Neonatal Informatics—Dream of a Paperless NICU: Part Four: Integrating Caregiving, Automated Process Management, and Clinical Decision Support

Abstract

Bedside physicians, neonatal nurse practitioners (NNPs), clinical bedside nurses, respiratory therapists, and unit clerks in the neonatal intensive care unit (NICU) work as the team primarily responsible for integrating clinical data, updating diagnoses, judging infant stability, acting on treatment decisions, and placing orders in their individual areas of professional expertise. Current hospital computerization is fragmented, with poorly integrated, department-based computer systems communicating by local programming workarounds or by human-to-computer retyping. Existing clinical installations are unnecessarily time-consuming, create serious distractions, and disrupt real-time, “multisynchronicity” (N)ICU workflows. (1)(2) Critical results must be communicated to the proper caregiver in time to effect care changes. Situational communication delays occur because of the time of day (physician and nursing shift change), hospital information system (HIS) downtimes, patient admission surges in the larger hospital, and local unit emergencies (eg, stat delivery of preterm triplets). Automating and streamlining processes could help caregivers avoid problems that contribute to suboptimal patient care, such as relieving critical caregivers of time-consuming clerical work involving data gathering from multiple fragmented systems and aggregating all “electronically charted” information into cognitively meaningful clinical formats. Clinical decision support for complex clinical systems can help prevent system breakdowns that occur when nurses, doctors, and ancillary support staff are distracted by more acutely urgent situations. Time-pressured clinicians need systems that have been designed using human factors engineering principles, tested for usability, and monitored for ongoing system performance. (2)(3)(4)(5)(6)(7) Human factors-based failures occur when context-based reconciliation jobs are bypassed in laboratory and drug ordering loops by poorly designed and implemented computerized physician order entry, nurse charting, or other hospital systems, especially ones that slow caregivers’ workflow during emergencies. (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) Changes in complex systems reverberate, altering outcomes. Therefore, change responses must involve solutions that improve critical care computerization, patient care, and safety and lower costs of wasted resources (staff time, products, length of stay, and quality measures derived from administratively defined modeling methodologies). Effective systems change is important for overall integrity of the United States health-care system.