Neonatal Informatics—Dream of a Paperless NICU: Part Three: Complex Crashes

Abstract

Tracking changes over time is key for clinical decision-making in intensive care units (ICUs). Critical caregivers need fast data from the laboratory and monitoring and treatment machines as well as time-stamped drug and fluids information. Workflow interactions with temporal urgencies complicated by multiple handovers and delays in return of laboratory results and delivery of care products are common in all ICUs. Temporally and physiologically integrating critical clinical information, spotting deteriorating trends, and conveying the information asynchronously to the health-care team in ICUs historically was accomplished by redundant, overlapping human workflow systems. Current computerized information systems for “charting” and “ordering” have fragmented capabilities for recording and managing date/time elements, falling far behind fast-moving events because they require time-consuming typed data entry. These facts contribute to slow recognition of subtly deteriorating patient conditions. Root cause analysis of problem situations often leads to discovery of the reason(s) for a poor outcome. Problem situations develop progressively from delays in generating and moving information. There is no predictable lull in the action in most critical care units; perinatal emergencies cannot wait for computers. Human workarounds continue to support ongoing clinical processes, including family visits, despite the information flow chaos that emerges when emergencies occur at change of shift. Expert neonatal clinicians cope by using teamwork-based, multilayered methods. Existing clinical computer systems rarely are capable of supporting multitasking clinicians effectively. Decision support could assist caregivers in critical care situations with a computer system that “watches” for expected laboratory results via an institutional protocol that differs by care unit, then notifies the correct covering person when the time limit is exceeded. Adequate critical care decision support requires highly robust HISs; fail-over servers; fault-tolerant software architecture designs; and modular, maintainable, standards-based, integrated utility systems (eg, laboratory, pharmacy, radiology, blood bank) that communicate time-stamped information in real-time using “standardized” health-care messaging. An engineering solution is needed, with attention to human factors engineering. The United States health-care computerization effort needs a parallel project to define and develop political and business management systems solutions to ascertain adequate funding for developing, disseminating, implementing, and maintaining airplane quality, real-time hospital information management systems for neonates and other critical patients.