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Objectives: The intensive care unit (ICU) is a complex environment in terms of data density and alerts, with alert fatigue, a recognized barrier to patient safety. The Electronic Health Record (EHR) is a major source of these alerts. Although studies have looked at the incidence and impact of active EHR alerts, little research has studied the impact of passive data alerts on patient safety., Method: We reviewed the EHR database of 100 consecutive ICU patient records; within, we assessed the number of values flagged as either as abnormal or "panic" across all data domains. We used data from our previous studies to determine the 10 most commonly visited screens while preparing for rounds to determine the total number of times, an abnormal value would be expected to be viewed., Results: There were 64.1 passive alerts/patient per day, of which only 4.5% were panic values. When accounting for the commonly used EHR screens by providers, this was increased to 165.3 patient/d. Laboratory values comprised 71% of alerts, with the remaining occurring in vitals (25%) and medications (6%). Despite the high prevalence of alerts, certain domains including ventilator settings (0.04 flags/d) were rarely flagged., Conclusions: The average ICU patient generates a large number of passive alerts daily, many of which may be clinically irrelevant. Issues with EHR design and use likely further magnify this problem. Our results establish the need for additional studies to understand how a high burden of passive alerts impact clinical decision making and how to design passive alerts to optimize their clinical utility.

Objectives: Incomplete patient data, either due to difficulty gathering and synthesizing or inappropriate data filtering, can lead clinicians to misdiagnosis and medical error. How completely ICU interprofessional rounding teams appraise the patient data set that informs clinical decision-making is unknown. This study measures how frequently physician trainees omit data from prerounding notes ("artifacts") and verbal presentations during daily rounds., Design: Observational study., Setting: Tertiary academic medical ICU with an established electronic health record and where physician trainees are the primary presenters during daily rounds., Subjects: Presenters (medical student or resident physician), interprofessional rounding team., Interventions: None., Measurements and Main Results: We quantified the amount and types of patient data omitted from photocopies of physician trainees' artifacts and audio recordings of oral ICU rounds presentations when compared with source electronic health record data. An audit of 157 patient presentations including 6,055 data elements across nine domains revealed 100% of presentations contained omissions. Overall, 22.9% of data were missing from artifacts and 42.4% from presentations. The interprofessional team supplemented only 4.1% of additional available data. Frequency of trainee data omission varied by data type and sociotechnical factors. The strongest predictor of trainee verbal omissions was a preceding failure to include the data on the artifact. Passive data gathering via electronic health record macros resulted in extremely complete artifacts but paradoxically predicted greater likelihood of verbal omission when compared with manual notation. Interns verbally omitted the most data, whereas medical students omitted the least., Conclusions: In an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. Additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.

Objectives: The electronic health record is a primary source of information for all professional groups participating in ICU rounds. We previously demonstrated that, individually, all professional groups involved in rounds have significant blind spots in recognition of patient safety issues in the electronic health record. However, it is unclear how team dynamics impacts identification and verbalization of viewed data. Therefore, we created an ICU rounding simulation to assess how the interprofessional team recognized and reported data and its impact on decision-making., Design: Each member of the ICU team reviewed a simulated ICU chart in the electronic health record which contained embedded patient safety issues. The team conducted simulated rounds according to the ICU's existing rounding script and was assessed for recognition of safety issues., Setting: Academic medical center., Subjects: ICU residents, nurses, and pharmacists., Intervention: None., Measurements and Main Results: Twenty-eight teams recognized 68.6% of safety issues with only 50% teams having the primary diagnosis in their differential. Individually, interns, nurses, and pharmacists recognized 30.4%, 15.6%, and 19.6% of safety items, respectively. However, there was a negative correlation between the intern's performance and the nurse's or the pharmacist's performance within a given team. The wide variance in recognition of data resulted in wide variance in orders. Overall, there were 21.8 orders requested and 21.6 orders placed per case resulting in 3.6 order entry inconsistencies/case. Between the two cases, there were 145 distinct orders place with 43% being unique to a specific team and only 2% placed by all teams., Conclusions: Although significant blind spots exist in the interprofessional team's ability to recognize safety issues in the electronic health record, the inclusion of other professional groups does serve as a partial safety net to improve recognition. Electronic health record-based, ICU rounding simulations can serve as a test-bed for innovations in ICU rounding structure and data collection.

Objectives: Accurately communicating patient data during daily ICU rounds is critically important since data provide the basis for clinical decision making. Despite its importance, high fidelity data communication during interprofessional ICU rounds is assumed, yet unproven. We created a robust but simple methodology to measure the prevalence of inaccurately communicated (misrepresented) data and to characterize data communication failures by type. We also assessed how commonly the rounding team detected data misrepresentation and whether data communication was impacted by environmental, human, and workflow factors., Design: Direct observation of verbalized laboratory data during daily ICU rounds compared with data within the electronic health record and on presenters' paper prerounding notes., Setting: Twenty-six-bed academic medical ICU with a well-established electronic health record., Subjects: ICU rounds presenter (medical student or resident physician), interprofessional rounding team., Interventions: None., Measurements and Main Results: During 301 observed patient presentations including 4,945 audited laboratory results, presenters used a paper prerounding tool for 94.3% of presentations but tools contained only 78% of available electronic health record laboratory data. Ninty-six percent of patient presentations included at least one laboratory misrepresentation (mean, 6.3 per patient) and 38.9% of all audited laboratory data were inaccurately communicated. Most misrepresentation events were omissions. Only 7.8% of all laboratory misrepresentations were detected., Conclusion: Despite a structured interprofessional rounding script and a well-established electronic health record, clinician laboratory data retrieval and communication during ICU rounds at our institution was poor, prone to omissions and inaccuracies, yet largely unrecognized by the rounding team. This highlights an important patient safety issue that is likely widely prevalent, yet underrecognized., Competing Interests: Dr. Artis disclosed other support from the Agency for Healthcare Research and Quality (AHRQ). Her institution received funding from the AHRQ. Dr. Mohan’s institution received funding from the AHRQ. Dr. Gold’s institution received funding from the AHRQ. Dr. Dyer has disclosed that he does not have any potential conflicts of interest.

With the rapid adoption of electronic health records (EHR), there is a growing appreciation for the central role they play in clinical decision making and team communication, with many studies documenting new safety issues with integration of the EHR into the clinical enterprise. To study these issues, we created a high-fidelity simulation instance of our clinical EHR. In this paper, we describe the impact of integrating the EHR into high-fidelity, interprofessional intensive care unit (ICU) simulations, and the errors induced. We found a number of safety issues directly related to the EHR including alert fatigue, negative impacts on interprofessional communication, and problems with selective data gathering, and these issues were present for all members of the interprofessional team. Through successful integration of the EHR into high-fidelity team-based simulations, we now have an infrastructure to focus educational initiative and deploy informatics solutions to mitigate these safety issues.

Background: Electronic health records (EHR) are becoming increasingly integrated into the clinical environment. With the rapid proliferation of EHRs, a number of studies document an increase in adverse patient safety issues due to the EHR-user interface. Because of these issues, greater attention has been placed on novel educational activities which incorporate use of the EHR. The ICU environment presents many challenges to integrating an EHR given the vast amounts of data recorded each day, which must be interpreted to deliver safe and effective care. We have used a novel EHR based simulation exercise to demonstrate that everyday users fail to recognize a majority of patient safety issues in the ICU. We now sought to determine whether participation in the simulation improves recognition of said issues., Methods: Two ICU cases were created in our EHR simulation environment. Each case contained 14 safety issues, which differed in content but shared common themes. Residents were given 10 minutes to review a case followed by a presentation of management changes. Participants were given an immediate debriefing regarding missed issues and strategies for data gathering in the EHR. Repeated testing was performed in a cohort of subjects with the other case at least 1 week later., Results: 116 subjects have been enrolled with 25 subjects undergoing repeat testing. There was no difference between cases in recognition of patient safety issues (39.5% vs. 39.4%). Baseline performance for subjects who participated in repeat testing was no different than the cohort as a whole. For both cases, recognition of safety issues was significantly higher among repeat participants compared to first time participants. Further, individual performance improved from 39.9% to 63.6% (p = 0.0002), a result independent of the order in which the cases were employed. The degree of improvement was inversely related to baseline performance. Further, repeat participants demonstrated a higher rate of recognition of changes in vitals, misdosing of antibiotics and oversedation compared to first time participants., Conclusion: Participation in EHR simulation improves EHR use and identification of patient safety issues.

This article reviews the pathophysiology, diagnosis, and treatment of alcohol withdrawal syndromes in the intensive care unit as well as the literature on the optimal pharmacologic strategies for treatment of alcohol withdrawal syndromes in the critically ill. Treatment of alcohol withdrawal in the intensive care unit mirrors that of the general acute care wards and detoxification centers. In addition to adequate supportive care, benzodiazepines administered in a symptom-triggered fashion, guided by the Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar), still seem to be the optimal strategy in the intensive care unit. In cases of benzodiazepine resistance, numerous options are available, including high individual doses of benzodiazepines, barbiturates, and propofol. Intensivists should be familiar with the diagnosis and treatment strategies for alcohol withdrawal syndromes in the intensive care unit.

OBJECTIVES:Genetic disorders are a leading contributor to mortality in the neonatal ICU and PICU in the United States. Although individually rare, there are over 6,200 single-gene diseases, which may preclude a genetic diagnosis prior to ICU admission. Rapid whole genome sequencing is an emerging method of diagnosing genetic conditions in time to affect ICU management of neonates; however, its clinical utility has yet to be adequately demonstrated in critically ill children. This study evaluates next-generation sequencing in pediatric critical care. DESIGN:Retrospective cohort study. SETTING:Single-center PICU in a tertiary children's hospital. PATIENTS:Children 4 months to 18 years admitted to the PICU who were nominated between July 2016 and May 2018. INTERVENTIONS:Rapid whole genome sequencing with targeted phenotype-driven analysis was performed on patients and their parents, when parental samples were available. MEASUREMENTS AND MAIN RESULTS:A molecular diagnosis was made by rapid whole genome sequencing in 17 of 38 children (45%). In four of the 17 patients (24%), the genetic diagnoses led to a change in management while in the PICU, including genome-informed changes in pharmacotherapy and transition to palliative care. Nine of the 17 diagnosed children (53%) had no dysmorphic features or developmental delay. Eighty-two percent of diagnoses affected the clinical management of the patient and/or family after PICU discharge, including avoidance of biopsy, administration of factor replacement, and surveillance for disorder-related sequelae. CONCLUSIONS:This study demonstrates a retrospective evaluation for undiagnosed genetic disease in the PICU and clinical utility of rapid whole genome sequencing in a portion of critically ill children. Further studies are needed to identify PICU patients who will benefit from rapid whole genome sequencing early in PICU admission when the underlying etiology is unclear.

Numerous reports describe unintended consequences of electronic health record implementation. Having previously described physicians’ failures to recognize patient safety issues within our electronic health record simulation environment, we now report on our use of eye and screen-tracking technology to understand factors associated with poor error recognition during an intensive care unit–based electronic health record simulation. We linked performance on the simulation to standard eye and screen-tracking readouts including number of fixations, saccades, mouse clicks and screens visited. In addition, we developed an overall Composite Eye Tracking score which measured when, where and how often each safety item was viewed. For 39 participants, the Composite Eye Tracking score correlated with performance on the simulation (p = 0.004). Overall, the improved performance was associated with a pattern of rapid scanning of data manifested by increased number of screens visited (p = 0.001), mouse clicks (p = 0.03) and saccades (p = 0.004). Eye tracking can be successfully integrated into electronic health record–based simulation and provides a surrogate measure of cognitive decision making and electronic health record usability. [ABSTRACT FROM AUTHOR]

During interprofessional intensive care unit (ICU) rounds each member of the interprofessional team is responsible for gathering and interpreting information from the electronic health records (EHR) to facilitate effective team decision-making. This study was conducted to determine how each professional group reviews EHR data in preparation for rounds and their ability to identify patient safety issues. Twenty-five physicians, 29 nurses, and 20 pharmacists participated. Individual participants were given verbal and written sign-out and then asked to review a simulated record in our institution’s EHR, which contained 14 patient safety items. After reviewing the chart, subjects presented the patient and the number of safety items recognised was recorded. About 40%, 30%, and 26% of safety issues were recognised by physicians, nurses, and pharmacists, respectively (p = 0.0006) and no item recognised 100% of the time. There was little overlap between the three groups with only 50% of items predicted to be recognised 100% of the time by the team. Differential recognition was associated with marked differences in EHR use, with only 3/152 EHR screens utilised by all three groups and the majority of screens used exclusively only by one group. There were significant and non-overlapping differences in individual profession recognition of patient safety issues in the EHR. Preferential identification of safety issues by certain professional groups may be attributed to differences in EHR use. Future studies will be needed to determine if shared decision-making during rounds can improve recognition of safety issues. [ABSTRACT FROM PUBLISHER]

The relationship between neighborhood/individual characteristics and pediatric intensive care unit (PICU) outcomes is largely unexplored. We hypothesized that individual-level racial/ethnic minority status and neighborhood-level low socioeconomic status and minority concentration would adversely affect children's severity of illness on admission to the PICU. Retrospective analyses (1/1/2007-5/23/2011) of clinical, geographic, and demographic data were conducted at an academic, tertiary children's hospital PICU. Clinical data included age, diagnosis, insurance, race/ethnicity, Pediatric Index of Mortality 2 score on presentation to the PICU (PIM2), and mortality. Residential addresses were geocoded and linked with 2010 US Census tract data using geographic information systems geocoding techniques. Repeated measures models to predict PIM2 and mortality were constructed using three successive models with theorized covariates including the patient's race/ethnicity, the predominant neighborhood racial/ethnic group, interactions between patient race/ethnicity and neighborhood race/ethnicity, neighborhood socioeconomic status, and insurance type. Of the 5,390 children, 57.8 % were Latino and 70.1 % possessed government insurance. Latino children (β = 0.31; p < 0.01), especially Latino children living in a Latino ethnic enclave (β = 1.13; p < 0.05), had higher PIM2 scores compared with non-Latinos. Children with government insurance (β = 0.29; p < 0.01) had higher PIM2 scores compared to children with other payment types and median neighborhood income was inversely associated with PIM2 scores (β = −0.04 per $10,000/year of income; p < 0.05). Lower median neighborhood income, Latino ethnicity, Latino children living in a predominantly Latino neighborhood, and children possessing government insurance were associated with a higher severity of illness on PICU admission. The reasons why these factors affect critical illness severity require further exploration. [ABSTRACT FROM AUTHOR]

Background: Severe systemic reactions resembling septic shock have been described following trimethoprim-sulfamethoxazole (TMP-SMX) administration. Nearly all cases described in the literature occurred in HIV-infected patients. Case presentation: We present a 42-year-old woman with a history of systemic lupus erythematosus (SLE) who was admitted to the Intensive Care Unit (ICU) twice with fever and circulatory shock after taking a dose of TMP-SMX 800–160 mg. She had no respiratory distress, urticarial rash or eosinophilia on presentation. Infectious workup during both admissions was negative and treatment with antibiotics, steroids and vasopressors was de-escalated with clinical improvement. She was found to be HIV negative, however, labs revealed a low CD4+ count. Conclusions: TMP-SMX can rarely result in a severe, non-anaphylactic circulatory shock; if initially unrecognized, patients may undergo repeat drug exposure with an associated high morbidity risk. While more commonly reported in HIV individuals, this case demonstrates that TMP-SMX related circulatory shock can occur in a HIV negative patient. [ABSTRACT FROM AUTHOR]

An abstract of the study "An On-the-Job Mindfulness-Based Intervention for Pediatric ICU Nurses: A Pilot Study" by Tina Gauthier and colleagues is presented.

Purpose A study was conducted using high-fidelity electronic health record (EHR)–based simulations with incorporated eye tracking to understand the workflow of critical care pharmacists within the EHR, with specific attention to the data elements most frequently viewed. Methods Eight critical care pharmacists were given 25 minutes to review 3 simulated intensive care unit (ICU) charts deployed in the simulation instance of the EHR. Using monitor-based eye trackers, time spent reviewing screens, clinical information accessed, and screens used to access specific information were reviewed and quantified to look for trends. Results Overall, pharmacists viewed 25.5 total and 15.1 unique EHR screens per case. The majority of time was spent looking at screens focused on medications, followed by screens displaying notes, laboratory values, and vital signs. With regard to medication data, the vast majority of screen visitations were to view information on opioids/sedatives and antibiotics. With regard to laboratory values, the majority of views were focused on basic chemistry and hematology data. While there was significant variance between pharmacists, individual navigation patterns remained constant across cases. Conclusion The study results suggest that in addition to medication information, laboratory data and clinical notes are key focuses of ICU pharmacist review of patient records and that navigation to multiple screens is required in order to view these data with the EHR. New pharmacy-specific EHR interfaces should consolidate these elements within a primary interface. [ABSTRACT FROM AUTHOR]