Development of the CDSS
infection, hematoma
EVENT, OF DELAYED WOUND HEALING, WOUND DEHISCENCE, INFECTION, DECUBITUS, HEMATOMA, APPENDIX, COMPLICATIONS
The objective of the CDSS was to illustrate interprofessional management according to the Basel Decubitus Approach and to guide the HCPs through the complex treatment intervention. The development of the CDSS involved four steps.First, during the preparation phase from 2015 to 2016, the core team (a specialized physician [AS-S], a wound care nurse [KGL], a quality management expert [KS], and an information technology (IT) specialist [SS]) defined the use case. A “use case” is the starting point in the IT logic for creating a business process modeling notation (BPMN). It includes a list of actions or event steps in this specific process. The core team defined the milestones during the treatment process. For example, after the flap surgery the patient was immobilized on an airflow mattress. If there were no complications, the suture material was removed 21 days after the surgery. In case of delayed wound healing, wound dehiscence, or other complications, such as hematoma or infection, the timing of the suture removal was determined individually by the plastic surgeon. Influential dependencies between each step were described and visualized according to the Basel Decubitus Approach. The core team determined that the CDSS should guide the HCPs through the treatment process and make the process visible. The CDSS informed the physicians of the list of required steps during the treatment process (prescription of various assessments, examinations, and other therapies). The CDSS guided the interprofessional team through the complex treatment process with relevant milestones, which were integrated into their clinical management. The IT process and milestones were adapted if required based on clinically indicated individual changes in treatment.Second, we defined the measurement of baseline assessments, milestones, timelines, and outcomes according to the Basel Decubitus Approach (Table The “Basel Decubitus Approach” structured to focus, profession and contentParaplegiologistPlastic SurgeonNurseClassification of PI according to definition of the EPUAP and NPUAP (reference).Documentation following international recommendations (reference) including photosParaplegiologistPlastic SurgeonNurseParaplegiologistPlastic SurgeonNurseApplication of dressing according to the TIME concept.Removal of necroses, treatment of infection (local disinfection and/ or surgical debridement) and negative pressure therapy or three times per day wet dressings.ParaplegiologistNursePhysical therapyExamination of pulmonary function.Breathing therapy and exercise.ParaplegiologistPhysical therapyOccupational therapyPlastic surgeonParaplegiologistInfectiologistPlastic surgeonParaplegiologistIndividual risk analysesEvaluation of seating position and cushionEvaluation of transfer techniques and strengthening of the upper extremityTreatment principles and milestones in the “ Basel Decubitus Approach”. Authors own work, copyright @anke.scheel-sailerThird, consensus conferences were held with experts from all disciplines involved (physician specialists for paraplegiology; a plastic surgeon; an infectiologist; nurses; physio-, occupational and nutritional therapists; and a psychologist) to review the first draft and describe the use case based on key principles of the Basel Decubitus Approach. Several adaptations were necessary, including feedback systems, dependencies between different sub-processes, the need and controlling for assessments, consultations, and visibility.Fourth, IT specialists were responsible for converting the use case into a BPMN. The CDSS was pilot tested in three cases with the responsible interprofessional team during the pre-test period. The core team participated in weekly meetings in which they demonstrated and documented the treatment procedures. After the pilot testing, dependencies between suture removal and changes in mattresses were no longer automatically connected due to frequent individual changes. In the CDSS, three key aspects of the process were visible: treatment elements, consultations, and milestones (Appendix Fig. 