The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts

UTILIZATION OF ELECTRONIC DOCUMENTATION TO ASSESS PATIENT OUTCOMES.

Kenneth Miller, Diane Horoski, Robert Leshko, Micheal Weiss, Angela Lutz; Respiratory Care, LVHN, Allentown, PA

Introduction: Health information technology is being increasingly used in the intensive care unit population to improve patient outcomes and monitor staff performance. Methods: We implemented an intensive care unit electronic medical record (ICU EMR) that would serve both as a bedside medical record and database. Data was self-populated electronically from the mechanical ventilators and manually entered by the bedside respiratory therapist. A Clinical Information System Specialist (CISS) supervised the implementation and data entry. Clinical Information System Specialist was a respiratory therapist with extensive clinical background. Data could be queried in real time and on an ongoing basis. Results: Patients were enrolled over an 18-month period, from January 1st, 2008 to June 30th, 2009. There were a total of 4569 episodes in which a patient required mechanical ventilation. Of the 4569 episodes, 4020 (88.0%) had respiratory therapist entered outcomes data whereas no outcome data was entered for the remaining 549 (12.0%) episodes. Of the 4020 mechanical ventilation episodes with outcomes data, 3296 episodes (82.0%) were extubated successfully without a need for reintubation. The mechanical ventilator was withdrawn as part of the palliative care process in 392 episodes (9.8%). One-hundred twenty-nine mechanical ventilation episodes (3.2%) resulted in death while the patient was receiving mechanical ventilation. Eighty-eight patients (2.2%) were transferred to long-term care facilities while being ventilated and twelve patients (0.3%) were sent home on a ventilator. There were 102 self-extubations episodes (2.5%) of which eighteen (17.6%) required reintubation. Of the 4020 episodes of mechanical ventilation, 162 (4.0%) required re-intubation within 24 hours and 146 (3.6%) required re-intubated after 24 hours. Conclusion: We implemented an ICU EMR that accepts data both electronically and manually from our respiratory therapy providers. The ICU EMR serving both as a bedside medical record and database will allow us to easily monitor our mechanical ventilation outcomes on an ongoing basis and monitor staffÂ’s clinical documentation. Sponsored Research - None