Knowing when to begin weaning patients from sedative medications and mechanical ventilation is not easy or precise. Evidence shows that well-designed assessment processes can help improve patient outcomes. Translating such evidence into clinical practice, however, can be a challenge.
Rising to that challenge, a multidisciplinary team at Penn Medicine developed a computerized dashboard and clinician alert system to promote more rapid weaning. The computer application (app) converts data stored in the electronic health record (EHR) into actionable information. The ABC app, as the program is called, enables continuous screening of patient eligibility for a reduction in sedative medications and for weaning from the ventilator, and it prompts staff when actions are needed.
This innovative initiative earned the Penn Medicine team ECRI Institute’s 2019 Health Devices Achievement Award. Presented each May, the award recognizes exceptional initiatives to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology.
“Penn Medicine’s project shows how technology teams can impact patient care,” notes David Jamison, executive director, selection and evaluation, ECRI Institute. “The proactive use of EHR data to improve patient outcomes highlights what’s possible and provides a blueprint for other health systems to follow.”
The Challenge: Promoting Faster Weaning
Several years ago, Penn Medicine found that its patients remained on mechanical ventilation for 12 to 24 hours longer than expected, compared with external benchmarks. Contributing factors included delays by nurses in reducing sedative medications, and delays by respiratory therapists in assessing patient readiness for a ventilator weaning trial, due to an inefficient and complex screening process.
The extended duration of mechanical ventilation had patient care implications, as well as financial ones:
Mechanical ventilators are a life-sustaining technology, but their use is not without risks for the patient. Patient complications include ventilator-associated pneumonia, ventilator-induced lung injury, deep venous thrombosis, pneumothorax, gastrointestinal bleeding and sepsis. Clinicians seek to wean patients from mechanical ventilation as soon as possible to minimize the risk of such complications.
Additionally, the longer a patient remains on a ventilator, the longer that patient needs to stay in the ICU. Longer stays increase costs – ICU care is expensive to provide – and they reduce ICU bed access for other patients requiring this level of care. A lack of available ICU beds can affect other patients within the hospital, and it can prevent the hospital from accepting patients from referring institutions.
By promoting faster weaning, the organization could both improve patient care and positively impact the bottom line.
The Solution: Making Meaningful Use of EHR Data
Penn Medicine clinicians teamed up with colleagues in their Data Science, Center for Health Care Innovation, and Information Services departments to devise a solution that could help reduce the duration of mechanical ventilation. The result was an app that leverages information stored in the EHR to provide clinicians with real-time access to meaningful sedation and ventilation protocol data.
Named the ABC app – for awakening and breathing coordination, which are core components of an ICU bundle of care used at Penn – the app includes two key components:
Core to the functioning of the app are real-time data streams from the EHR. The EHR vendor enabled real-time streaming of HL7 clinical data, which was stored in a time series format and aggregated and normalized. This database was leveraged for the in-house development of the web dashboard and notification system.
Similarly, the app relies on clinical decision support (CDS) rules to guide the data analysis, display and transmittal. These rules are based on Penn Medicine’s complex ICU treatment protocols and on input from clinical experts.
After implementing the ABC app, the health system observed a statistically significant reduction in the duration of mechanical ventilation. The duration was reduced by more than 24 hours, compared with the baseline period. A corresponding significant reduction in ICU length of stay was also observed, as was a trend toward a significant reduction in hospital length of stay. Nurses stopped sedative medications faster during the intervention period, and respiratory therapists performed ventilator liberation trials sooner, both of which contributed to more rapid extubation and ICU transfer.
The app’s ability to provide immediate feedback about the documentation of, and adherence to, ICU protocols was judged to be a key feature in improving the outcomes of ICU patients. The health system found tremendous power in having meaningful, real-time data and CDS available to bedside clinicians, quality administrators and the entire team.
Whereas most EHRs function as data repositories for documentation of the care process, Penn Medicine’s ABC app makes use of that technology – real, meaningful use – to facilitate the delivery of care.
Also Deserving Recognition . . .
In addition to honoring the team from Penn Medicine, ECRI Institute commended teams from the following organizations for their efforts to improve patient safety, reduce costs or otherwise facilitate better strategic management of health technology:
For details about all the honorees and their projects, see https://www.ecri.org/components/HDJournal/Pages/hd-achievement-award.aspx.
If your organization has engaged in a health technology management project that deserves recognition, ECRI Institute wants to hear about it. Submissions for next year’s award will be accepted starting in November. To learn more, visit https://www.ecri.org/health-devices-award-winners, or contact ECRI Institute by telephone at 610-825-6000, ext. 5891, or by email at firstname.lastname@example.org.
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