Improving Patient Care Through Data Availability in the ICU

An underlying challenge in critical care informatics, notes clinical informatics nurse Karen Bondi, R.N., is “the volume of data constantly being entered into the charts” in the ICU. “I think people didn't actually appreciate that until we actually started charting on IView.” In fact, she says, “The amount of data charted is overwhelming. And the status of patients continually changes. So you have all this data, and you have to make sense of it some way and very quickly, because the patient is going to change very quickly, especially in a pediatric setting.” The fast pace of the ICU environment, and the limited real estate available on the iAware screen, are the elements that led, necessarily, to the intensivists needing to select the key data elements to appear on the screen. Still, the flexibility of the technology has allowed for slight customizations among the three ICUs - general, CICU and NICU - in terms of the data points presented.

Virtualization to Boost Server Utilization

WHO: Children's Hospital of Pittsburgh, a member of the 20-hospital University of Pittsburgh Medical center health system.

WHAT: Alpha site co-development of a readily available clinical dashboard for use in decision-making and charting by intensivists and nurses in the hospital's three ICUs.

WHEN: February-July 2008

RESULTS: Improved patient safety, clinician workflow, physician-nurse communications.

THEMES: Workflow and patient safety innovation, clinician/IT collaboration, and co-development with vendor.

SECRETS OF THEIR SUCCESS: A culture of innovation, collaboration, and patient safety at Children's Hospital; strong prior experience with EMR/CPOE; intensive clinician-IT team-based work on the solution; a collaborative partnership with the hospital's clinical IT vendor.

“Technically, there were certain things we asked for that we couldn't pull into the dashboard easily; so we had to cut certain practical corners,” says pediatric intensivist Shekhar Venkataraman, M.D. “But though we got a dashboard that wasn't everything we wanted, it provided most of the key elements we needed.” Satisfaction increased with each of about “three or four iterations” of rearrangement of the data elements to be included inside the window views, he adds.

“You have all this data, and you have to make sense of it … very quickly, because the patient is going to change very quickly, especially in a pediatric setting.”

In addition, says Beverly Brozanski, M.D., the hospital's NICU director, it can provide data in the smallest patients. “The other good thing about the dashboard is that, when children are in intensive care, they tend to be very sedated, and tend to be on major fluids, so we can really monitor their intake and output, and that's very helpful, because it can give us an idea of fluid-electrolyte balances,” she says.

Seeds planted in fertile ground

Many hospitals have helped to co-develop clinical IT solutions, and many more have automated or at least partly automated their ICUs. So what sets Children's Hospital of Pittsburgh apart? Four factors in particular seem to have played a role in the success of the iAware initiative. They are: several years' experience operating in a live EMR/CPOE environment prior to the start of this initiative; a strong, collaborative partnership with the organization's core clinical IT vendor; intensive collaboration among all stakeholder groups, including physicians, nurses, clinical informaticists, and IT; and above all, a culture focused on continuous improvement in patient safety and care quality, something that Children's Hospital and indeed all of the University of Pittsburgh Medical Center organization are both known for.

With regard to the vendor interaction, CMIO Levin says, “We pushed Cerner in a way that was not their typical current approach, asking their developers to come onsite here to work; and in addition, the whole process was very rapid from beginning to end.” He adds that for any kind of co-development like this one to succeed, a deep mutual commitment between customer organization and vendor is an absolute prerequisite.

Then there is the level of collaboration that has evolved between and among clinicians, clinician leaders, clinical informaticists, and IT executives and managers at Children's. That spirit of collaboration, says Sue Park, R.N., the hospital's director of clinical and operational informatics, certainly infused the iAware initiative. “From the clinical perspective,” Park observes, “the clinicians obviously want to be providing the best care they can provide. So they've always worked well with other disciplines. And in moving forward on online documentation, they wanted to make it the best they could, pulling the data out and getting a better view of their child's condition.”