Quality Outcomes in the Surgical Intensive Care Unit after Electronic Health Record Implementation

Abstract

KeywordsElectronic health records, quality improvement, critical care, surgical intensive care SummaryBackground: The electronic health record (EHR) is increasingly viewed as a means to provide more coordinated, patient-centered care. Few studies consider the impact of EHRs on quality of care in the intensive care unit (ICU) setting. Objectives: To evaluate key quality measures of a surgical intensive care unit (SICU) following implementation of the Epic EHR system in a tertiary hospital. Methods: A retrospective chart review was undertaken to record quality indicators for all patients admitted to the SICU two years before and two years after EHR implementation. Data from the twelve-month period of transition to EHR was excluded. We collected length of stay, mortality, central line associated blood stream infection (CLABSI) rates, Clostridium difficile (C. diff.) colitis rates, readmission rates, and number of coded diagnoses. To control for variation in the patient population over time, the case mix indexes (CMIs) and APACHE II scores were also analyzed. Results: There was no significant difference in length of stay, C. diff. colitis, readmission rates, or case mix index before and after EHR. After EHR implementation, the rate of central line blood stream infection (CLABSI) per 1 000 catheter days was 85% lower (2.16 vs 0.39; RR, 0.18; 95% CI, 0.05 to 0.61, p < .005), and SICU mortality was 28% lower (12.2 vs 8.8; RR, 1.35; 95% CI, 1.06 to 1.71, p < .01). Moreover, after EHR there was a significant increase in the average number of coded diagnoses from 17.8 to 20.8 (p < .000). Conclusions: EHR implementation was statistically associated with reductions in CLABSI rates and SICU mortality. The EHR had an integral role in ongoing quality improvement endeavors which may explain the changes in CLABSI and mortality, and this invites further study of the impact of EHRs on quality of care in the ICU.

What to expect from electronic patient record system implementation: lessons learned from published evidence

“…Few studies report direct effects on patient outcome, most focusing on billing and efficiency, but in one intensive care unit (ICU) study, whilst there was no significant difference in length of stay or readmission rates, there was significant reduction in central-line infection and overall mortality rates 92. Similarly, another ICU study reported significantly decreased overall mortality, due to reduced medication errors 93…”

Implementation of electronic health records systems in surgical units and its impact on performance

“…Some studies suggest that there may be improvements in length of stay, mortality, inpatient rate of infections, adherence to guidelines, rate of medication errors, costs and utilization of physician time. [10][11][12][13][14][15][16] Other studies have reported that the introduction of EHR may result in less orders for unnecessary tests and imaging and can possibly influence confidence in diagnosis. 17,18 The difficulty in reaching a conclusion as to benefits of EHR is due to multiple factors, these include a wide spectrum of commercially available EHR systems, mixed taxonomy utilized by different studies, intrinsic site and utilization differences and an absence of standardized measure in the assessment of EHR performance.…”

Review of information technology for surgical patient care

“…[29] Flatow and colleagues found an 85% decrease in central line associated blood stream infections per 1000 catheter days and a 28% decline in mortality within a surgical intensive care unit after the institution of an EHR; however, there were many associated confounders. [32]…”