Pearls

Introduction

The past two decades have seen significant advances in medical and nursing care for critically ill infants and children. These advances have stemmed from increased research and clinical experience as well as better appreciation for the appropriate use of technology to monitor and deliver state of the art medical care. The incorporation of microprocessors has revolutionized bedside critical care nursing. From networked monitors to ventilators to infusion pumps, many technologic advances have been incorporated into the routine workflow at the bedside.

Information technology is the latest set of tools for the critical care setting. Traditionally, IT was relegated to the administrative tasks of managing and processing transactions for hospital departments. These systems included those used to process and track patient census, billing, the laboratory system, materials management, and pharmacy. Whereas the functions of these systems are essential to the delivery of medical care, these systems were not directly involved at the point of care. Recent efforts have now focused on better use of computerized systems to improve the process of care delivery.

Several major issues have prompted focused effort to use IT tools more effectively in healthcare. The cost of healthcare in the United States continues to rise. Despite the expenditures, healthcare providers are finding it increasingly difficult to balance budgets and grow resources to meet demand. Cost pressures are contributing to increasing staffing shortages.

In the past decade, many examples of error, waste, and inefficiency in healthcare have been identified. In 1999, the Institute of Medicine (IOM) estimated that nearly 100,000 hospitalized patients die each year from medical errors.¹² The IOM report led to increased scrutiny of the safety and efficiency of the healthcare system. In 2003, the analysis by McGlynn and others⁹ documented a significant gap between the care that patients need and the care that is provided. In a sample of more than 6700 adult patients in 12 metropolitan cities, only 54.9% of patients received the recommended care.⁹

IT is a potential tool to reduce errors. A reduction in errors can result from the role of IT in managing information, its utility in standardizing care, and through its role as a vehicle to change roles and processes in an effort to reduce cost, variability, and waste. These efforts can result in improved outcomes (Fig. 23-1)

Fig. 23-1 Key drivers of healthcare information technology.

Information systems work by several mechanisms to reduce human error. The process of delivering good care is getting more difficult as the result of the sheer volume of data that clinicians must review and evaluate. This volume can range from the hundreds of data points to be analyzed from a patient’s vital sign flow sheet to the thousands of new journal articles written every year that can affect management of a disease or complication. The computer can be an excellent tool to help collate, retrieve, and store this information so that it can be used effectively. Reducing the reliance on human memory can help to mitigate situations in which care is delayed or omitted.

IT can help to improve healthcare delivery by simplifying processes. It takes a lot of time to fill out multiple requisition forms to communicate with a variety of hospital departments. Using IT tools, forms can be completed and routed electronically; this can reduce time for the entire care process and improve the delivery of care. Computer systems are also highly effective in ensuring completeness of a process. Through the use of constraints or forcing functions, such as requiring that a name be filled in or dose specified in the case of a medication order, the system as a whole can be made more efficient.

Computerized systems can be used to promote the use of standard protocols or checklists to ensure that providers undertake all necessary and effective care steps. These approaches all center on the concept of decision support. Decision support in a computerized system helps the user make the best patient care or management decisions by assembling all necessary information and by reducing the number of steps or processes to making the given decision. The effective use of these tools can decrease dependence on vigilance and reduce handoffs and redundant data entry, all of which have been shown to contribute to errors in healthcare.

Implemention of clinical information systems

Despite the great promise of electronic systems and substantial financial investment in such systems, there continues to be significant variability in the success of information system implementation and adoption by clinicians. According to the Office of the National Coordinator for Health Information Technology, almost one third of electronic medical records technology implementations fail. Healthcare providers and IT experts are now beginning to understand the challenges of introducing technology into clinical workflow.

IT implementation often fails because clinical users are unprepared for the additional burden that interaction with an electronic system will place on their work patterns and clinical care delivery. In addition, the systems must be developed with adequate input from the users, and careful planning for unique hospital needs. Several high-profile implementations of computerized provider order entry (CPOE) have provided excellent case studies to teach improved approaches to IT implementation.

A large hospital in Los Angeles implemented a multimillion-dollar CPOE system with little physician input. Shortly after implementation, clinicians complained that the system was not working and patient care was being compromised. Three months after implementation, the hospital was forced to uninstall the system.

In another case, in the first 5   months following implementation of a commercially purchased CPOE system in a pediatric critical care unit at a leading children’s hospital in the northeast, mortality during interfacility patient transfer more than doubled (from 2.8% to 6.6%) when compared with the mortality in the 13   months preceding CPOE implementation.³ Several factors may have contributed to this rise. First, the system was rapidly deployed. Second, the clinical care team was not allowed to enter orders until the patient physically entered the hospital. Third, order sets were not developed to help clinicians rapidly enter common orders. Fourth, simultaneous with the CPOE implementation, the hospital dispensing process for medications was changed. All of these factors directly affected patient care.

A second children’s hospital in the northwest installed the same commercial CPOE system. When the effects of the implementation system on the northwest children’s hospital was studied by Del Beccaro and others,² they found no difference in mortality in the preimplementation and postimplementation periods.

The Agency for Healthcare Research and Quality (AHRQ) calls for careful and thoughtful implementation of CPOE systems. Koppel’s study of CPOE systems, funded by the AHRQ,⁷ found two key problem areas in implementation: