Usability Testing of Situation Awareness Clinical Decision Support in the Intensive Care Unit

OBJECTIVE

 Our objective was to evaluate the usability of an automated clinical decision support (CDS) tool previously implemented in the pediatric intensive care unit (PICU) to promote shared situation awareness among the medical team to prevent serious safety events within children's hospitals.

METHODS

 We conducted a mixed-methods usability evaluation of a CDS tool in a PICU at a large, urban, quaternary, free-standing children's hospital in the Midwest. Quantitative assessment was done using the system usability scale (SUS), while qualitative assessment involved think-aloud usability testing. The SUS was scored according to survey guidelines. For think-aloud testing, task times were calculated, and means and standard deviations were determined, stratified by role. Qualitative feedback from participants and moderator observations were summarized.

RESULTS

 Fifty-one PICU staff members, including physicians, advanced practice providers, nurses, and respiratory therapists, completed the SUS, while ten participants underwent think-aloud usability testing. The overall median usability score was 87.5 (interquartile range: 80-95), with over 96% rating the tool's usability as "good" or "excellent." Task completion times ranged from 2 to 92 seconds, with the quickest completion for reviewing high-risk criteria and the slowest for adding to high-risk criteria. Observations and participant responses from think-aloud testing highlighted positive aspects of learnability and clear display of complex information that is easily accessed, as well as opportunities for improvement in tool integration into clinical workflows.

CONCLUSION

 The PICU Warning Tool demonstrates good usability in the critical care setting. This study demonstrates the value of postimplementation usability testing in identifying opportunities for continued improvement of CDS tools.

Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU

OBJECTIVES

To use improved situation awareness to decrease cardiopulmonary resuscitation events by 25% over 18 months and demonstrate process and outcome sustainability.

DESIGN

Structured quality improvement initiative.

SETTING

Single-center, 35-bed quaternary-care PICU.

PATIENTS

All patients admitted to the PICU from February 1, 2017, to December 31, 2020.

INTERVENTIONS

Interventions targeted situation awareness and included bid safety huddles, bedside mitigation signs and huddles, smaller pod-based huddles, and an automated clinical decision support tool to identify high-risk patients.

MEASUREMENTS AND MAIN RESULTS

The primary outcome metric, cardiopulmonary resuscitation event rate per 1,000 patient-days, decreased from a baseline of 3.1-1.5 cardiopulmonary resuscitation events per 1,000 patient-days or by 52%. The secondary outcome metric, mortality rate, decreased from a baseline of 6.6 deaths per 1,000 patient-days to 3.6 deaths per 1,000 patient-days. Process metrics included percent of clinical deterioration events predicted, which increased from 40% to 67%, and percent of high-risk patients with shared situation awareness, which increased from 43% to 71%. Balancing metrics included time spent in daily safety huddle, median 0.4 minutes per patient (interquartile range, 0.3-0.5), and a number needed to alert of 16 (95% CI, 14-25). Neither unit acuity as measured by Pediatric Risk of Mortality III scores nor the percent of deaths in patients with do-not-attempt resuscitation orders or electing withdrawal of life-sustaining technologies changed over time.

CONCLUSIONS

Interprofessional teams using shared situation awareness may reduce cardiopulmonary resuscitation events and, thereby, improve outcomes.

Midterm results after revision rotator cuff reconstruction: Can ultrasound predict outcome of revision surgery?

PURPOSE

Structural failures after rotator cuff repair are well known, and despite advances and improved techniques in rotator cuff repair (RCR), retear rates remain high. The aim of this study was to (1) evaluate the midterm clinical and radiological outcomes after revision RCR and to (2) analyze whether preoperative ultrasound can predict outcome of open revision rotator cuff repair.

METHODS

Twenty-five patients who underwent revision RCR in a single institution between 2010 and 2012 were retrospectively reviewed at a minimum follow-up of 2 years. The Constant Score (CS) and the Disabilities of the Arm, Shoulder and Hand score were collected. Ultrasound examination was used both before revision surgery and at follow-up to determine tendon integrity.

RESULTS

At the final follow-up, 69.6% patients showed an intact rotator cuff and their CS had improved from 28.3 to 77. 30.4% patients had a persisting rotator cuff defect, and the CS had improved from 24 to 47.7. A preoperative tear size of more than 20 mm from an ultrasound examination could be identified as a factor that would risk structural failure of revision RCR.

CONCLUSION

(1) Clinical outcomes after revision RCR improve in both patients with an intact RC and those with a retear at midterm follow-up. (2) Ultrasound seems to be a useful tool to predict whether reconstruction of recurrent rotator cuff tears is feasible.

LEVEL OF EVIDENCE

IV, Case series.

Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support

BACKGROUND

Sepsis is an uncontrolled inflammatory reaction caused by infection. Clinicians in the pediatric intensive care unit (PICU) developed a paper-based tool to identify patients at risk of sepsis. To improve the utilization of the tool, the PICU team integrated the paper-based tool as a real-time clinical decision support (CDS) intervention in the electronic health record (EHR).

OBJECTIVE

This study aimed to improve identification of PICU patients with sepsis through an automated EHR-based CDS intervention.

METHODS

A prospective cohort study of all patients admitted to the PICU from May 2017 to May 2019. A CDS intervention was implemented in May 2018. The CDS intervention screened patients for nonspecific sepsis criteria, temperature dysregulation and a blood culture within 6 hours. Following the screening, an interruptive alert prompted nursing staff to complete a perfusion screen to assess for clinical signs of sepsis. The primary alert performance outcomes included sensitivity, specificity, and positive and negative predictive value. The secondary clinical outcome was completion of sepsis management tasks.

RESULTS

During the 1-year post implementation period, there were 45.0 sepsis events per 1,000 patient days over 10,805 patient days. The sepsis alert identified 392 of the 436 sepsis episodes accurately with sensitivity of 92.5%, specificity of 95.6%, positive predictive value of 46.0%, and negative predictive value of 99.7%. Examining only patients with severe sepsis confirmed by chart review, test characteristics fell to a sensitivity of 73.3%, a specificity of 92.5%. Prior to the initiation of the alert, 18.6% (13/70) of severe sepsis patients received recommended sepsis interventions. Following the implementation, 34% (27/80) received these interventions in the time recommended, p = 0.04.

CONCLUSION

An EHR CDS intervention demonstrated strong performance characteristics and improved completion of recommended sepsis interventions.

Histamine H1 receptor antagonists enhance the efficacy of antibacterials against Escherichia coli

Background

H₁ receptor antagonists are commonly used for the treatment of allergic diseases. The aim of this study was to find out, if antihistaminic compounds like mepyramine have the ability to influence the activity of antibacterials. Therefore, the checkerboard method was chosen to detect these possible effects in vitro. Studies were performed with two different Escherichia coli (E. coli) strains as test microbes, treated with antibacterials in combination with mepyramine.

Results

The minimum inhibitory concentration (MIC) of E. coli ATCC® 25922™ and E. coli PIG 01 was reduced by combinations of the tested antibacterials with mepyramine.

Conclusions

These results have to be confirmed in vivo, before the use of antihistamines should be considered as potential way to minimize the amount of used antibacterials for treatment of E. coli infections.

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records

Objectives

Electronic trigger detection tools hold promise to reduce Adverse drug event (ADEs) through efficiencies of scale and real-time reporting. We hypothesized that such a tool could automatically detect medication dosing errors as well as manage and evaluate dosing rule modifications.

Materials and Methods

We created an order and alert analysis system that identified antibiotic medication orders and evaluated user response to dosing alerts. Orders associated with overridden alerts were examined for evidence of administration and the delivered dose was compared to pharmacy-derived dosing rules to confirm true overdoses. True overdose cases were reviewed for association with known ADEs.

Results

Of 55 546 orders reviewed, 539 were true overdose orders, which lead to 1965 known overdose administrations. Documentation of loose stools and diarrhea was significantly increased following drug administration in the overdose group. Dosing rule thresholds were altered to reflect clinically accurate dosing. These rule changes decreased overall alert burden and improved the salience of alerts.

Discussion

Electronic algorithm-based detection systems can identify antibiotic overdoses that are clinically relevant and are associated with known ADEs. The system also serves as a platform for evaluating the effects of modifying electronic dosing rules. These modifications lead to decreased alert burden and improvements in response to decision support alerts.

Conclusion

The success of this test case suggests that gains are possible in reducing medication errors and improving patient safety with automated algorithm-based detection systems. Follow-up studies will determine if the positive effects of the system persist and if these changes lead to improved safety outcomes.

Determinants of tick-borne encephalitis virus antibody presence in roe deer (Capreolus capreolus) sera

In order to identify variables associated with the presence of the tick-borne encephalitis (TBE) virus, we conducted a serological survey of roe deer [Capreolus capreolus (Artiodactyla: Cervidae, Linnaeus 1758)] in three forest districts of southern Hesse, Germany. Overall, 24 out of 105 (22.9%) of the sera were positive (≥1 : 10 plaque reduction neutralization test). Using a logistic regression approach, we found that unexplained spatial variation, indexed roe deer density (positive correlation), hind foot length of the tested roe deer (positive correlation) and infestation with female Ixodes spp. ticks (negative correlation) predicted the probability of TBE virus antibody presence in individual roe deer sera. Spring temperature increase and host sex were rejected as explanatory variables. We found considerable differences in TBE virus antibody seroprevalence (50.0% vs. 17.6%) between two forest districts located in the same county; this finding questions the current county-resolution of public health recordings. Given the high seroprevalence of roe deer and the considerable explanatory power of our model, our approach appears suitable to delineate science-based risk maps at a smaller spatial scale and to abandon the current human incidence per county criterion. Importantly, using roe deer as sentinels would eliminate the inherent bias of risk maps based on human incidence (varying levels of immunization and exposure of humans).

Effect of recombinant human granulocyte colony-stimulating factor on hemodynamic and cytokine response in a porcine model of Pseudomonas sepsis

To investigate the effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on sepsis, chronically catheterized conscious pigs were challenged with Pseudomonas aeruginosa (8 x 10(7) colony-forming units kg-1 h-1) for 84 h (Group A, n = 8). Group B (n = 7) also received rhG-CSF at 5 micrograms kg-1 d-1, the first dose being given 30 min before starting bacterial infusion. Two of the animals in Group A died from pulmonary failure, whereas all those treated with rh-GCSF survived. Fever, severe pulmonary hypertension and systemic hypotension--the latter accompanied at first by a transient hypodynamic, and later a hyperdynamic response--were observed in all of the animals. In Group B, however, the rise in temperature, mean pulmonary arterial pressure (at a later stage of the observation), plasma levels of tumor necrosis factor, and endotoxin were significantly less than in Group A. In the rhG-CSF-treated pigs, an initial leukopenia completely recovered within 24 h (p < .05 vs. Group A). These data suggest that rhG-CSF might be beneficial in the treatment of sepsis.