International Journal of ClinicalMonitoring and Computing 9: 159-163, 1992. 9 1992KluwerAcademic Publishers. Printedin the Netherlands.

Computer assisted management of information in an intensive care unit E. Cereijo Intensive Care Unit, Hospital de la Princesa, Universidad Autdnoma de Madrid, Madrid, Spain

Accepted6 March 1992

Key words: information systems, computer, intensive care units, critical care

Summary In order to use the capability of computers for handling large amounts of information, we developed a program for the acquisition, handling, storage and retrieval of administrative and clinical information generated in the 20 bedded multidisciplinary critical care unit of a University Hospital. At an initial phase a personal computer (PC) was used to collect information from 4362 patients, that included registration data, coded admission problems, techniques and special treatments, and final diagnosis. This information combined with free text provided a discharge report. Complementary programs allowed calculation and storage of hemodynamic and gas exchange parameters. This experience led to a second phase in which a computer with microprocessor Intel 80386 at 25 MHz, 8 MB RAM, 310 MB hard disk and a streamer for 150 MB cartridge tape back up, using UNIX operating system, permitted multiple users working simultaneously through I central console and 7 ASCII terminals. Data input included demographic data, previous and admission problems in coded form, present history and physical examination in free text, list of present problems in coded form, comments on evolution, record of special techniques and treatments, laboratory data, treatment, final diagnosis and facility for using all the information to elaborate the final report. Side modules provide help for drugs dosing, protocols for specific conditions and clerical routines. The system is open for connection to other areas of the Hospital. Data from more than 2000 patients have been included so far. The program is used by medical, nursing and clerical staff with high degree of acceptance. All patients have their clinical information filed and 100% of the final reports are elaborated with the program. We conclude that a PC supported application is not adequate for implementing a historical database. On the contrary the integration of a relational database management system with a text editor in a more potent multiuser set up, provides a highly efficient tool to handle all the data generated during the patients' admission.

Introduction The care of the critically ill patient generates large amounts of information that is often difficult to handle efficiently, to store orderly, and to retrieve quickly and completely when traditional handwritten paper records are used [1]. Several authors have shown that structured systems for information

recording are simple, allow quick revision of data and improve the flow of information [2-4]. Com~ puters offer an excellent tool for handling structured information and this is why they have been used to solve the problems and limitations of the traditional methods of clinical information management [5-9]. Their ability for processing stored data, analyzing information following previously defined

160 protocols and routines makes of computers useful tools to prevent mistakes and to help in the decision making process [10-11]. Trying to use these capabilities of computers we designed a simple application for the management of a clinical and administrative historical database that could permit the easy retrieval of information about the activity of our Unit. The experience gained with this application led us to expand our objectives aiming to optimize the management of most clinical information, substituting a computerized system for the poorly organized, handwritten, traditional clinical records.

7. Reliability. 8. Improved patient care as overall final aim. The system consists of a computer with microprocessor Intel 80386 at 25 MHz, 8 MB RAM, 310 MB hard disk and a streamer for 150 MB cartridge tape back up, and uses the multiuser UNIX operating system with 1 console, 7 ASCII terminals and 3 printers. The core of the application has been developed by means of a commercially available relational database management system (TransTools v.3.0.05, TransTools.SA, Madrid, SPAIN) that uses Structured Query Language (SQL) as language for access to the database. For management of text files, the UNIX standard tools are used through calls from TransTools.

Methods

The project was developed in a twenty bedded multidisciplinary intensive care unit of a six hundred bedded University Hospital, and it evolved in two phases. In phase 1 (from 1985 to 1990) a personal computer (PC) with microprocessor Intel 80286 and 20 MB hard disk was used. The main program was developed using FoxBase + 2.00 (Fox Software, Perrysburg, OH), a commercially available programmable relational database, and consisted of two tables, one for the collection of demographic data and presentation problem, and a second table that included coded diagnosis, techniques and special treatments. Complementary programs allowed calculation and storage of hemodynamic and gas exchange parameters. Phase 2 began in 1990 and was based on the experience gained during phase 1, that allowed us to define the following requirements for the application: 1. Completeness. The application must cope with most of the information generated. 2. Structured information emphasizing relevant data. 3. Logical allocation of data to places where they can be easily found. 4. Availability of all data of any patient at any time at any terminal for any user. 5. Friendliness. 6. Sparing of time.

Results

The program developed in phase 1 consisted of two tables. The first one for the collection of demographic data and presentation problem, which was fulfilled at the patient's admission, and a second table that included coded diagnosis, techniques and special treatments, which was fulfilled at discharge with the information previously collected in a specially designed hand-written form following the directions of the Problem-Oriented Medical Record system (POMR) [2]. That application did not modify the routine daily work except by the need that each patient had in his/her records the POMR form as complete as possible; that information was coded and entered into the second table at discharge. All these data could be combined with a free text file for history and evolution comments and treatment in order to elaborate a discharge report. Only demographic and coded information was stored in the computer while a hardcopy of the discharge report was filed separately. Phase 1 included 4362 patients and demographic data for all of them are available, which permit the quick calculation of simple statistics. However, only 62% of the patients have significant clinical information stored, because in the rest conventional handling of data was preferred by the physician in charge. The program developed in phase 2 consists of 4

161

Admisslon/Dtscharge ~

Nursing

Administrative

State ot the U n i t

~

Drugs

Stale

N e w Patient

Select by n a m e

Procedures

In/Outs

JUAN PEREZ GOMEZ

History

Problem

Transler

Search Patient

Procedures F l u i d Bcdance

Discharge

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Chemistry Microbiology

INTENSIVE CARE UNIT HOSPITAL DE LA PRINCESA - MADRID A d m i s s i o n Date 0 2 / 0 7 / 9 1

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APACHE Ii GROUP. C O R O N A R Y ARTERY DISEASE, PresentalIon Problem. Chest P a i n

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H, d e La P r l n c e s a

-Madrid-

]Print Discharge Report

Select Option w i t h ( R e t a r n }

Calculator

Back to M a i n M e n u w i t h (ESC),

U.C.L

Fig. 1. Main menu of the application. Only the headings and the

Fig. 2. Clinical data accessmenu.

options below the one selected are displayed in the screen.

groups of utilities that can be accessed from a main menu of the pulldown type (Fig. 1).

ologic survey and the early detection of changes in flora and sensitivity. 3. Nursing

1. Administrative data

Informs of the current occupancy of the Unit and allows control of admission, transfer and discharge of patients. 2. Clinical data

Includes all utilities for handling clinical information. After localizing the patient by name or bed number, the screen shows the patient's presentation problems and the menu for direct access to his/her history, list of problems with their corresponding evolution comments, fluids balance, control of invasive procedures, treatment, and request and storage of laboratory data (Fig. 2). The presentation problems, previous diagnosis, and active clinical problems are handled following the pattern of the P O M R system [2], they are managed in coded form but are associated to free text fields in order to complement and personalize the information. Each active problem is associated to a free text file where daily comments are stored, which may be recalled in order to assist in the elaboration of evolution summaries to be included in the discharge report. Prescription is done using a dictionary that offers basic information about drugs, and data on the time of beginning and end of treatments. Biochemistry and microbiology data are presented in tables ordered chronologically. The microbiology data stored allow a continuous epidemi-

Provides protocols for administration of drugs, directions for nursing care and procedures. 4. Clerical routines

Utility for localizing patients, presenting lists of patients, summaries of admissions and discharges, and general statistics of the activity of the Unit. We decided that, at this stage of development, the program would not deal with physiologic parameters, either directly acquired through monitors or manually fed by nurses, because the problems, both technical and financial, that their inclusion would pose [4, 9]. The application is open to integration with other areas in the Hospital, such as Biochemistry, Microbiology, Emergency Department and Central Archive Department, where compatible utilities are presently being developed. Phase 2 has been in operation for over 18 months and more than 2000 patients have been included so far. The program is regularly used by twelve doctors, and by nursing and clerical staff, with high degree of acceptance. After a brief adaptation period all patients have their clinical information stored. There has been no break down or block of the system that might have prevented its continuous u s e .

162 Discussion

Personal computers are nowadays commonly used in Intensive Care Units where they have proved very useful for applications such as hemodynamic or gas exchange calculations, drug dosing and so on. Although also applications for historical databases have been reported useful by different authors [12, 13], it is not clear however what is the ratio between the yield of the database and the effort necessary to feed it adequately. In a single-user system as that initially developed by us, access to an application is sequential, an user having to wait until the system is free in order to enter of retrieve information. In an environment where time is usually essential, this delay may be unacceptable. Moreover, the use of that program did not improve substantially patient care, and feeding data to the system was another burden added to the clinical work. All these reasons explain the low acceptance of the application developed in the first phase, and, as a result, the low proportion of clinical information fed into the system. Therefore, our PC supported database was useful to provide simple demographic indices and rough profiles of prevalence of different pathological conditions, but it showed very limited as an historical database. On the other hand, the association of a relational database management system with a text editor in a more potent multiuser system permits to handle most of the data generated during the patients' ICU stay. All clinical data are accessed through a single menu. The list of problems is particularly useful because it offers an immediate and comprehensive vision of the history of the patient, that is very important in an environment where decision making must often be quick. The list is the base of patient management and therefore it is continuously revised and modified, that makes it more precise and complete. The list of procedures permits the control of their number and duration. Moreover, problems and procedures are automatically stored in the database without any intervention by doctors, dispensing them of a job that was tedious in our previous application. Although apparently a minor problem, it has

been reported that up to 25 per cent of the information recorded in handwritten flowsheets were illegible [11]. Obviously computerized systems solve this problem. In general, the system highly improves the availability of information as data are at hand at any time, at any terminal and several users may have access to have same data simultaneously. Moreover, the orderly arrangement of information simplifies consultation and unifies the work methods. Direct acquisition of data for bedside monitors, ventilators and other equipment provided with analogue to digital converters has received special attention in most developed systems [5-7]. Kuperman et al. [5] studied extensively the problems posed by such applications. The lack of communication standards among different pieces of equipment and computers demand individual solutions. The 'Medical Information Bus' (MIB) is a microprocessor based device communications controller not yet commercially available, that efficiently communicates devices with different output with a computer and can be a good solution for this troublesome problem. Additional problems are related to the large amount of data provided by on line equipment, that demand pre-established selection routines and to the detection and suppression of artifacts and, what is more difficult, of real data that are not representative of the state of the patient. Moreover, a system dealing with physiologic parameters either acquired on line or fed manually by nurses, must also include a record of those interventions that are related to these parameters. For this reason terminals at the bedside are needed with the consequent rise in costs. Because all these difficulties we decided not to include on line acquisition of physiologic parameters in our application. The way in which computers handle data in a relational database accounts for many of the advantages of computers applied to the management of clinical information. The patients' data are stored in many tables adequately identified. By means of routines and specific protocols the application can spot all data needed for a particular task compared them with one another or with prefixed values and offer different responses according to rules predefined in the protocols. In this way the

163 application can perform tasks as simple as tell the name of the patient in a determined bed or as apparently complex as alert about the incorrect dosing of a drug according to the renal function, the height and the weight of a patient or about the incompatibility of two prescribed drugs [9, 10]. Also the system avoids redundant information, for instance, while the identification data of a patient are available on every report they are stored only once, preventing errors and making corrections easier. The high acceptance of our program is probably due to the fact that it does not compel the users to adopt new unfamiliar routines of work, but just to the contrary it adapts to and tries to optimize the established system. Although computers can help medical practice in many different areas, it is necessary to define precisely the objectives of the application in order to choose the tools suitable to the task. A PC may he useful for applications in which availability need not be immediate. For more flexible applications in which several people may need using the same information at the same time a multiuser system is necessary. Substitution of a computerized system for the conventional format clinical history results in better flow of information and allows the development of protocols and help routines that may improve the decision making process.

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provide more information than the standard medical record. JAMA 1985; 254: 1185-92. Gardner RM, Sittig DF, Budd MC. Computers in the intensive care unit: match or mismatch? In: Schoemaker WC, Ayres S, Grenvik A, Holbrook PR, Leigh Thompson W, editors. Textbook of Critical Care. 2nd ed. Philadelphia: WB. Saunders Co., 1989: 248-59. Kuperman GJ, Gardner RM, Pryor TA. HELP: A dynamic hospital information system. New York: Springer-Verlag, Inc., 1991. Bleich HL, Beckley RF, Horowitz GL. Clinical computing in a teaching hospital. N Engl J Med 1985; 312: 756-64. Diaz O. The computer and critical care medicine. In: Shoemaker WC, Leigh-Thompson W, editors. Critical Care. State of the Art. Vol. 4, Fullerton (CA): The Society of Critical Care Medicine, 1988. Manzano JL, Villalobos J, Church A, Manzano JJ. Computerized information system for ICU patient management. Crit Care Med 1980; 8: 745-7. Gardner RM, West BJ, Pryor A. Computer-based ICU data acquisition as an aid to clinical decision-making. Crit Care Med 1982; 10: 823-30. McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. New Engl J Med 1976; 295: 1351-5. Hammond J, Johnson HM, Varas R, Ward CG. A qualitative comparison of paper flowsheets vs a computer-based clinical information system. Chest 1991; 99: 155-7. Williams KN, Jones JA. Computerised note-keeping for the intensive care unit. Four year's experience. Clinical Intensive Care 1990; 1: 22-8. Ser6n Arbeloa C, Mont6n Dito J, Avellanas Chavata M, Cegofiino Gimdnez G, Laplaza Marfn J. Nuestra experiencia en el uso de una base de datos en una UCI polivalente. Med Intensiva 1990; 14: 126-9.

Address for offprints: References 1. Gardner RM, Shabot MM. Computerized ICU data management: Pitfalls and promises. Intt J Clin Monit Comput 1990; 7: 99-105. 2. Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278: 593. 3. Whiting-O'Keefe QE, Simborg DW, Epstein MV, Warger A. A computerized summary medical record system can

E. Cereijo, Unidad de Cuidados Intensivos, Hospital de la Princesa, Diego de Le6n 62, 28006 Madrid, Spain

Computer assisted management of information in an intensive care unit.

In order to use the capability of computers for handling large amounts of information, we developed a program for the acquisition, handling, storage a...
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