Testing modes of computerized sepsis alert notification delivery systems

Dziadzko et al. BMC Medical Informatics and Decision Making (2016) 16:156 DOI 10.1186/s12911-016-0396-y RESEARCH ARTICLE Open Access Testing modes of computerized sepsis alert notification delivery systems Mikhail A. Dziadzko1, Andrew M. Harrison2, Ing C. Tiong3, Brian W. Pickering1, Pablo Moreno Franco4 and Vitaly Herasevich1* Abstract Background: The number of electronic health record (EHR)-based notifications continues to rise. One common method to deliver urgent and emergent notifications (alerts) is paging. Despite of wide presence of smartphones, the use of these devices for secure alerting remains a relatively new phenomenon. Methods: We compared three methods of alert delivery (pagers, EHR-based notifications, and smartphones) to determine the best method of urgent alerting in the intensive care unit (ICU) setting. ICU clinicians received randomized automated sepsis alerts: pager, EHR-based notification, or a personal smartphone/tablet device. Time to notification acknowledgement, fatigue measurement, and user preferences (structured survey) were studied. Results: Twenty three clinicians participated over the course of 3 months. A total of 48 randomized sepsis alerts were generated for 46 unique patients. Although all alerts were acknowledged, the primary outcome was confounded by technical failure of alert delivery in the smartphone/tablet arm. Median time to acknowledgment of urgent alerts was shorter by pager (102 mins) than EHR (169 mins). Secondary outcomes of fatigue measurement and user preference did not demonstrate significant differences between these notification delivery study arms. Conclusions: Technical failure of secure smartphone/tablet alert delivery presents a barrier to testing the optimal method of urgent alert delivery in the ICU setting. Results from fatigue evaluation and user preferences for alert delivery methods were similar in all arms. Further investigation is thus necessary to understand human and technical barriers to implementation of commonplace modern technology in the hospital setting. Keywords: Methods of alert delivery, Sepsis, Alert fatigue, Notification, Decision support system Background Generation of computerized notifications and alarms by automated detection algorithms for a variety of clinical conditions leads to alarm fatigue, which is one of the most important health technology hazards over past years [1]. Several solutions have been proposed to improve alarm detection conditions in the healthcare setting [2]. In the case of alarm system management, the challenge is to deliver the correct alarm, using the right alarm delivery mode, to the right recipient(s) [3]. Minimizing the number of clinically insignificant alarms (better pattern recognition), optimizing alarm * Correspondence: 1 Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA Full list of author information is available at the end of the article notification, and response protocols are the goals to address clinical alarm hazards to insure patients receive appropriate care at the time it is needed [1, 4]. Perception of different methods of alert delivery is significantly influenced by complex human cognition factors [5, 6]. In the specific context of the hospital setting, mechanisms of notification or alert delivery have been exploited, including oral communication, charts, loudspeaker alerts, phones, paging, electronic health record (EHR) display, and email [7]. New methods of alert delivery have also led to the development of technology to reduce errors in the hospital setting [8]. Successful EHR notification delivery has the potential to reduce errors in the hospital setting [9–12]. However, it is not sufficient for a clinical alert system to be merely capable of generating medically meaningful alerts [4, 13]. © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dziadzko et al. BMC Medical Informatics and Decision Making (2016) 16:156 This is because implementation of any automated notification or alert system must be performed in the context of information overload and complex task interruption. In ICU setting, even meaningful alerts pose the risk of interruption [14] and information overload can alter alert perception [15, 16]. There is a need to consider how a system can generate clinically meaningful alerts, while concurrently minimizing information overload and task interruption. To do this, a better understanding of human cognition and user interfaces is required [17, 18]. An ideal communication tool should enable bi-directional, rapid, secure, and non-disruptive transmission of content-rich messages [19]. It should provide specific mechanisms to avoid any potential for protected health information security breach. Knowledge of optimal methods of delivery of urgent alerts in the intensive care unit (ICU) setting, particularly with the goal to shorten time-to-reaction and to decrease alert fatigue, is limited and contradictory [20, 21]. The objective of this study was to compare three methods of alert delivery - pagers, EMR-based notifications, and smartphones - to determine the best method of urgent alerting in the ICU setting. Methods Study design and setting This prospective randomized study was performed from October 2015 through December 2015 in the 54 beds ICU at Mayo Clinic in Jacksonville, FL. This ICU includes multidisciplinary beds including medical, surgical, transplant, and neurology critical care services. The Mayo Clinic Institutional Review Board (IRB) has approved this study. There were no changes in usual protocols of patient care. Oral consent was obtained from participating clinicians. Participants Clinicians with a personal iPhone Operating System (iOS) device (smartphone or tablet) were eligible to participate. One ICU 12-hour shift was treated as a study period for each participant. Participants were already familiar with the EHR electronic sepsis alerts and SSC (Surviving Sepsis Campaign) recommendations [22, 23] as they were routinely used in the ICU. Alert generation The automated, EMR-based sepsis detection tool (sepsis sniffer), already validated and described elsewhere [24], continuously assessed EHR data for sepsis criteria. In a case of automated detection, it generated an alert - a yellow triangular icon appeared within the EHR, indicating individual patient with sepsis. Standard practice includes alerting a nursing team leade (...truncated)