I was asked to blog about this little article – since it lies at the intersection of Emergency Medicine and informatics.
So, that feeling you get when you look at a patient who is obviously ill? Computers don’t have that yet. These folks tried to encapsulate that feeling of “sick” vs. “not sick” into the criteria for severe sepsis, which includes SIRS and hypotension. The hope was that an algorithmic approach that automatically recognized the vital sign and physiologic criteria for SIRS would trigger reminders to clinicians that would spark them to initiate certain quality care processes sooner.
Out of 33,460 patients processed by the system, 398 triggered the system. Less than half (46%) of those were true positives. To follow that up, they tried to evaluate their system for sensitivity and specificity by pulling 1 week’s worth of data (1,386 patients) for closer review – and they found the system generated 6 false positives, 7 true positives, and 4 false negatives. And those numbers speak for themselves.
Looking back at their four quality measures, they all showed a trend towards improvement – unfortunately three of their four quality measures don’t even have a theoretical connection to improved outcomes. Chest x-ray, blood cultures, and measuring a serum lactate are all clinically relevant in certain situations, but they are all diagnostic and management decisions independent of “quality”. Antibiotic administration, however, is part of EGDT for sepsis (for what it’s worth), and that trended towards improvement (OR 2.8, CI 0.9 to 8.6).
But the final killer? “In approximately half of patients electronically detected, patients had been detected by caregivers earlier”. So, clinicians were receiving automated pages suggesting they might consider an infectious cause to hypotension, probably while already placing central lines for septic shock.
Great concept – but automated systems just don’t yet have robust, rapid, high-quality inputs like those a clinician gets just by walking in the room. But, EM physicians in busy departments overlook things – and a well-designed system might in the future help catch some of those misses.
“Prospective Trial of Real-Time Electronic Surveillance to Expedite Early Care of Severe Sepsis.”