Introducing computerized alert systems into clinical practice in

Introducing computerized alert systems into clinical practice in the OR and ICU Azriel Perel in collaboration with Kantor G, Toderis L, Eden A*, Pizov R*, Segal E Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, and *Carmel Hospital, Technion Medical School, Haifa, Israel ESCTAIC 2005 Aalborg

Disclosure The speaker cooperates with the following companies Criti. Sense Drager-Siemens i. MDsoft * In. Sightec Philips Pulsion Medical Systems

The Event Manager Ø An advanced feature of the automated recordkeeper and the patient data-management system. Ø A configurable rule-based system that identifies pre-defined events in real time. Ø Triggers specific messages / alarms / waveform capture / diagnosis and treatment suggestions. Ø Improves response of care-giver to the ‘event’. Ø An example of how information-technology can improve patient safety.

Pager, E-mail, Cellphone MV Cluster / Server MVBS & Database Ethernet EVENT Client Printer Anesthesia Machine Switch Monitor Pump HIS Labs ADT Hospital network WAN Support Remote Workstation Terminal server Medical Devices Segment

The Event Manager is a tool that can potentially improve patient safety by preventing errors* that are mainly due to : Ø Disregard of available data Ø Failure to seek appropriate data Ø Incorrect respone to available data due to lack of knowledge * In this context ‘error’ may be due to either commission or omission.

Proc AMIA Symp. 2000

Closing the loop in ICU decision support: physiologic event detection, alerts, and documentation. Norris PR, Dawant BM. Proc AMIA Symp. 2001; : 498 -502 Event definitions for intracranial pressure and cerebral perfusion pressure were studied by implementing a reliable system to automatically deliver alerts to alphanumeric pagers.

Use of a clinical event monitor to prevent and detect medication errors. Payne TH et al, Proc AMIA Symp. 2000; : 640 -4. A growing collection of medication safety rules…. may be applied to each medication order message to provide an additional layer of protection beyond existing order checks, reminders, and alerts available within our computer-based record system.

Improving response to critical laboratory results with automation: results of a randomized controlled trial Kuperman GJ et al, J Am Med Inform Assoc. 1999; 6: 512 -22 An automatic alerting system reduced the time until an appropriate treatment was ordered for patients who had critical laboratory results. Information technologies that facilitate the transmission of important patient data can potentially improve the quality of care.

All these examples are usually ‘house-made’ and are not a part of a commercially available information system

Potential use of the Event Manager in the ICU • Medical – – Diagnosis-related information Improved detection of clinical events Procedure reminders Knowledge-base (algorithms, drugs, etc) • Nursing – Follow routines – Follow protocols • Pharmacy – Drug dosing, interactions, allergies

Examples of clinical implementation of the Meta. Vision Event Manager in our ICU Medical • • Chest x-ray following central line placement Anticoagulants following trauma Thyroid replacement in hypothyroidism Corticosteroids in sepsis Nursing • GCS after admission • Norton scale (prevention of pressure sores) • IV line set changes every 96 hours

First published report on the use of the Meta. Vision Event Manager Use of a computerized guideline for glucose regulation in the ICU improved both guideline adherence and glucose regulation E. Rood et al, J Am Med Inform Assoc 2005; 12: 172 -80 Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

Our preliminary results show that Hypokalemia-triggered message significantly reduced the time to potassium administration Segal E et al (in preparation)

The following event is being used in our ICU…. . A ‘persistent decrease in Sa. O 2’ event A reduction in Sa. O 2 of more than 4% lasting for more than 6 minutes The monitor default alarm for Sa. O 2 is normally set to 90%

A mild but sustained decrease in sp. O 2. The lowest level does not trigger the low sp. O 2 threshold which is set at 90%

An urgent CXR was performed and still did not reveal an explanation for this reduction in oxygenation. Since the patient was anyway scheduled for a maxillofacial CT we performed the CT immediately, and added a chest CT to the examination. The obtained chest CT revealed a large right pneumothorax, the drainage of which led to an immediate resolution of the hypoxemia. Segal E et al (submitted)

Comparing the OR to the ICU vis-a-vis the Event Manager - Similarities Ø Acute care environments with abundance of life- threatening situations and decisions. Ø Overload of information (intense monitoring, frequent lab tests). Ø Variety of sources of information.

Comparing the OR to the ICU vis-a-vis the Event Manager - Differences Ø OR - single care-giver; ICU - complex team. Ø Continuous anesthesiologist’s presence in the OR (qualifications may not always be adequate). Ø Time-constant of events during anesthesia is usually shorter. Ø Different workflow (in the OR you frequently do first and record later - no orders).

Potential use of the Event Manager in the OR Ø Administrative (e. g. , reminders) Ø Diagnosis-related (e. g. , preop clinic) Ø Pattern recognition of vital signs trends (e. g. , MH)* Ø ‘Smart alarms’ (e. g. , low Fi. O 2 **) * Remember that MVOR stores only one data point per minute ** The low Fi. O 2 alarm threshold in the GE ADU anesthesia machine is 18%!? !

Hyperlink to point-of-care information system (simulation)

Hyperlink to point-of-care information system (simulation)

Hyperlink to point-of-care information system (simulation)

The Event’s Statements The “Air. Embolism” Event Definition

The Malignat Hyperthermia Event Definition The Event’s Statements

A potential application of the Event manager in the OR: Scenario B Scenario A Patient goes off cardiopulmonary bypass. The Event Manager identifies the combination “Bypass on” + Surgeon: “You can start to ventilate” “Alarms off” + evidence of pulsations >>>> Anesthesiologist hooks ventilation circuit but forgets to turn on the ventilator. All alarms are “ Off ”. “Please turn on alarms” After a few minutes surgeon says: “The blood is very dark”. “Please turn on alarms”

Resumption of pulsatile flow is detected by an algorithm that is based on blood pressure and pulse pressure values The preliminary algorithm was revised and fine-tuned following its activation on 150 records of patients that underwent cardiac surgery.

Following our request i. MDsoft has included the alarm status of the GE-Datex monitor in MVOR

Another potential application of the Event Manager: “Bypass on” + evidence of pulsations >>>> Off-bypass check-list

THE FUTURE Pattern recognition of vital signs trends WARNING Sudden Pet. CO 2 +Sao 2 + significant decrease in BP + ventilation parameters unchanged. Consider 1. Sudden decrease in CO. 2. Possible Air embolism. Do • Switch to 100% O 2. • Make a choice between 1 & 2.

A ‘good’ Event should fulfill the following criteria: 1. Clinically significant 2. Offer opportunity for corrective action 3. Come out of necessity, i. e. , the recognition that it may be missed due to overload of tasks or information 4. Well defined 5. Not too common 6. High sensitivity and specificity

Limitations and pitfalls Ø The concepts of clinical significance and opportunity for corrective action are difficult to define in automated systems Ø The definition of a successful event may prove to be difficult and time-consuming Ø Overloading the system with too many events is unwelcome by users Ø Events should not be trivial Ø Lack of sensitivity (false negative) and/or specificity (false positive) are both dangerous and annoying

Use of a clinical event monitor to prevent and detect medication errors. Payne TH et al, Proc AMIA Symp. 2000; : 640 -4. A growing collection of medication safety rules…. may be applied to each medication order message to provide an additional layer of protection beyond existing order checks, reminders, and alerts available within our computer-based record system. During a typical day the event monitor receives 4802 messages, of which 4719 pertain to medication orders. We have found the clinical event monitor to be a valuable tool for clinicians and quality management groups charged with improving medication safety.

Closing the loop in ICU decision support: physiologic event detection, alerts, and documentation. Norris PR, Dawant BM. Proc AMIA Symp. 2001; : 498 -502 Event definitions for intracranial pressure and cerebral perfusion pressure were studied by implementing a reliable system to automatically deliver alerts to alphanumeric pagers. During a 6 -month test period in the trauma ICU 530 alerts were detected in 2280 hours of data spanning 14 patients. Retrospectively classifying documentation based on therapeutic actions taken, or reasons why actions were not taken, provided useful information about ways to potentially improve event definitions and enhance system utility.

Improving recognition of drug interactions: benefits and barriers to using automated drug alerts. Glassman PA et al, Med Care. 2002 ; 40: 1161 -71 Nearly 90% of clinicians thought drug alerts would be helpful to identify interactions yet 55% of clinicians perceived that the most significant barrier to utilizing existing alerts was poor signal to noise ratio, meaning too many non-relevant warnings. CONCLUSIONS: The perceived poor specificity of drug alerts may be an important obstacle to efficient utilization of information and may impede the ability of such alerts to improve patient safety.

The Cedars-Sinai experience Wireless clinical alerts and patient outcomes in the SICU Major K, Shabot MM, Cunneen S. Am Surg. 2002; 68: 1057 -60 A total of 15, 066 alert pages were sent, including alerts for physiologic condition (6, 163), laboratory data (4, 951), blood gas (3, 774), drug allergy (130), and toxic drug levels (48). Too many alerts?

Cedars-Sinai Doctors Cling to Pen and Paper By Ceci Connolly, Monday, March 21, 2005; Page A 01 washingtonpost. com LOS ANGELES -- The marriage of information technology and medicine is all the rage in health policy circles…. Five years after the Institute of Medicine issued a landmark report cataloguing the life-and-death consequences of medical errors, corporate leaders, politicians and physicians are embracing computerassisted health care. (However) …. an array of problems that grew into a fullblown staff rebellion in the fall of 2002 forced Cedars. Sinai to shelve its $34 million computer system after three months.

…. . the biggest complaint -- with potentially dangerous implications -- involved the automatic alerts that flashed on the screen every time a doctor made an out-of-theordinary request. Designed to catch errors before they occur, the alerts became an unending series of questions, reminders and requests on fairly basic decisions. Cedars-Sinai was unable to strike a balance between useful computer warnings and a machine that seemed to constantly cry wolf…. washingtonpost. com Monday, March 21, 2005; Page A 01

Conclusions The introduction of the Event Manager offers exciting possibilities in using information technology to improve task performance and patient safety. Preliminary lessons from its implementation in the ICU environment are very promising. Introducing this powerful tool into the OR may improve decision making and help prevent errors. The careful selection and design of new ‘events’ is the key to the successful implementation of this new tool.

“If we truly want safer care, we will have to design safer systems” Berwick, Leape BMJ 1999; 319: 136 -7 Thank you!

Thank You!