Introducing computerized alert systems into clinical practice in the OR and ICU

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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
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Disclosure The speaker cooperates with the
following companies
CritiSense Drager-Siemens iMDsoft
InSightec Philips Pulsion Medical Systems
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The Event Manager

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

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Pager, E-mail, Cellphone
EVENT
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The Event Manager is a tool that can potentially
improve patient safety by preventing errors that
are mainly due to

• Disregard of available data
• Failure to seek appropriate data
• Incorrect respone to available data due to
• lack of knowledge

In this context error may be due to either
commission or omission.
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Proc AMIA Symp. 2000
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Closing the loop in ICU decision support
physiologic event detection, alerts, and
documentation.  Norris PR, Dawant BM. Proc AMIA
Symp. 2001498-502
  Event definitions for intracranial pressure and
cerebral perfusion pressure were studied by
implementing a reliable system to automatically
deliver alerts to alphanumeric pagers.
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Use of a clinical event monitor to prevent and
detect medication errors.  Payne TH et al, Proc
AMIA Symp. 2000640-4.  
  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.
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Improving response to critical laboratory results
with automation results of a randomized
controlled trial  Kuperman GJ et al, J Am Med
Inform Assoc. 19996512-22  
 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.
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All these examples are usually house-made and
are not a part of a commercially available
information system
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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

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Medical
Examples of clinical implementation of the
MetaVision Event Manager in our ICU

• 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

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First published report on the use of the
MetaVision 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
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Our preliminary results show that
Hypokalemia-triggered message significantly
reduced the time to potassium administration Segal
E et al (in preparation)
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The following event is being used in our ICU..
A persistent decrease in SaO2 event
A reduction in SaO2 of more than 4 lasting for
more than 6 minutes
The monitor default alarm for SaO2 is normally
set to 90
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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)
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Comparing the OR to the ICU vis-a-vis the Event
Manager - Similarities

• Acute care environments with abundance of life-
• threatening situations and decisions.
• Overload of information (intense monitoring,
• frequent lab tests).
• Variety of sources of information.

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Comparing the OR to the ICU vis-a-vis the Event
Manager - Differences

• OR - single care-giver ICU - complex team.
• Continuous anesthesiologists presence in the
• OR (qualifications may not always be
  adequate).
• Time-constant of events during anesthesia is
• usually shorter.
• Different workflow (in the OR you frequently do
  
• first and record later - no orders).

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• Potential use of the Event Manager in the OR
• Administrative (e.g., reminders)
• Diagnosis-related (e.g., preop clinic)
• Pattern recognition of vital signs trends
• (e.g., MH)
• Smart alarms (e.g., low FiO2 )

Remember that MVOR stores only one data
point per minute The low FiO2 alarm threshold
in the GE ADU anesthesia machine is 18!?!
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Hyperlink to point-of-care information
system (simulation)
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Hyperlink to point-of-care information
system (simulation)
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Hyperlink to point-of-care information
system (simulation)
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The Events Statements
The AirEmbolism Event Definition
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The Malignat Hyperthermia Event Definition
The Events Statements
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A potential application of the Event manager in
the OR Scenario A Patient goes off
cardiopulmonary bypass. Surgeon You can start
to ventilate Anesthesiologist hooks ventilation
circuit but forgets to turn on the
ventilator. All alarms are Off . After a few
minutes surgeon says The blood is very dark.
Scenario B Patient goes off cardiopulmonary
bypass. The Event Manager identifies the
combination Bypass on Alarms off
evidence of pulsations gtgtgtgt
Please turn on alarms
Please turn on alarms
Please turn on alarms
Please turn on alarms
Please turn on alarms
Please turn on alarms
Please turn on alarms
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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.
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Following our request iMDsoft has included the
alarm status of the GE-Datex monitor in MVOR
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Another potential application of the Event
Manager Bypass on evidence of
pulsations gtgtgtgt
Off-bypass check-list
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THE FUTURE
Pattern recognition of
vital signs trends
WARNING
Sudden PetCO2 Sao2 significant decrease in
BP ventilation parameters unchanged.

• Consider
• 1. Sudden decrease in CO.
• 2. Possible Air embolism.
• Do
• Switch to 100 O2.
• Make a choice between 1 2.

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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
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Limitations and pitfalls

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

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Use of a clinical event monitor to prevent and
detect medication errors.  Payne TH et al, Proc
AMIA Symp. 2000640-4.  
  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.
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Closing the loop in ICU decision support
physiologic event detection, alerts, and
documentation.  Norris PR, Dawant BM. Proc AMIA
Symp. 2001498-502
  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.
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Improving recognition of drug interactions
benefits and barriers to using automated drug
alerts.  Glassman PA et al, Med Care. 2002
401161-71  
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.
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The Cedars-Sinai experience
Wireless clinical alerts and patient outcomes in
the SICU  Major K, Shabot MM, Cunneen S. Am Surg.
2002 681057-60
  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?
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Cedars-Sinai Doctors Cling to Pen and Paper
By Ceci Connolly, Monday, March 21,
2005 Page A01 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 computer-assisted health
care. (However) .an array of problems that grew
into a full-blown staff rebellion in the fall of
2002 forced Cedars-Sinai to shelve its 34
million computer system after three months.
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..the biggest complaint -- with potentially
dangerous implications -- involved the automatic
alerts that flashed on the screen every time a
doctor made an out-of-the-ordinary 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
A01
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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.
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If we truly want safer care, we will have to
design safer systems Berwick, Leape BMJ
1999319136-7
Thank you!
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Thank You!