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New software aims to prevent intensive care unit delirium

Jan. 8, 2020, 3:17 PM

Interventions such as daily spontaneous waking trials can help patients avoid injuries associated with intensive care.
Interventions such as daily spontaneous waking trials can help patients avoid injuries associated with intensive care. (photo by Anne Rayner)

by Paul Govern

Intensive care unit delirium, a fertile area of clinical research and patient care innovation associated with Vanderbilt University Medical Center, is beginning to reshape how commercial electronic health record (EHR) systems are engineered with regard to intensive care.

Seminal studies at VUMC over the past two decades by pulmonary and critical care specialist E. Wesley Ely, MD, and colleagues have spurred widespread interest in ICU delirium research, and the resulting body of evidence has come to inform critical care guidelines endorsed by medical societies in several countries.

One of the nation’s largest health information technology companies, Epic Systems Corp., based in Verona, Wisconsin, has released a system update that stands to advance prevention of ICU delirium and improve patient outcomes.

Ely and his team assisted Epic with the update.

“New support from a major EHR company like Epic means that fewer patients stand to undergo ICU delirium and its harrowing consequences. This Epic Foundation System build allows streamlined implementation and better compliance, which, according to more than 20,000 patients worth of data we’ve published, yields less time on the ventilator, shorter ICU stays, reduced costs and improved survival,” said Ely, professor of Medicine and co-director of the Critical Illness, Brain Dysfunction, and Survivorship Center at VUMC.

Leading the project for Epic has been Jeff Wolanin, lead, Epic Foundation System.

“We worked closely with Wes Ely’s team both to design what these workflows would look like in Epic and to craft recommendations to help hospitals operationalize this way of doing things in the ICU. We feel very passionate that this clinical program not only saves lives but also improves the quality of people’s lives post-ICU,” Wolanin said.

According to KLAS Research, in 2018 Epic had a 28% market share with respect to EHR systems used in acute care hospitals in the U.S.

The system update and associated ICU workflows — involving nurses, pharmacists, physicians, physical therapists, occupational therapists, respiratory therapists, family members — are in use at VUMC and other centers that assisted Epic with the update.

Ely served as the principal investigator for a project sponsored by the Society of Critical Care Medicine to improve patient outcomes in U.S. hospitals using a clinical protocol called the ICU Liberation Bundle, also known as ABCDEF. This protocol is the basis for the Epic software update.

The protocol includes well calibrated pain management with prompt discontinuation of analgesics and sedatives, daily spontaneous awakening trials, daily spontaneous breathing trials, delirium assessments throughout the day, early mobility and exercise, and family engagement.

“What this bundle does is stop people from just looking at one organ at a time. It takes the overall person and says, ‘This is a whole human being and we’re going to pay attention to how their brain is working, and their liver and lung and kidney, all at once. And we’re going to wake them up, we’re going to get them out of the bed, we’re going to walk them.’ It makes us take a step back and help people avoid injury that might otherwise occur in intensive care,” Ely said.

Joining Ely in assisting Epic have been VUMC pharmacist Joanna Stollings, PharmD, and medical ICU nurse Charlotte Garwood, RN, and colleagues from the University of Colorado, the University of California San Francisco and California-based Sutter Health.

In November 2017, software from Epic came to form the greater part of VUMC’s clinical enterprise system, eStar. Two years ago, Kevin Johnson, MD, MS, professor and chair of the Department of Biomedical Informatics and informatician-in-chief at VUMC, raised critical findings on ICU delirium with Epic’s Founder and CEO, Judy Faulkner. The conversation spurred interest at the tech company.

“The implications for patient outcomes are stark and so is the improvement opportunity,” Johnson said.

“There’s a vital role here for clinical information technology. We’re very pleased that our colleagues at Epic have fully embraced this opportunity and are working closely with VUMC and others to promote and support new workflows in the ICU.”

With Epic’s next software release in February 2020 the ICU Liberation Bundle will become a standard part of the company’s EHR system, and in the meantime it’s available to Epic customers as an add-on.

Ely’s team and Epic are now working together on information systems support for ICU patient outcomes monitoring.

For more on ICU delirium and how to prevent it, visit icudelirium.org.

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