The Impact of a Clinical Information System in an Intensive Care Unit
Donati A, Gabbanelli V, Pantanetti S, Carletti P, Principi T, Marini B, Nataloni S, Sambo G, Pelaia P. The Impact of a Clinical Information System in an Intensive Care Unit. J Clin Monit Comput. 2007 Nov 24.
Intensive care unit (ICU) commonly also referred to as Critical Care Unit (CCU) or Intensive Treatment Unit (ITU), is a specialized department in hospital that provides intensive care medicine. Further hospitals may also have intensive care units for specialized area of medicine (1). ICU setting typically provides life support or organ support systems in patient’s who are critically ill and who require intensive monitoring(2,3).Because the patients in an ICU are critically ill, the hospital staff is required to provide a rapid, high quality care with as less errors as possible. The use of Information technology such as the Clinical Information Systems(CIS) in such setting may enhance patient care by improving access to clinical data, reducing errors, tracking compliance with high quality standards and providing decision support(3). ICU is a data rich environment. In such cases the errors occur because of enormous volume of data. The IOM report “To Err Is Human” shed light on the errors occurring in ICU, suggesting an ICU risk as high as 17.7% for death or disability and about 46% for any type of adverse event(4). Today the massive amounts of information generated during critical care are documented and stored using CIS. The clinical usefulness of CIS has been shown by several studies. In this paper the authors compared time spent charting with pen and paper patient with the time spent with new electronic CIS and also evaluated staff perceptions of a CIS in an ICU. The results showed that implementation of CIS was associated with reduced time spent for daily activity and a good medical and nursing staff perception.
A similar study carried out by Bosman.R et al(2003) demonstrated the effect of intensive care information system on nursing activity in an 18 bed medical-surgical ICU in a teaching hospital. The study revealed that the use of such as information system in patients after cardiothoracic surgery alters nursing activity by reducing the time for documentation from initial 20.5% with paper to 14.4% with intensive care information system, corresponding to 29 min( per 8 hr nursing shift) thereby allocating this time to patient care(5).
However another study carried out by Saarinen.K et al (2005) compared the ICU nurses working time utilization before and after implementation of CIS. This study actually revealed a result contradictory to the two studies above and showed that following implementation of CIS the total time the nurses spent on documentation of nursing care increased by 3.6% which accounts for about 15 minutes per shift of 8hr per nurse and the intensive care nursing activities increased by 3.7%, 14 minutes and Total time spent on patient care increased by 5.5%, 21 minutes. (6) The time spent by nurses on documentation is just one aspect of the health care quality. CIS implementation has also been shown to improve health care quality in ICU by affecting other factors such as reducing medication errors, documentation errors
A study carried out by Shulman R etal (2004) compared the medication error rate in hand written and electronic prescription .The study showed that introduction of GE systems QS5.6 clinical information system and the electronic prescription facility provided by the system significantly reduced medication errors from initial 6.7% to 4.7% (7).
Further Hammond.J et al(1999) performed a qualitative comparison of paper flowsheets versus a computer based CIS and found that errors occurred at least once in 25% of handwritten flow sheet records for each 12 hour nursing shift and these can be eliminated with the use of CIS(8).
In yet another research study Amarsingham.R et al (2007) developed a survey based metric to assess the automation and usability of an ICU’s clinical information system and to try to correlate the scores with improved outcomes in multi institution quality improvement collaborative. The study showed that the presence of more sophisticated clinical information system in ICU was associated with greater reductions in catheter related bloodstream infection rate (9).
Despite all these studies that indicate a positive effect of CIS on the health care process, there is still a reluctance to embrace IT in healthcare. The IT system is being used for business administration, billing and accounting world wide. Although these systems have some IT infrastructure to support clinical systems, most of them lack the capability of handling the kind of medical information that is necessary to manage the process of health care (10). Today there are only a few examples of well integrated and robust clinical information systems in United States (11). For e.g. Only 20 full CPOE systems are installed in US hospitals (10). There are several factors responsible for the reluctance to adopt such systems one of the major issues being time and money. Most physicians are reluctant to use the new CIS because of the extra time it takes. For e.g. a study at Regenstreif institute found that it took about 5.5minutes per patient per day to enter orders using CPOE versus handwritten orders. With an average ICU census of about 12 critically ill patients, the time spent could be more than an hour for intensivist’s day in performing function usually done by unit clerks. (12)When it comes to cost CIS implementation may require as high as $5-$20 million for a single hospital (10). Conclusion: The implementation of CIS has a positive impact on the health care process in Intensive Care Unit as proved by a number of studies above. However the wide spread adoption of CIS is hindered by several factors most importantly the time spent on working with these systems and cost of implementation of the system. Thus there is a need to further explore the possibilities of developing systems that are less time consuming and achieve a balance between the costs of implementing the system and the benefits of using the system to provide a high quality care in ICU.
3. Lapinsky.S., Holt.D., Hallett.D., Abdolell.M. and Adhikari.N. Survey of information technology in Intensive Care Units in Ontario, Canada. BMC Medical Informatics and Decision Making. (2008);8:5.
4. Andrews.L.B., Stocking.C., Krizek.t.,et al. An alternative strategy for studying adverse clinical events in medical care. Lancet. (1997); 393-408.
5. Bosman.R., Rood.E., Oudemans-van Straaten.H., Van der Spoel.J., Johannus Wester.J., Durk Zandstra.D. Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery. Intensive Care Med.(2003);29:83-90.
6. Saarinen, K.; Aho, M. Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care? Acta Anaesthesiologica Scandinavica.(2005);49(1):62-65. 7. Shulman.R., Bellingan.G. and Singer.M. Medication errors: comparison of electronic and hand-written prescribing in the ICU. Critical Care 2004, 8(Suppl 1):338. 8. Hammond.J.,Johnson.H.M.,Varas.R.,Ward.C.G. A Qualitative Comparison of Paper Flowsheets vs A Computer-Based Clinical Information System. CHEST.(1991).99(1):155-157. 9 Amarasingham.R., Pronovost.P.J., Diener-West.M., Goeschel.C., Dorman.T., M Thiemann.D.R., and R. Powe.R.N. Measuring Clinical Information Technology in the ICU Setting: Application in a Quality Improvement Collaborative. J Am Med Inform Assoc. (2007)14:288-294.
10. Martich.D.G., Waldmann.C.S and Imhoff.M. Clinical Informatics in Critical Care. Journal of Intensive care Medicine. June(2004).19(3):127-176.
11. Crossing the Quality Chasm. http://www.nap.edu/openbook.php?isbn=0309072808
Submitted by : Sathaye Gauri on 02/23/2008