Theme Issue Editorial
Quantifying the volume of documented clinical information in critical illness

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Abstract

Objectives

The purpose of this study is to describe the volume of clinical information documented in critical illness, its relationship to the use of intensive care unit (ICU) technology, and changes over time.

Methods

We performed a 6-year retrospective cohort study. Eligible patients were admitted to a university-affiliated pediatric ICU for at least 24 hours during the years 2000 to 2005. For each complete 24-hour period (midnight-midnight) that each patient was admitted to the ICU, we extracted the total number of items of documented clinical information and the use of 5 ICU technologies. For each day of the study, we calculated the total volume of documented information available to inform the daily ward round. A 2-level hierarchical linear model was used to analyze the primary outcome variable.

Main Measurements and Results

There were 5623 admissions and 41 202 complete patient-days studied. The median number of items of documented clinical data for each complete 24-hour period was 1348 (interquartile range, 1018-1664; mean, 1341). Significantly, more clinical information was documented about children who were ventilated with conventional ventilation (1483), children on inotropes or vasoactive medications (1685) and high-frequency oscillation (1726), and children receiving extracorporeal membrane oxygenation therapy (2354) or hemodialysis (1889) than children not in these categories (all P < .0001). The number of items documented per patient-day increased by 26% from 1165 in 2000 to 1471 items in 2005 (P < .0001). This finding was independent of ICU technology use.

Conclusions

A large and increasing volume of information was documented during the course of critical illness. More information was documented in patients receiving ICU technologies, suggesting that the volume of documented information is a marker of therapeutic intensity. It is also a source of workload and provides opportunity for error. Our findings underscore the importance of effective information management and communication strategies. Additional work is needed to evaluate the implications of current documentation practices for workload and quality of care.

Introduction

Critical illness is characterized by dynamic and severe physiologic abnormalities. These abnormalities are described by frequently repeated clinical measurements and treated with intensive care unit (ICU) technologies that include pharmacologic interventions and mechanical cardiorespiratory support. Invasive monitoring and frequent observation generate clinical information that is documented and used to validate the indication for current therapies or to justify their modification.

Critical illness is a 24-hour phenomenon. The limitations of human endurance necessitate transitions between frontline health care professionals to provide the continuous care required [1], [2], [3], [4]. Serial communication between these health care professionals about past, recent, and current clinical information ensures continuity of patient care, and improved communication between health care professionals working concurrently improves clinical outcomes [5], [6], [7], [8]. In addition, clinical data are continuously generated, observed, validated, and documented to become the clinical information from which time-sensitive decisions need to be made and implemented.

We sought to quantify the volume of clinical information documented about children admitted to a quaternary pediatric ICU (PICU). We hypothesized that there was a significant amount of information to communicate about each patient at times of handover, and that the amount of information was proportional to the use of ICU technology. A retrospective observational study was performed.

Section snippets

Materials and methods

The volume and composition of the clinical information documented during admission to a university-affiliated pediatric intensive care unit was retrospectively evaluated. Patient-level analyses evaluated the number of documented information items per complete 24-hour period in the ICU, and an ICU-level analysis evaluated the amount of information recorded in the ICU each day.

Eligible patients were admitted to the PICU for at least 24 hours in the 6 years ending December 31, 2005. The primary

Results

Over the 6-year period studied, 10 533 patients were admitted to the PICU for 61 450 patient-days. There were 8835 admissions of at least 24-hour duration that were included in the ICU-level evaluation and 5623 admissions with one or more complete patient-days that were included in the patient-level analysis.

Discussion

We performed a 6-year single-center retrospective study of 5623 patients who were admitted to a university affiliated PICU for more than 24 hours. We found that a mean of 1341 items of clinical information was documented each day, and that the volume of this information was greater in patients receiving ICU technologies. The volume of information we report is conservative because it did not include current information about medications, past clinical information, and nonlaboratory investigation

Conclusions

In this 6-year retrospective study, we found that, on average, one item of clinical information was documented during each minute a patient was in the ICU. The amount of documented information increased by more than a quarter over the 6 years studied. This reflects increasing patient-associated workload, greater burden of communication, and more opportunity for error. Our data highlight the need for efforts to improve existing information systems and staff-staff communication. Further

Acknowledgment

This study was funded by the Department of Critical Care Medicine and The Research Institute at the Hospital for Sick Children, Ontario, Canada. Dr C. Parshuram is a recipient of a Career Scientist award from the Ontario Ministry of Health and Long-Term Care. The authors were solely responsible for the design and analysis of data presented. None of the authors have a conflict of interest to declare.

References (27)

  • D. Dawson et al.

    Managing fatigue: it's about sleep

    Sleep Med Rev

    (2005)
  • G. Kuhn

    Circadian rhythm, shift work, and emergency medicine

    Ann Emerg Med

    (2001)
  • D.J. Dula et al.

    The effect of working serial night shifts on the cognitive functioning of emergency physicians

    Ann Emerg Med

    (2001)
  • D. Dawson et al.

    Fatigue, alcohol and performance impairment

    Nature

    (1997)
  • L.L. Leape et al.

    Pharmacist participation on physician rounds and adverse drug events in the intensive care unit

    JAMA

    (1999)
  • A.G. Thompson et al.

    Do post-take ward round proformas improve communication and influence quality of patient care?

    Postgrad Med J

    (2004)
  • P.M. Dodek et al.

    Explicit approach to rounds in an ICU improves communication and satisfaction of providers

    Intensive Care Med

    (2003)
  • S. Wright et al.

    The communication gap in the ICU—a possible solution

    Nurs Crit Care

    (1996)
  • T. Snijders et al.

    Multilevel analysis: an introduction to basic and advanced multilevel modeling

    (1999)
  • L.A. Hawryluck et al.

    Pulling together and pushing apart: tides of tension in the ICU team

    Acad Med

    (2002)
  • L. Lingard et al.

    Communication failures in the operating room: an observational classification of recurrent types and effects

    Qual Saf Health Care

    (2004)
  • J.D. Neaton et al.

    An examination of the efficiency of some quality assurance methods commonly employed in clinical trials

    Stat Med

    (1990)
  • A. Hall et al.

    Information overload within the health care system: a literature review

    Health Info Libr J

    (2004)

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