Introduction

Acute cardiac care has changed dramatically over the past decennia: the first critical care units were established to provide monitoring for and treatment of life threatening arrhythmias in patients with acute myocardial infarction (AMI). The introduction of thrombolytic therapy, and later primary percutaneous intervention for the treatment of AMI provided challenges to the management of these patients. The fact that delay in treatment is to provides specific challenges with regard to the pre-hospital and in-hospital care processes. It would be an understatement to say that the role of information technology in health care has gone unnoticed. Quite to the contrary, it is difficult to imagine a critical care environment without computers. The effectiveness of computers as an aid in the decision making and health care delivery process however, is less apparent. Chapter 1 describes the role of clinical decision support systems in critical care and emphasizes factors for successful implementation.

Part one describes strategies to improve the processes of triage in patients with chest pain. Interpretation of the pre-hospital 12 lead electrocardiogram is a key element in this process. Chapter 2 describes ability of paramedics’ to diagnose ST elevation acute myocardial infarction (AMI), and to assess the influence of confounding electrocardiographic factors on the paramedics’ diagnosis. Chapter 3 describes the technical aspects of implementing a system for pre-hospital ECG transmission from the ambulance to a cardiologist. In Chapter 4 presents initial results and shows examples of such a system with regard to effectiveness in a subset of patients with chest pain. To reduce in-hospital delay to reperfusion therapy, the effectiveness of a set of hospital care improvement strategies was evaluated; the results of these are presented in Chapter 5.

Improvements in patient monitoring technology have transformed the intensive cardiac care unit into an environment with multiple advanced technological devices. Ability and necessity to monitor more clinical parameters (due to increasing complexity of admitted patients), leading an increase in alerts generated by the monitoring devices. In part two of this thesis Chapter 6 describes the distribution of patient monitoring device alarms with regard to distribution over time and type of alarm. To introduce interventions that can reduce frequency and improve relevance of alarms, a system is needed that collects and channels alarm data from different monitoring devices from different manufacturers thru a central portal. Such a solution for managing patient device alarms is described in Chapter 7. The next logical step is improving the delivery of the alarms to the dedicated caregiver. Electronic portable devices can provide a platform for this as described in Chapter 8.

Part three touches a controversial issue: glucose regulation and outcomes in critical illness. An overview of the studies done to regulate glucose in patients with acute coronary disease is given in Chapter 9. The association between hyperglycemia and mortality in high risk patients admitted to the intensive cardiac care unit is investigated in chapter 10. Chapters 11 and 12 describe the process of implementing a computerized clinical decision support system for glucose control in the intensive cardiac care unit. In Chapter 13 the effect of implementing a CDSS for glucose control is described with regard to compliance with the insulin protocol and achievement of glycemic targets. One of the characteristics of a CDSS is the ability to generate data with regard to compliance to a protocol or guideline, which in turn can be used to modify and improve the system. In Chapter 14 this process evaluating CDSS data to improve compliance with an insulin protocol and achieve lower glucose level, and describe important lessons learned from this experience.