Facilitators and Barriers to Interacting With Clinical Decision Support in the ICU: A Mixed-Methods Approach

Adrian Wong; Lucas A Berenbrok; Lauren Snader; Yu Hyeon Soh; Vishakha K Kumar; Muhammad Ali Javed; David W Bates; Lauren R Sorce; Sandra L Kane-Gill

doi:10.1097/CCE.0000000000000967

Facilitators and Barriers to Interacting With Clinical Decision Support in the ICU: A Mixed-Methods Approach

Crit Care Explor. 2023 Aug 25;5(9):e0967. doi: 10.1097/CCE.0000000000000967. eCollection 2023 Sep.

Authors

Affiliations

¹ Beth Israel Deaconess Medical Center, Department of Pharmacy, Boston, MA.
² University of Pittsburgh, School of Pharmacy, Pittsburgh, PA.
³ Society of Critical Care Medicine, Mount Prospect, IL.
⁴ Mercy Hospital, St. Louis, MO.
⁵ Brigham and Women's Hospital, Division of General Internal Medicine and Primary Care, Boston, MA.
⁶ Harvard Medical School, School of Medicine, Boston, MA.
⁷ Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
⁸ Northwestern University Feinberg School of Medicine, Division of Pediatric Critical Care, Chicago, IL.

Abstract

Objectives: Clinical decision support systems (CDSSs) are used in various aspects of healthcare to improve clinical decision-making, including in the ICU. However, there is growing evidence that CDSS are not used to their full potential, often resulting in alert fatigue which has been associated with patient harm. Clinicians in the ICU may be more vulnerable to desensitization of alerts than clinicians in less urgent parts of the hospital. We evaluated facilitators and barriers to appropriate CDSS interaction and provide methods to improve currently available CDSS in the ICU.

Design: Sequential explanatory mixed-methods study design, using the BEhavior and Acceptance fRamework.

Setting: International survey study.

Patient/subjects: Clinicians (pharmacists, physicians) identified via survey, with recent experience with clinical decision support.

Interventions: An initial survey was developed to evaluate clinician perspectives on their interactions with CDSS. A subsequent in-depth interview was developed to further evaluate clinician (pharmacist, physician) beliefs and behaviors about CDSS. These interviews were then qualitatively analyzed to determine themes of facilitators and barriers with CDSS interactions.

Measurements and main results: A total of 48 respondents completed the initial survey (estimated response rate 15.5%). The majority believed that responding to CDSS alerts was part of their job (75%) but felt they experienced alert fatigue (56.5%). In the qualitative analysis, a total of five facilitators (patient safety, ease of response, specificity, prioritization, and feedback) and four barriers (excess quantity, work environment, difficulty in response, and irrelevance) were identified from the in-depth interviews.

Conclusions: In this mixed-methods survey, we identified areas that institutions should focus on to improve appropriate clinician interactions with CDSS, specific to the ICU. Tailoring of CDSS to the ICU may lead to improvement in CDSS and subsequent improved patient safety outcomes.

Keywords: alert fatigue; clinical decision support systems; implementation science; intensive care unit; patient safety.