Implementing real-time sepsis alerts using middleware and smartphone technology

Abstract

A s clinical practice continues to evolve and improve, technology has become increasingly integrated into everyday clinical workflow. From alarms and alerts to pointof-care electronic clinical communication tools, the future of healthcare depends on the ability to implement technology to improve quality and safety of patient care.1 Adoption of electronic health records (EHRs) has been found to improve clinicians’ performance by providing access to aggregated patient information such as lab results, nursing notes, and alerts.2 The use of decision support system technology, along with clinical reasoning, can help decrease errors and avoid delays in treatment.3 Real-time alerts and data to and from mobile platforms can lead to early diagnosis and detection, with the opportunity to improve quality of life and reduce healthcare costs.4 However, caution must be taken with these implementations to evaluate and address alert fatigue (often called alarm fatigue) and ensure alerts are clinically actionable and relevant.5 Development of alert algorithms through an EHR should help provide clinical decision support by supplying relevant information, at the time it is needed, to the correct clinician.6 An example of this includes the high-risk scenario of sepsis identification, with alerts triggered from the EHR. Research has shown that sepsis alerts can help improve patient outcomes by assisting with early detection.7,8 A study by Dziadzko and colleagues compared the emergence of smartphones for sepsis alerts to EHR-based notifications and pagers to determine the best method of notification delivery.6 Due to technologic failures and barriers, sepsis smartphone alerts were unsuccessful, and clinicians continued to use pagers and EHR-based alerts.6 Continued research and development were identified as needs to better evaluate the efficacy of smartphone alerts in a clinical setting.6 Since May 2013, the New York State Department of Health (NYSDOH) has regulated that hospitals maintain sepsis protocols that use explicit algorithms and/ or alert systems to assist in the early identification of patients with severe sepsis and septic shock.9,10 However, in January 2017, regulatory changes necessitated real-time, prospective identification of sepsis and standardized clinician documentation.11 This documentation was needed to record an initial assessment, and recognition of sepsis signs and symptoms as well as verifying reassessment of the patient’s sepsis signs and symptoms within 6 hours of management. At Memorial Sloan Kettering Cancer Center (MSKCC), the alert algorithm was initially set so that patients with three simultaneous abnormal vital signs, new (in a 24-hour period) altered mental status, or rigors in the presence of two abnormal vital signs triggered an alert. MSKCC has a unique population of oncology patients, and patient signs and symptoms or treatment adverse reactions could often be similar to sepsis indicators. Sepsis alerts were put in place to help with management of their complex healthcare needs and assist in identifying possible early sepsis. The nurse or patient-care technician, depending on who documented the vital signs/altered mental status, was then alerted via an instantaneous pop-up in the EHR to contact the responsible clinician to screen the patient for possible sepsis. This led to delays in clinician awareness of possible sepsis; among them was that the algorithm was designed based on nursing documentation workflows with limiting factors