Collinsworth Ashley W, Masica Andrew L, Priest Elisa L, Berryman Candice D, Kouznetsova Maria, Glorioso Oscar, Montgomery Donna
Baylor Scott & White Health.
EGEMS (Wash DC). 2014 Dec 18;2(1):1121. doi: 10.13063/2327-9214.1121. eCollection 2014.
Electronic health records (EHRs) have been promoted as a key driver of improved patient care and outcomes and as an essential component of learning health systems. However, to date, many EHRs are not optimized to support delivery of quality and safety initiatives, particularly in Intensive Care Units (ICUs). Delirium is a common and severe problem for ICU patients that may be prevented or mitigated through the use of evidence-based care processes (daily awakening and breathing trials, formal delirium screening, and early mobility-collectively known as the "ABCDE bundle"). This case study describes how an integrated health care delivery system modified its inpatient EHR to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative.
In order to facilitate uptake of the ABCDE bundle and measure delivery of the care processes within the bundle, we worked with clinical and technical experts to create structured data fields for documentation of bundle elements and to identify where these fields should be placed within the EHR to streamline staff workflow. We created an "ABCDE" tab in the existing patient viewer that allowed providers to easily identify which components of the bundle the patient had and had not received. We examined the percentage of ABCDE bundle elements captured in these structured data fields over time to track compliance with data entry procedures and to improve documentation of care processes.
Modifying the EHR to support ABCDE bundle deployment was a complex and time-consuming process. We found that it was critical to gain buy-in from senior leadership on the importance of the ABCDE bundle to secure information technology (IT) resources, understand the different workflows of members of multidisciplinary care teams, and obtain continuous feedback from staff on the EHR revisions during the development cycle. We also observed that it was essential to provide ongoing training to staff on proper use of the new EHR documentation fields. Lastly, timely reporting on ABCDE bundle performance may be essential to improved practice adoption and documentation of care processes.
The creation of learning health systems is contingent on an ability to modify EHRs to meet emerging care delivery and quality improvement needs. Although this study focuses on the prevention and mitigation of delirium in ICUs, our process for identifying key data elements and making modifications to the EHR, as well as the lessons learned from the IT components of this program, are generalizable to other health care settings and conditions.
电子健康记录（EHRs）已被视作改善患者护理及治疗结果的关键驱动力，以及学习型医疗系统的重要组成部分。然而，时至今日，许多电子健康记录并未得到优化，无法支持质量与安全举措的实施，尤其是在重症监护病房（ICU）。谵妄是重症监护病房患者常见且严重的问题，可通过采用循证护理流程（每日唤醒与呼吸试验、正式谵妄筛查以及早期活动，统称为“ABCDE集束化治疗”）来预防或缓解。本案例研究描述了一个综合医疗服务系统如何修改其住院患者电子健康记录，以加速将ABCDE集束化治疗作为一项安全与质量举措进行实施及评估。
为了促进ABCDE集束化治疗的采用，并衡量集束化治疗中护理流程的实施情况，我们与临床和技术专家合作，创建结构化数据字段以记录集束化治疗的要素，并确定这些字段在电子健康记录中的位置，以简化工作人员的工作流程。我们在现有的患者查看器中创建了一个“ABCDE”标签，使医护人员能够轻松识别患者已接受和未接受的集束化治疗的哪些组成部分。我们检查了随着时间推移在这些结构化数据字段中捕获的ABCDE集束化治疗要素的百分比，以跟踪数据录入程序的合规情况，并改进护理流程的记录。
修改电子健康记录以支持ABCDE集束化治疗的部署是一个复杂且耗时的过程。我们发现，让高层领导认可ABCDE集束化治疗的重要性以确保信息技术（IT）资源、了解多学科护理团队成员的不同工作流程，以及在开发周期中获得工作人员对电子健康记录修订的持续反馈至关重要。我们还观察到，对工作人员进行关于正确使用新电子健康记录文档字段的持续培训至关重要。最后，及时报告ABCDE集束化治疗的绩效对于提高实践采用率和护理流程记录可能至关重要。
学习型医疗系统的创建取决于修改电子健康记录以满足新出现的护理提供和质量改进需求的能力。尽管本研究侧重于重症监护病房中谵妄的预防和缓解，但我们识别关键数据要素并对电子健康记录进行修改的过程，以及从该项目的IT组件中学到的经验教训，可推广到其他医疗环境和情况。
