Multicenter derivation and validation of an early warning score for acute respiratory failure or death in the hospital.

BACKGROUND: Acute respiratory failure occurs frequently in hospitalized patients and often starts before ICU admission. A risk stratification tool to predict mortality and risk for mechanical ventilation (MV) may allow for earlier evaluation and intervention. We developed and validated an automated electronic health record (EHR)-based model-Accurate Prediction of Prolonged Ventilation (APPROVE)-to identify patients at risk of death or respiratory failure requiring >= 48 h of MV. METHODS: This was an observational study of adults admitted to four hospitals in 2013 or a fifth hospital in 2017. Clinical data were extracted from the EHRs. The 2013 patients were randomly split 50:50 into a derivation/validation cohort. The qualifying event was death or intubation leading to MV >= 48 h. Random forest method was used in model derivation. APPROVE was calculated retrospectively whenever data were available in 2013, and prospectively every 4 h after hospital admission in 2017. The Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) were calculated at the same times as APPROVE. Clinicians were not alerted except for APPROVE in 2017cohort. RESULTS: There were 68,775 admissions in 2013 and 2258 in 2017. APPROVE had an area under the receiver operator curve of 0.87 (95% CI 0.85-0.88) in 2013 and 0.90 (95% CI 0.84-0.95) in 2017, which is significantly better than the MEWS and NEWS in 2013 but similar to the MEWS and NEWS in 2017. At a threshold of > 0.25, APPROVE had similar sensitivity and positive predictive value (PPV) (sensitivity 63% and PPV 21% in 2013 vs 64% and 16%, respectively, in 2017). Compared to APPROVE in 2013, at a threshold to achieve comparable PPV (19% at MEWS > 4 and 22% at NEWS > 6), the MEWS and NEWS had lower sensitivity (16% for MEWS and NEWS). Similarly in 2017, at a comparable sensitivity threshold (64% for APPROVE > 0.25 and 67% for MEWS and NEWS > 4), more patients who triggered an alert developed the event with APPROVE (PPV 16%) while achieving a lower false positive rate (FPR 5%) compared to the MEWS (PPV 7%, FPR 14%) and NEWS (PPV 4%, FPR 25%). CONCLUSIONS: An automated EHR model to identify patients at high risk of MV or death was validated retrospectively and prospectively, and was determined to be feasible for real-time risk identification. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02488174 . Registered on 18 March 2015.

Can a Novel ICU Data Display Positively Affect Patient Outcomes and Save Lives?

The aim of this study was to quantify the impact of ProCCESs AWARE, Ambient Clinical Analytics, Rochester, MN, a novel acute care electronic medical record interface, on a range of care process and patient health outcome metrics in intensive care units (ICUs). ProCCESs AWARE is a novel acute care EMR interface that contains built-in tools for error prevention, practice surveillance, decision support and reporting. We compared outcomes before and after AWARE implementation using a prospective cohort and a historical control. The study population included all critically ill adult patients (over 18 years old) admitted to four ICUs at Mayo Clinic, Rochester, MN, who stayed in hospital at least 24 h. The pre-AWARE cohort included 983 patients from 2010, and the post-AWARE cohort included 856 patients from 2014. We analyzed patient health outcomes, care process quality, and hospital charges. After adjusting for patient acuity and baseline demographics, overall in-hospital and ICU mortality odds ratios associated with AWARE intervention were 0.45 (95% confidence interval 0.30 to 0.70) and 0.38 (0.22, 0.66). ICU length of stay decreased by about 50%, hospital length of stay by 37%, and total charges for hospital stay by 30% in post AWARE cohort (by $43,745 after adjusting for patient acuity and demographics). Better organization of information in the ICU with systems like AWARE has the potential to improve important patient outcomes, such as mortality and length of stay, resulting in reductions in costs of care.

Suprazygomatic Access for Continuous Bilateral Mandibular Nerve Block for Pain and Trismus Relief in the Tetraplegic Patient.

PURPOSE: Extraoral mandibular nerve block (MNB) is used in oropharyngeal surgery for analgesia and anesthesia. Repeated or continuous MNB has been used successfully as treatment for uncontrollable pain, masseter spasticity, and airway assessment. The usual technique involves transcutaneous infrazygomatic access. However, in some specific settings, this approach is not always feasible. MATERIALS AND METHODS: A continuous bilateral MNB with a suprazygomatic approach to the pterygomandibular space was used to resolve a case of refractory and painful trismus in a patient with tetraplegia. RESULTS: Analgesia was achieved and maintained by bilateral catheter placement to the pterygomandibular space and repeated injection of local anesthetic for 48 hours. The right-side catheter was accidentally withdrawn; the left-side catheter was maintained up to 72 hours. The efficiency of analgesia was not affected. This block provided effective analgesia within the first few hours after local anesthetic injection, helped to improve mouth opening, and resolved acute pain. Because kinesitherapy could be introduced, the patient was left on nonopioid analgesics. CONCLUSION: Continuous bilateral MNB through the suprazygomatic approach was used safely and efficiently. The suggested approach is quite unique, as is the clinical circumstance, and might be considered when the usual technique is challenging.

Testing modes of computerized sepsis alert notification delivery systems.

BACKGROUND: The number of electronic health record (EHR)-based notifications continues to rise. One common method to deliver urgent and emergent notifications (alerts) is paging. Despite of wide presence of smartphones, the use of these devices for secure alerting remains a relatively new phenomenon. METHODS: We compared three methods of alert delivery (pagers, EHR-based notifications, and smartphones) to determine the best method of urgent alerting in the intensive care unit (ICU) setting. ICU clinicians received randomized automated sepsis alerts: pager, EHR-based notification, or a personal smartphone/tablet device. Time to notification acknowledgement, fatigue measurement, and user preferences (structured survey) were studied. RESULTS: Twenty three clinicians participated over the course of 3 months. A total of 48 randomized sepsis alerts were generated for 46 unique patients. Although all alerts were acknowledged, the primary outcome was confounded by technical failure of alert delivery in the smartphone/tablet arm. Median time to acknowledgment of urgent alerts was shorter by pager (102 mins) than EHR (169 mins). Secondary outcomes of fatigue measurement and user preference did not demonstrate significant differences between these notification delivery study arms. CONCLUSIONS: Technical failure of secure smartphone/tablet alert delivery presents a barrier to testing the optimal method of urgent alert delivery in the ICU setting. Results from fatigue evaluation and user preferences for alert delivery methods were similar in all arms. Further investigation is thus necessary to understand human and technical barriers to implementation of commonplace modern technology in the hospital setting.

Towards automated calculation of evidence-based clinical scores.

AIM: To determine clinical scores important for automated calculation in the inpatient setting. METHODS: A modified Delphi methodology was used to create consensus of important clinical scores for inpatient practice. A list of 176 externally validated clinical scores were identified from freely available internet-based services frequently used by clinicians. Scores were categorized based on pertinent specialty and a customized survey was created for each clinician specialty group. Clinicians were asked to rank each score based on importance of automated calculation to their clinical practice in three categories - "not important", "nice to have", or "very important". Surveys were solicited via specialty-group listserv over a 3-mo interval. Respondents must have been practicing physicians with more than 20% clinical time spent in the inpatient setting. Within each specialty, consensus was established for any clinical score with greater than 70% of responses in a single category and a minimum of 10 responses. Logistic regression was performed to determine predictors of automation importance. RESULTS: Seventy-nine divided by one hundred and forty-four (54.9%) surveys were completed and 72/144 (50%) surveys were completed by eligible respondents. Only the critical care and internal medicine specialties surpassed the 10-respondent threshold (14 respondents each). For internists, 2/110 (1.8%) of scores were "very important" and 73/110 (66.4%) were "nice to have". For intensivists, no scores were "very important" and 26/76 (34.2%) were "nice to have". Only the number of medical history (OR = 2.34; 95%CI: 1.26-4.67; P < 0.05) and vital sign (OR = 1.88; 95%CI: 1.03-3.68; P < 0.05) variables for clinical scores used by internists was predictive of desire for automation. CONCLUSION: Few clinical scores were deemed "very important" for automated calculation. Future efforts towards score calculator automation should focus on technically feasible "nice to have" scores.

Acute psychological trauma in the critically ill: Patient and family perspectives.

OBJECTIVE: Post-intensive care syndrome (PICS), which encompasses profound psychological morbidity, affects many survivors of critical illness. We hypothesize that acute psychological stress during the intensive care unit (ICU) confinement likely contributes to PICS. In order to develop strategies that mitigate PICS associated psychological morbidity, it is paramount to first characterize acute ICU psychological stress and begin to understand its causative and protective factors. METHODS: A structured interview study was administered to adult critical illness survivors who received ≥48h of mechanical ventilation in medical and surgical ICUs of a tertiary care center, and their families. RESULTS: Fifty patients and 44 family members were interviewed following ICU discharge. Patients reported a high level of psychological distress. The families' perception of patient's stress level correlated with the patient's self-estimated stress level both in daily life (rho=0.59; p<0.0001) and in ICU (rho=0.45; p=0.002). 70% of patients experienced fear of death, 38% had additional other fears, 48% had hallucinations. Concerns included inability to communicate (34%), environmental factors (30%), procedures and restraints (24%), and being intubated (12%). Emotional support of family/friend/staff/clergy (86%), and physical therapy/walking (14%) were perceived to be important mitigating factors. Clinicians' actions that were perceived to be very constructive included reassurance (54%), explanations (32%) and physical touch (8%). CONCLUSIONS: Fear, hallucinations, and the inability to communicate, are identified as central contributors to psychological stress during an ICU stay; the presence of family, and physician's attention are categorized as important mitigating factors. Patients and families identified several practical recommendations which may help assuage the psychological burden of the ICU stay.

Comparison of methods of alert acknowledgement by critical care clinicians in the ICU setting.

BACKGROUND: Electronic Health Record (EHR)-based sepsis alert systems have failed to demonstrate improvements in clinically meaningful endpoints. However, the effect of implementation barriers on the success of new sepsis alert systems is rarely explored. OBJECTIVE: To test the hypothesis time to severe sepsis alert acknowledgement by critical care clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement system compared to a text paging-based system. STUDY DESIGN: In one arm of this simulation study, real alerts for patients in the medical ICU were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts were delivered through text paging. The primary outcome was time to alert acknowledgement. The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal group interview. RESULTS: The alert acknowledgement rate from the severe sepsis alert system was 3% (N = 148) and 51% (N = 156) from simulated severe sepsis alerts through traditional text paging. Time to alert acknowledgement from the severe sepsis alert system was median 274 min (N = 5) and median 2 min (N = 80) from text paging. The response rate from the EHR-based alert system was insufficient to compare primary measures. However, secondary measures revealed important barriers. CONCLUSION: Alert fatigue, interruption, human error, and information overload are barriers to alert and simulation studies in the ICU setting.

Clinical calculators in hospital medicine: Availability, classification, and needs.

OBJECTIVE: Clinical calculators are widely used in modern clinical practice, but are not generally applied to electronic health record (EHR) systems. Important barriers to the application of these clinical calculators into existing EHR systems include the need for real-time calculation, human-calculator interaction, and data source requirements. The objective of this study was to identify, classify, and evaluate the use of available clinical calculators for clinicians in the hospital setting. METHODS: Dedicated online resources with medical calculators and providers of aggregated medical information were queried for readily available clinical calculators. Calculators were mapped by clinical categories, mechanism of calculation, and the goal of calculation. Online statistics from selected Internet resources and clinician opinion were used to assess the use of clinical calculators. RESULTS: One hundred seventy-six readily available calculators in 4 categories, 6 primary specialties, and 40 subspecialties were identified. The goals of calculation included prediction, severity, risk estimation, diagnostic, and decision-making aid. A combination of summation logic with cutoffs or rules was the most frequent mechanism of computation. Combined results, online resources, statistics, and clinician opinion identified 13 most utilized calculators. CONCLUSION: Although not an exhaustive list, a total of 176 validated calculators were identified, classified, and evaluated for usefulness. Most of these calculators are used for adult patients in the critical care or internal medicine settings. Thirteen of 176 clinical calculators were determined to be useful in our institution. All of these calculators have an interface for manual input.

User perception and experience of the introduction of a novel critical care patient viewer in the ICU setting.

OBJECTIVE: Failure to rapidly identify high-value information due to inappropriate output may alter user acceptance and satisfaction. The information needs for different intensive care unit (ICU) providers are not the same. This can obstruct successful implementation of electronic medical record (EMR) systems. We evaluated the implementation experience and satisfaction of providers using a novel EMR interface-based on the information needs of ICU providers-in the context of an existing EMR system. METHODS: This before-after study was performed in the ICU setting at two tertiary care hospitals from October 2013 through November 2014. Surveys were delivered to ICU providers before and after implementation of the novel EMR interface. Overall satisfaction and acceptance was reported for both interfaces. RESULTS: A total of 246 before (existing EMR) and 115 after (existing EMR+novel EMR interface) surveys were analyzed. 14% of respondents were prescribers and 86% were non-prescribers. Non-prescribers were more satisfied with the existing EMR, whereas prescribers were more satisfied with the novel EMR interface. Both groups reported easier data gathering, routine tasks & rounding, and fostering of team work with the novel EMR interface. This interface was the primary tool for 18% of respondents after implementation and 73% of respondents intended to use it further. Non-prescribers reported an intention to use this novel interface as their primary tool for information gathering. CONCLUSION: Compliance and acceptance of new system is not related to previous duration of work in ICU, but ameliorates with the length of EMR interface usage. Task-specific and role-specific considerations are necessary for design and successful implementation of a EMR interface. The difference in user workflows causes disparity of the way of EMR data usage.

Automatic quality improvement reports in the intensive care unit: One step closer toward meaningful use.

AIM: To examine the feasibility and validity of electronic generation of quality metrics in the intensive care unit (ICU). METHODS: This minimal risk observational study was performed at an academic tertiary hospital. The Critical Care Independent Multidisciplinary Program at Mayo Clinic identified and defined 11 key quality metrics. These metrics were automatically calculated using ICU DataMart, a near-real time copy of all ICU electronic medical record (EMR) data. The automatic report was compared with data from a comprehensive EMR review by a trained investigator. Data was collected for 93 randomly selected patients admitted to the ICU during April 2012 (10% of admitted adult population). This study was approved by the Mayo Clinic Institution Review Board. RESULTS: All types of variables needed for metric calculations were found to be available for manual and electronic abstraction, except information for availability of free beds for patient-specific time-frames. There was 100% agreement between electronic and manual data abstraction for ICU admission source, admission service, and discharge disposition. The agreement between electronic and manual data abstraction of the time of ICU admission and discharge were 99% and 89%. The time of hospital admission and discharge were similar for both the electronically and manually abstracted datasets. The specificity of the electronically-generated report was 93% and 94% for invasive and non-invasive ventilation use in the ICU. One false-positive result for each type of ventilation was present. The specificity for ICU and in-hospital mortality was 100%. Sensitivity was 100% for all metrics. CONCLUSION: Our study demonstrates excellent accuracy of electronically-generated key ICU quality metrics. This validates the feasibility of automatic metric generation.

Systematic Review of the Use of Phytochemicals for Management of Pain in Cancer Therapy.

Pain in cancer therapy is a common condition and there is a need for new options in therapeutic management. While phytochemicals have been proposed as one pain management solution, knowledge of their utility is limited. The objective of this study was to perform a systematic review of the biomedical literature for the use of phytochemicals for management of cancer therapy pain in human subjects. Of an initial database search of 1,603 abstracts, 32 full-text articles were eligible for further assessment. Only 7 of these articles met all inclusion criteria for this systematic review. The average relative risk of phytochemical versus control was 1.03 [95% CI 0.59 to 2.06]. In other words (although not statistically significant), patients treated with phytochemicals were slightly more likely than patients treated with control to obtain successful management of pain in cancer therapy. We identified a lack of quality research literature on this subject and thus were unable to demonstrate a clear therapeutic benefit for either general or specific use of phytochemicals in the management of cancer pain. This lack of data is especially apparent for psychotropic phytochemicals, such as the Cannabis plant (marijuana). Additional implications of our findings are also explored.