Natalie M. Pageler

Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost.

OBJECTIVE: We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs. METHODS: We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay. RESULTS: We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

717, 538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7–1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods. CONCLUSIONS: Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.

Effect of head orientation on gaze processing in fusiform gyrus and superior temporal sulcus.

Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non–evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital’s system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.

Refocusing medical education in the EMR era.

We used functional MRI with an event-related design to dissociate the brain activation in the fusiform gyrus (FG) and posterior superior temporal sulcus (STS) for multiple face and gaze orientations. The event-related design allowed for concurrent behavioral analysis, which revealed a significant effect of both head and gaze orientation on the speed of gaze processing, with the face and gaze forward condition showing the fastest reaction times. In conjunction with this behavioral finding, the FG responded with the greatest activation to face and gaze forward, perhaps reflecting the unambiguous social salience of congruent face and gaze directed toward the viewer. Random effects analysis showed greater activation in both the FG and posterior STS when the subjects viewed a direct face compared to an angled face, regardless of gaze direction. Additionally, the FG showed greater activation for forward gaze compared to angled gaze, but only when the face was forward. Together, these findings suggest that head orientation has a significant effect on gaze processing and these effects are manifest not only in the STS, but also the FG.

Use of Electronic Medical Record–Enhanced Checklist and Electronic Dashboard to Decrease CLABSIs

There is increasing recognition that medical education should be adapted to address the integration of the electronic medical record (EMR) into medical practice, but how this should occur and the specific educational goals have not been well defined. In this Viewpoint, we offer suggestions for updating the Accreditation Council for Graduate Medical Education (ACGME) competencies to promote optimal integration of the EMR into clinical practice, guidance for using data available within the EMR to support and evaluate the achievement of ACGME milestones, and specific steps that individual institutions can take to support this evolution in medical education. Introduction of the EMR is greatly changing the practice of medicine, bringing the benefits of increased access to data, automated clinical decision support, and opportunities for enhanced communication among physicians and with patients. As with many new technologies, the introduction of the EMR has also introduced a wide range of unintended negative consequences. A recent commentary by a ward attending at a major academic medical center described how his trainees held rounds in a secluded work room and were overly focused on the patients’ data in the EMR, often failing to incorporate significant information from the physical examination and interactions with the patient into their assessments.1 Others have noted examples of clinicians’ attention to the computer disrupting the patientphysician relationship in the pediatric examination room, to poignant effect.2 Trainees may use EMR functionality to copy large amounts of data into their progress notes, making them difficult to read and understand.3 Furthermore, clinicians are susceptible to automation bias, the tendency to place too much trust in decision support systems without recognizing the limitations of such systems.4 Given these examples of poor integration of the EMR into clinical practice, as well as the unrealized potential for the EMR to enhance medical education, it is important to examine the effect of the EMR on each of the core competencies and the role it may play in supporting the achievement of educational milestones. The medical education community has recognized that stakeholders expect physicians to use health information technology to optimize both individual and population health. The 2013 ACGME common program requirements list use of information technology as one of the competencies under practice-based learning and improvement.5 But information technology significantly affects all aspects of medical practice and therefore relates to all ACGME core competencies.6 Competency in use of the EMR should not be a goal but instead integrated into each aspect of medical practice as a tool for helping trainees achieve the 6 core competencies. For example, physician training should explicitly address and provide feedback on trainees’ ability to balance engagement with the patient and the EMR to both strengthen the patient-physician relationship and promote highly reliable patient care through accurate documentation and prudent use of clinical decision support. Communication subcompetencies should evolve to include skills for appropriately identifying and using online media such as e-mail, patient portals, and evolving mobile technologies to maintain and enhance the patient-physician relationship between office visits. As part of practice-based learning and improvement, trainees should be taught to access reports from the EMR that show their patterns of patient management for patients with specific diseases and enable the trainees to identify for themselves possible areas for practice improvement. The Table provides additional examples of potential EMR-related subcompetencies. Although this table is structured around graduate medical education core competencies, many of the lessons about optimal integration of the EMR into patient care can and should start with medical students. Emphasizing the key supportive role that technology can play in each of the core competencies should help trainees maintain the patient as the focus of attention and appropriately position the EMR as a tool to support the core mission of patient care. In addition to introducing new required skills and associated training requirements, the EMR provides new tools that can be harnessed to help achieve and evaluate previously identified milestones. The routine collection of electronic data enables the production of reports to track trainees’ experience with various types of patients, documentation of procedures, compliance with best practice guidelines in management of patients with specific diseases (eg, adequate blood pressure control in patients with hypertension), and quality of documentation of key patient information such as medication and problem lists. Specific clinical decision support tools can be developed to directly address knowledge gaps,7 and reports of alerts can be used to help identify such gaps. The Table summarizes medical education tools that should be available within a highly functional EMR. Individual academic institutions can take several steps to enable these suggestions. First, institutions can create simulated EMR environments for simulationbased training and testing of medical students and residents. In these environments, trainees can gather information from a mock patient record, be coached on how to best enter new information, and receive feedback on their ability to balance engagement with the patient and electronic documentation of the encounter. Second, academic medical centers can routinely allow medical students access to the EMR during their clinical rotations for documentation and order entry.8 Although students take care of relatively few patients, the opportuVIEWPOINT

Embedding time-limited laboratory orders within computerized provider order entry reduces laboratory utilization.

OBJECTIVES: We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line–associated bloodstream infections (CLABSI). METHODS: We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children’s hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data. RESULTS: CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes. CONCLUSIONS: Use of an electronic medical record–enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.

Propylene Glycol Toxicity in Children

Objectives: To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization. Design: Cohort study with historical controls. Setting: A 20-bed PICU in a freestanding, quaternary care, academic children’s hospital. Patients: This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009). Intervention: A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test. Measurements and Main Results: Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day. Conclusions: Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.

Severe lactic acidosis and multiorgan failure due to thiamine deficiency during total parenteral nutrition

Propylene glycol (PG) is a commonly used solvent for oral, intravenous, and topical pharmaceutical agents. Although PG is generally considered safe, when used in high doses or for prolonged periods, PG toxicity can occur. Reported adverse effects from PG include central nervous system (CNS) toxicity, hyperosmolarity, hemolysis, cardiac arrhythmia, seizures, agitation, and lactic acidosis. Patients at risk for toxicity include infants, those with renal or hepatic insuficiency, epilepsy, and burn patients receiving extensive dermal applications of PG containing products. Laboratory monitoring of PG levels, osmolarity, lactate, pyruvate, bicarbonate, creatinine, and anion gap can assist practitioners in making the diagnosis of PG toxicity. Numerous studies and case reports have been published on PG toxicity in adults. However, very few have been reported in pediatric patient populations. A review of the literature is presented.

Safety analysis of proposed data‐driven physiologic alarm parameters for hospitalized children

A 16-year-old perioperative paediatric patient presented with refractory lactic acidosis and multiorgan failure due to thiamine-deficient total parenteral nutrition during a recent national multivitamin shortage. Urgent empiric administration of intravenous thiamine resulted in prompt recovery from this life-threatening condition. Despite readily available treatment, a high index of suspicion is required to prevent cardiovascular collapse and mortality.

Optimizing care of adults with congenital heart disease in a pediatric cardiovascular ICU using electronic clinical decision support

INTRODUCTION Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values. METHODS In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits. RESULTS There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context. CONCLUSIONS A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823.