (Abbott et al., 2006). This study involved the adoption of a ventilator-associated pneumonia guideline. The behavior change should be sustained for improved outcomes, and nurse administrators, educators, specialists, and researchers should emphasize strategies to facilitate practice changes (Abbott et al., 2006). Cost savings and declined length of hospital stay were described as possible results in two studies (Abbott et al., 2006; Andreessen et al., 2012). Catheter-associated urinary tract infections accounted for 40% of all infections in a hospital. Implementing a set of guidelines led to a decreased number of adverse effects. Catheter use was reduced by 57%. Cost analysis of possible savings should be computed to determine cost savings (Abbott et al., 2006; Andreessen et al., 2012). Other


892


studies reported that more patients were treated, the number of consultations increased, and treatment decreased, but these authors did not describe the reasons for these changes (Andreessen et al., 2012; Diby et al., 2005; Sinuff et al., 2003; M. Thomas et al., 2010). Reductions in inconsistencies in practice were described in two studies (Britton et al., 2013; M. Thomas et al., 2010), and decreased morbidity and mortality were observed in one study (Andreessen et al., 2012). Another study reported that bedside use enabled better communication between the staff and patients (Hyde & Murphy, 2012), and the same study reported that the use of CCGs also enabled better communication between shifts and among health care workers (Hyde & Murphy, 2012). One of the papers described increased user satisfaction and time savings. Overwhelmed nurses preferred the computerized protocol (Lee et al., 2010). One paper described using guidelines on a bedside mobile workstation (M. Thomas et al., 2010). In a survey conducted 3 months after implementation of the guideline, 80% of the respondents reported that they felt moderately to very confident that using the guideline had improved care in the unit (M. Thomas et al., 2010).

Patient Safety With regard to patient safety, four papers concluded that the use of guidelines led to increased patient safety (Andreessen et al., 2012; Hoekstra et al., 2010; McMullin et al., 2006; M. Thomas et al., 2010). Two of the papers mentioned the importance of compliance or adherence to guidelines in reducing errors and improving patient safety. The adherence differed between local and national guidelines. Ambiguity-reducing strategies could lead to compliance and could reduce health care–associated infections (Gurses et al., 2008; Johansson et al., 2008). Four papers found that the use of CCGs led to improved quality of care or patient outcomes (De Laat et al., 2006; Higuchi et al., 2011; Sinuff et al., 2003; Webb et al., 2006). The described quality of care included improved monitoring and increased pulmonary consultations for patients with acute respiratory failure. This study also demonstrated changes in behavior; therefore, guidelines could reduce unnecessary variability in utilization and could encourage evidence-based practice. Appropriate antibiotic treatment improved from 78% to 94%. Inadequate prevention of ulcers was reduced from 19% to 4%, and inadequate treatment decreased from 60% to 30%. There was an increase in the assessment of risk factors for foot ulcers among diabetes patients, from 44% to 98.5% 3 years after implementing guidelines (De Laat et al., 2006; Higuchi et al., 2011; Sinuff et al., 2003; Webb et al., 2006). A reduction in the incidence of errors was also


893

Hovde et al.

reported in two papers (Britton et al., 2013; Lee et al., 2010), and one paper concluded that, if the practice was sustained, it would likely result in an improvement in patient outcomes (Abbott et al., 2006). However, another paper did not note any difference in patient satisfaction with regard to the implementation of pediatric pain management guidelines (Habich et al., 2012). Patient satisfaction was measured according to the patient outcomes related to the implementation of clinical guidelines.

Discussion These 16 studies found in the current literature investigated the factors influencing nurses’ use of CCGs and the effects of nurses’ use of CCGs on patient safety in hospitals. The studies used similar research designs; however, the study results differed considerably. The results showed that the focus of the included papers was mainly on adherence to guidelines and improvements in care processes, rather than on measuring the effects of CCGs on patient outcomes and/or patient safety. These results were consistent with the results from a systematic review of computerized clinical decision support systems for acute care management, conducted by Sahota et al. (2011), and those of a systematic review conducted by Damiani et al. (2010), who explored the effectiveness of CCGs in care processes. The importance of having the computerized information available to improve care processes and patient outcomes has been discussed in the literature (Kawamoto et al., 2005; Shojania et al., 2009). The papers included in this review mentioned that guidelines were computerized, but this factor was not given primary emphasis. Most of the reviewed studies did not compare paper versus computerized guidelines. Only one of the papers included in this review found computerized protocols superior to paper protocols (Hoekstra et al., 2010). Nurses working with this protocol found that the computerized protocol was easy to work with and reliable (Hoekstra et al., 2010). Future studies should investigate the effects of the computerization of guidelines (Bates et al., 2003) and should include effect indicators regarding patient safety and quality of care (Andreessen et al., 2012; Hoekstra et al., 2010; Hyde & Murphy, 2012). The need to include relevant effect indicators in the strategic planning of the implementation of CCGs has been emphasized in the development and implementation of CCG systems for use in hospitals (Osheroff et al., 2007). We recommend that future studies use quantitative study designs to focus on measuring nurses’ direct use of the CCGs, including measurable patient outcomes relevant for patient safety. Use and user experiences are related to the effects and net benefits of information systems (Petter, DeLone, & McLean, 2008).


894


Overall, the results of this study were mixed with regard to the factors that influenced nurses’ use of guidelines and their effects on patient safety. The three most important factors were the following: lack of time, the computer system as an interactive part of patient care, and the importance of guidelines being in close proximity to patients. Although M. Thomas et al. (2010) did not directly describe the importance of guidelines being in close proximity to patients, the study used mobile workstations, which had shortcuts to the guidelines installed on a desktop computer. These mobile workstations made it possible to use CCGs in close proximity to patients. A total of 80 respondents stated that the implementation of the guidelines led to an improvement of care. In the reviewed studies, the use of guidelines was measured according to nurses’ adherence to or compliance with guidelines. Accordingly, the studies were related to the implementation of a new guideline, rather than to nurses’ actual use of the computerized guidelines. The use of CCGs affected care processes and practices were modified. This result was consistent with the results of another review by Damiani et al. (2010). These authors also found that the positive effects might have been related to time saving for clinicians, as well as other facilitations (Damiani et al., 2010); however, earlier research has also shown modest effects on the process of care (Shojania et al., 2009). All of the papers in our review described at least one positive effect, and five main effects were found. These effects included improved quality of care, prevention of complications, economic benefits, standardized care, and improvements in communication and stimulation of increased use of guidelines (Britton et al., 2013; Higuchi et al., 2011; Hoekstra et al., 2010; Hyde & Murphy, 2012; Lee et al., 2010; M. Thomas et al., 2010). The inclusion criteria allowed for the inclusion of all types of studies. Our results showed an absence of evidence for effects on patient safety, indicating that increased focus on the strategic planning of patient outcomes in the development and implementation of CCGs is required. However, most of the studies addressed different outcomes, and the variables studied were limited to only a few relevant patient safety outcome measurements. An increase in patient safety, as a result of CCGs, was mentioned in four of the papers (Andreessen et al., 2012; Hoekstra et al., 2010; McMullin et al., 2006; M. Thomas et al., 2010). In other papers, increased quality of care, improved patient outcomes, and reduced errors were described. These results could be considered patient safety indicators although the specific concept of patient safety was not used. A substantial proportion of adverse hospital events are preventable, and further research on the effects of CCGs on patient safety could substantially improve hospital care (de Vries et al., 2008). The papers in this review mostly studied parameters pre- and post-guideline implementation. Various challenges in the implementation processes were


895

Hovde et al.

described. Several of the papers found that further research was necessary to identify facilitators and barriers in the process of implementation. McMullin and colleagues (2006) investigated effective methods for implementing guidelines and found that studying the baseline and outcome after the guideline was implemented was important. McMullin et al. also found that alerts, prompts, and reminders were effective during guideline implementation. Two papers that were included in our review also discussed the use of reminders to secure guideline implementation (Higuchi et al., 2011; M. Thomas et al., 2010). Reminders could also increase the use of CCGs (Andreessen et al., 2012), which was also found to be important in additional reviews (Grimshaw et al., 2005; Kawamoto et al., 2005; Shojania et al., 2009). Our literature search was supported by a medical research and project librarian. We used the PICO tool with the literature searches and screened more than 5,000 papers. The review was performed by two of the authors (B. H. and K. H. J.). We included only English-language papers. Although all of the papers that were included mentioned CCGs, the computerization of guidelines was not a primary emphasis. This finding suggested a lack of available studies meeting all of our inclusion criteria. We included both qualitative and quantitative studies. In addition, four of the included papers described more than guidelines. We did not include clinical decision support systems; however, we might have lost some information by excluding this element from the literature search. Further studies should investigate the effects of CCGs, with a specific focus on guidelines being computerized or a focus on comparing computerized guidelines with paper-based guidelines. It would also be interesting to investigate how often CCGs are actually used; accordingly, future studies should employ high-quality study designs to measure nurses’ use of CCGs directly. Nurses’ use of CCGs led to improvements in care processes. It is important that nurses adhere to and comply with CCGs to benefit from them. The use of CCGs by nurses could potentially improve patient safety, patient outcomes, and quality of care in hospitals; however, the reviewed studies did not specifically reveal any effects on patient safety. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.


896


References Abbott, C. A., Dremsa, T., Stewart, D. W., Mark, D. D., & Swift, C. C. (2006). Adoption of a ventilator-associated pneumonia clinical practice guideline. Worldviews on Evidence-Based Nursing, 3, 139-152. Andreessen, L., Wilde, M., & Herendeen, P. (2012). Preventing catheter-associated urinary tract infections in acute care: The bundle approach. Journal of Nursing Care Quality, 27, 209-217. Aspden, P., Corrigan, J., Wolcott, J., & Erickson, S. (2004). Patient safety: Achieving a new standard for care. Washington, DC: National Academies Press. Bates, D., Evans, R., Murff, H., Stetson, P., Pizziferri, L., & Hripcsak, G. (2003). Detecting adverse events using information technology. Journal of the American Medical Informatics Association, 10, 115-128. Britton, D., Bloch, R., Strout, T., & Baumann, M. (2013). Impact of a computerized order set on adherence to centers for disease control guidelines for the treatment of victims of sexual assault. The Journal of Emergency Medicine, 44, 528-535. The Critical Appraisal Skills Programme. (1993). Retrieved from http://www.caspuk.net/#!casp-tools-checklists/c18f8 Damiani, G., Pinnarelli, L., Colosimo, S. C., Almiento, R., Sicuro, L., Galasso, R., . . . Ricciardi, W. (2010). The effectiveness of computerized clinical guidelines in the process of care: A systematic review. BMC Health Services Research, 10, 2. De Laat, E. H., Schoonhoven, L., Pickkers, P., Verbeek, A. L., & Van Achterberg, T. (2006). Implementation of a new policy results in a decrease of pressure ulcer frequency. International Journal for Quality in Health Care, 18, 107-112. de Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: A systematic review. Quality & Safety in Health Care, 17, 216-223. Diby, M., Merlani, P., Garnerin, P., & Ricou, B. (2005). Harmonization of practice among different groups of caregivers: A guideline on arterial blood gas utilization. Journal of Nursing Care Quality, 20, 327-334. Garrard, J. (2013). Health sciences literature review made easy. Burlington, MA: Jones & Bartlett Learning. Greene, J. A., & Kesselheim, A. S. (2011). Why do the same drugs look different? Pills, trade dress, and public health. New England Journal of Medicine, 365, 83-89. Grimshaw, J. M., Thomas, R. E., MacLennan, G., Fraser, C., Ramsay, C. R., Vale, L., . . . Donaldson, C. (2005). Effectiveness and efficiency of guideline dissemination and implementation strategies. International Journal of Technology Assessment in Health Care, 21, 144-150. Gurses, A. P., Seidl, K. L., Vaidya, V., Bochicchio, G., Harris, A. D., Hebden, J., & Xiao, Y. (2008). Systems ambiguity and guideline compliance: A qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Quality & Safety in Health Care, 17, 351-359. doi:10.1136/qshc.2006.021709 Habich, M., Wilson, D., Thielk, D., Melles, G. L., Crumlett, H. S., Masterton, J., & McGuire, J. (2012). Evaluating the effectiveness of pediatric pain management guidelines. Journal of Pediatric Nursing, 27, 336-345.


897

Hovde et al.

Higuchi, K. S., Davies, B. L., Edwards, N., Ploeg, J., & Virani, T. (2011). Implementation of clinical guidelines for adults with asthma and diabetes: A three-year follow-up evaluation of nursing care. Journal of Clinical Nursing, 20, 1329-1338. Hoekstra, M., Vogelzang, M., Drost, J., Janse, M., Loef, B., Van der Horst, I., . . . Nijsten, M. (2010). Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit-a before and after analysis. BMC Medical Informatics and Decision Making, 10, 5. Hoonhout, L. H., de Bruijne, M. C., Wagner, C., Asscheman, H., van der Wal, G., & van Tulder, M. W. (2010). Nature, occurrence and consequences of medicationrelated adverse events during hospitalization: A retrospective chart review in the Netherlands. Drug Safety: An International Journal of Medical Toxicology and Drug Experience, 33, 853-864. Hyde, E., & Murphy, B. (2012). Computerized clinical pathways (care plans): Piloting a strategy to enhance quality patient care. Clinical Nurse Specialist, 26, 277-282. Johansson, M. E., Pilhammar, E., Khalaf, A., & Willman, A. (2008). Registered nurses’ adherence to clinical guidelines regarding peripheral venous catheters: A structured observational study. Worldviews on Evidence-Based Nursing, 5, 148-159. Jones, J. B., Stewart, W. F., Darer, J. D., & Sittig, D. F. (2013). Beyond the threshold: Real-time use of evidence in practice. BMC Medical Informatics and Decision Making, 13, 47. Kawamoto, K., Houlihan, C. A., Balas, E. A., & Lobach, D. F. (2005). Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. British Medical Journal, 330, 765-768. Lee, A., Faddoul, B., Sowan, A., Johnson, K., Silver, K., & Vaidya, V. (2010). Computerisation of a paper-based intravenous insulin protocol reduces errors in a prospective crossover simulated tight glycaemic control study. Intensive and Critical Care Nursing, 26, 161-168. McMullin, J., Cook, D., Griffith, L., McDonald, E., Clarke, F., Guyatt, G., . . . Crowther, M. (2006). Minimizing errors of omission: Behavioural rEenforcement of heparin to avert venous emboli: The BEHAVE study. Critical Care Medicine, 34, 694-699. Middleton, S., McElduff, P., Ward, J., Grimshaw, J. M., Dale, S., D’Este, C., . . . Levi, C. (2011). Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): A cluster randomised controlled trial. The Lancet, 378, 1699-1706. doi:10.1016/ S0140-6736(11)61485-2 Osheroff, J., Teich, J., Middleton, B., Steen, E., Wright, A., & Detmer, D. (2007). A roadmap for national action on clinical decision support. Journal of the American Medical Informatics Association, 14, 141-145. Petter, S., DeLone, W., & McLean, E. (2008). Measuring information systems success: Models, dimensions, measures, and interrelationships. European Journal of Information Systems, 17, 236-263.


898


Sahota, N., Lloyd, R., Ramakrishna, A., Mackay, J. A., Prorok, J. C., Weise-Kelly, L., . . . Haynes, R. B. (2011). Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implementation Science, 6, 91-98. Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7, 16. Shojania, K. G., Jennings, A., Mayhew, A., Ramsay, C. R., Eccles, M. P., & Grimshaw, J. (2009). The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database of Systematic Reviews, 3, 1-72. doi:10.1002/14651858.CD001096.pub2 Silow-Carroll, S., Edwards, J., & Rodin, D. (2012). Using electronic health records to improve quality and efficiency: The experiences of leading hospitals. Issue Brief (Commonwealth Fund), 17, 1-38. Sinuff, T., Cook, D. J., Randall, J., & Allen, C. J. (2003). Evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure. CHEST Journal, 123, 2062-2073. Thomas, E. J., Studdert, D. M., Newhouse, J. P., Zbar, B. I., Howard, K. M., Williams, E. J., & Brennan, T. A. (1999). Costs of medical injuries in Utah and Colorado. Inquiry, 36, 255-264. Thomas, M., Dhanani, S., Irwin, D., & Doherty, D. (2010). Development, dissemination and implementation of a sedation and analgesic guideline in a pediatric intensive care unit. It takes creativity and collaboration. Dynamics, 21, 16-25. van Gaal, B. G., Schoonhoven, L., Mintjes, J. A., Borm, G. F., Koopmans, R. T., & van Achterberg, T. (2011). The SAFE or SORRY? programme. Part II: Effect on preventive care. International Journal of Nursing Studies, 48, 1049-1057. Webb, A., Flagg, R., & Fink, A. (2006). Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration. The American Journal of Surgery, 192, 663-668.


Nurses' perceptions of patient safety culture in Jordanian hospitals.

Examining nurses' work environments to improve safety.

Local anesthetics in liposuction: considerations for new practice advisory guidelines to improve patient safety.

Local anesthetics in liposuction: considerations for new practice advisory guidelines to improve patient safety.

Reply: local anesthetics in liposuction: considerations for new practice advisory guidelines to improve patient safety.

Reducing Acute Kidney Injury Due to Contrast Material: How Nurses Can Improve Patient Safety.

What are hospital nurses' strengths and weaknesses in patient safety competence? Findings from three Korean hospitals.

Nurses in successful trusts helping 'special measures' hospitals improve.

Empowering students to help improve patient safety.

Technology and simulation to improve patient safety.

Aviation tools to improve patient safety.

Patient safety culture among nurses.

Use of foreign-educated nurses and patient satisfaction in U.S. hospitals.

Patient-oriented Computerized Clinical Guidelines for Mobile Decision Support in Gestational Diabetes.

Using preoperative assessment and patient instruction to improve patient safety.

Use of omalizumab to improve desensitization safety in allergen immunotherapy.

Patient safety: Committing to learn and acting to improve.

A multidisciplinary three-phase approach to improve the clinical utility of patient safety indicators.

How to use information technology to improve medication safety.

Safety guidelines for use of nitric oxide.

Teamwork and clinical error reporting among nurses in Korean hospitals.

Doctor-patient relationships, laws, clinical guidelines, best practices, evidence-based medicine, medical errors and patient safety.

Legal and Policy Interventions to Improve Patient Safety.

Developing a ward round checklist to improve patient safety.