Effect of an electronic medical record alert for severe sepsis among ED patients

Narayanan, Navaneeth; Gross, Allison; Pintens, Megan; Fee, Christopher; MacDougall, Conan

doi:10.1016/j.ajem.2015.10.005

Cited by 56 publications

(65 citation statements)

References 15 publications

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“…In another small study (n=214) in the US the introduction of an alert was associated with an improvement in patients receiving timely antibiotics, from 48.6% to 76.7%, and a significant reduction in length of stay. [17] There was no significant impact on in-hospital mortality, which may be explained by the low numbers in the study. Westra [30] and Guirgis [31] found the introduction of an alert, bundled with education, training and structured care sets, to be associated with reductions in mortality and length of stay.…”

Section: Discussionmentioning

confidence: 88%

“…The introduction of electronic health records (EHRs) has provided the opportunity to embed digital alerts based on current and past clinical measurements. A range of screening algorithms have been used, including the St John Sepsis Algorithm (SJSA) [15–16], the Severe-Sepsis Best Practice Alert [17] and hospital designed alerts. [18] The evidence for the effectiveness of these alerts on patient outcomes is mixed.…”

Section: Introductionmentioning

confidence: 99%

“…Some studies have shown that introduction of digital sepsis alerts have led to increases in the proportion of patients with suspected sepsis receiving IV-antibiotics in one hour,[17] reduced ICU and hospital length of stay [19] and reduced in-hospital mortality,[18–19] whilst others have shown no significant effect on length of stay [19–20] or in-hospital mortality. [17] A recent randomized control trial (RCT) analysing the impact of the introduction of an alert for inpatients in a US hospital found no association between the introduction of an alert and an improvement in patient outcomes, although the study was underpowered. [21] The majority of evidence comes from small, ICU based studies in the US healthcare system.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Evaluating a digital sepsis alert in a London multi-site hospital network: a natural experiment using electronic health record data

Honeyford¹,

Cooke

Kinderlerer

et al. 2019

Preprint

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ObjectiveTo determine the impact of a digital sepsis alert on patient outcomes in a UK multi-site hospital network.MethodsA natural experiment utlising the phased introduction of a digital sepsis alert into a multi-site hospital network. Sepsis alerts were either visible to clinicans (the ‘intervention’ group) or running silently and not visible (the control group). Inverse probability of treatment weighted multivariable logistic regression was used to estimate the effect of the intervention on patient outcomes.Outcomes: In-hospital 30-day mortality (all inpatients), prolonged hospital stay (≥7 days) and timely antibiotics (≤60 minutes of the alert) for patients who alerted in the Emergency Department.ResultsThe introduction of the alert was associated with lower odds of death (OR:0.76; 95%CI:(0.70, 0.84) n=21,183); lower odds of prolonged hospital stay ≥7 days (OR:0.93; 95%CI:(0.88, 0.99) n=9988); and in patients who required antibiotics, an increased odds of receiving timely antibiotics (OR:1.71; 95%CI:(1.57,1.87) n=4622).DiscussionCurrent evidence that digital sepsis alerts are effective is mixed. In this large UK study a digital sepsis alert has been shown to be associated with improved outcomes, including timely antibiotics, which may suggest a causal pathway. It is not known whether the presence of alerting is responsible for improved outcomes, or whether the alert acted as a useful driver for quality improvement initiatives.ConclusionsThese findings strongly suggest that the the introduction of a network-wide digital sepsis alert is associated with improvements in patient outcomes, demonstrating that digital based interventions can be successfully introduced and readily evaluated.FundingImperial NIHR Biomedical Research Centre: NIHR-BRC-P68711.

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Section: Discussionmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Evaluating a digital sepsis alert in a London multi-site hospital network: a natural experiment using electronic health record data

Honeyford¹,

Cooke

Kinderlerer

et al. 2019

Preprint

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“…Perhaps more challenging than accurately diagnosing sepsis is recognizing the onset of sepsis in a timely manner Despite the wealth of data captured from usual clinical care within the EHR, most electronic sepsis alerts have had difficulty in the timeliness of diagnosis. Evidence suggests that early detection can improve outcomes [20]. Existing guidelines that define time zero as the time of triage in the Emergency Department does not apply well to the inpatient setting, In hospitalized patients, the period between onset of sepsis and identification by the physician may provide the best opportunity to improve treatment outcomes [21].…”

Section: Introductionmentioning

confidence: 99%

Validation of test performance and clinical time zero for an electronic health record embedded severe sepsis alert

Rolnick¹,

Downing²,

Shepard³

et al. 2016

Appl Clin Inform

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SummaryBachground: Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management. Objective: To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR. Methods: The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis. Results: Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen. Conclusion:We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems. BackgroundSepsis is the most common cause of death in hospitalized patients and costs the U.S. health care system $20 billion annually [1][2]. Similar to other acute medical conditions such as acute myocardial infarction or stroke, early diagnosis and treatment of sepsis is critical to positive treatment outcomes. For every hour delay in initiating antibiotics after the development of severe sepsis, expected patient mortality increases significantly [3][4][5]. Though timely administration of antibiotics and fluids is associated with improved patient outcomes, barriers to early recognition and treatment of sepsis continue to present significant challenges. Early signs of the progression from simple sepsis to sepsis with end-organ dysfunction (severe sepsis) may be subtle and non-specific. For that reason, treatment often fails to adhere to guidelines despite generally consistent evidence supporting standardized treatment [6].The recent widespread adoption of electronic health record systems (EHRs), combined with increasingly sophisticated clinical decision support, has generated i...

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“…This high rate has been attributed in part to delays in timely diagnosis, leading to delays in the initiation of appropriate therapy [3][4][5][6][7]. Screening tools and treatment protocols aimed at earlier diagnosis and subsequent initiation of early goal-directed treatment have shown promising results [8][9][10][11][12][13].…”

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confidence: 99%

Electronically Triggered Sepsis Alert in Non-Intensive Care Inpatients Using Modified Systemic Inflammatory Response Syndrome Criteria: A Retrospective Observational Study with In-Depth Analysis of Surgical Patients

Muratore

Coughlan

Glover

et al. 2019

Surgical Infections

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Background: Our center initiated an electronic Sepsis Best Practice Alert (sBPA) protocol to aid in early sepsis detection and treatment. However, surgery alters peri-operative physiology, which may trigger an sBPA for noninfectious causes. This study aimed to provide early evaluation of automated sBPA utility in surgical patients. Methods: This study was a retrospective review of the outcomes of patients admitted to the University of Minnesota Medical Center (but not to the intensive care unit) from August 2015-March 2016 and compared how the sBPA performed in those having and not having surgery. An sBPA prompted nursing to draw blood for an immediate lactate assay if two modified systemic inflammatory response syndrome (mSIRS) criteria or three mSIRS criteria within 24 hours after surgery were met. Physicians were notified if the lactate concentration was >2 mmol/L. Further review was performed of data collected prospectively on the surgical patients. Results: A total of 10,335 patients were admitted (2,158 surgery and 8,177 non-surgery). Of these, 33% of the surgery patients and 35% of the patients not having surgery triggered sBPAs. In surgery patients, 13% of lactate concentrations were >2 mmol/L versus 25% in patients not having surgery. An sBPA was triggered more frequently after procedures with a wound class of 4 (5% vs. 2%), emergency operation (23% vs. 10%), and longer operations (280 min vs. 222 min (p < 0.05 for all). Surgery patients triggering sBPAs had longer hospital stays (9.6 vs. 4.4 days; p < 0.05), more surgical site infections (7% vs. 2%; p < 0.05), and a similar mortality rate (3% vs. 4%; p = 0.15) than those who did not trigger an sBPA. Conclusion: An sBPA fired in a third of all inpatients, and an sBPA that prompted lactate measurements was less likely to be abnormal in surgery patients than in those not having surgery. There was no difference in the mortality rate in surgical patients who fired and those who did not; however, the sBPA did identify patients with a more complicated post-operative course. Further refinements of the electronic trigger should increase BPA specificity.

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Effect of an electronic medical record alert for severe sepsis among ED patients

Cited by 56 publications

References 15 publications

Evaluating a digital sepsis alert in a London multi-site hospital network: a natural experiment using electronic health record data

Evaluating a digital sepsis alert in a London multi-site hospital network: a natural experiment using electronic health record data

Validation of test performance and clinical time zero for an electronic health record embedded severe sepsis alert

Electronically Triggered Sepsis Alert in Non-Intensive Care Inpatients Using Modified Systemic Inflammatory Response Syndrome Criteria: A Retrospective Observational Study with In-Depth Analysis of Surgical Patients

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