Accuracy of Noninvasive Blood Pressure Monitoring in Critically Ill Adults.

Background: Blood pressure (BP) is routinely invasively monitored by an arterial catheter in the intensive care unit (ICU). However, the available data comparing the accuracy of noninvasive methods to arterial catheters for measuring BP in the ICU are limited by small numbers and diverse methodologies. Purpose: To determine agreement between invasive arterial blood pressure monitoring (IABP) and noninvasive blood pressure (NIBP) in critically ill patients. Methods: This was a single center, observational study of critical ill adults in a tertiary care facility evaluating agreement (≤10% difference) between simultaneously measured IABP and NIBP. We measured clinical features at time of BP measurement inclusive of patient demographics, laboratory data, severity of illness, specific interventions (mechanical ventilation and dialysis), and vasopressor dose to identify particular clinical scenarios in which measurement agreement is more or less likely. Results: Of the 1852 critically ill adults with simultaneous IABP and NIBP readings, there was a median difference of 6 mm Hg in mean arterial pressure (MAP), interquartile range (1-12), P < .01. A logistic regression analysis identified 5 independent predictors of measurement discrepancy: increasing doses of norepinephrine (adjusted odds ratio [aOR] 1.10 [95% confidence interval, CI 1.08-1.12] P = .03 for every change in 5 µg/min), lower MAP value (aOR 0.98 [0.98-0.99] P < .01 for every change in 1 mm Hg), higher body mass index (aOR 1.04 [1.01-1.09] P = .01 for an increase in 1), increased patient age (aOR 1.31 [1.30-1.37] P < .01 for every 10 years), and radial arterial line location (aOR 1.74 [1.16-2.47] P = .04). Conclusions: There was broad agreement between IABP and NIBP in critically ill patients over a range of BPs and severity of illness. Several variables are associated with measurement discrepancy; however, their predictive capacity is modest. This may guide future study into which patients may specifically benefit from an arterial catheter.

Electronic Health Record Use Issues and Diagnostic Error: A Scoping Review and Framework.

BACKGROUND: Diagnostic errors are a major source of patient harm, most of which are caused by cognitive errors and biases. Despite research showing the relationship between software systems and cognitive processes, the impact of the electronic health record (EHR) on diagnostic error remains unknown. METHODS: We conducted a scoping review of the scientific literature to (1) survey the association between aspects of the EHR and diagnostic error, and (2) through a human-systems integration lens, identify the types of EHR issues and their impact on the stages of the diagnostic process. RESULTS: We analyzed 11 research articles for the relationship between EHR use and diagnostic error. These articles highlight specific technical, usability, and workflow issues with the EHR that pose risks for diagnostic error at every stage of the diagnostic process. DISCUSSION: Although technical problems such as EHR interoperability and data integrity pose critical issues for the diagnostic process, usability and workflow issues such as poor display design, and inability to track test results also hamper clinicians' ability to track, process, and act in the diagnostic process. Current research methods have limited coverage over clinical settings, are not standardized, and rarely include measures of patient harm. CONCLUSIONS: The available evidence shows that EHRs pose risks for diagnostic error throughout the diagnostic process, with most issues involving their incompatibility with providers' cognitive processing. A structured and systematic model of collecting and reporting on these errors is needed to understand how the EHR shapes the diagnostic process and improve diagnostic accuracy.

Risky Business: Predicting patient mortality at a glance.

Clinicians are constantly forecasting patient trajectories to make critical point of care decisions intended to influence clinical outcomes. Little is known, however, about how providers interpret mortality risk against validated scoring systems. This research aims to understand how providers forecast mortality specifically for that of patients with sepsis. Defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, sepsis is commonly hard to diagnose, progresses rapidly, and lacks a "gold standard" test. Participants were nurses and doctors from the general medical and surgical floors of six different hospitals. Each was presented with ten different patient cases, categorized into low and high severity sepsis, and were asked about care decisions, along with estimations of mortality risk. The resulting data provides a unique look into the differences of risk forecasting between profession and patient severity.

Variations in Physician Telemedicine Provision.

This cross-sectional study assesses variation in the provision of telemedicine services among primary care physicians and quantifies the extent to which this variation may be explained by the individual physician vs temporal, patient, or visit factors.