Penn Medicine reduces ICU stays with a clinical alert app built in-house

By some estimates, more than half of patients in the intensive-care unit are put on mechanical ventilators in the first 24 hours after their admission. While these machines can be life-saving, they also carry the risk of such complications as pneumonia and lung damage. 

“And the longer patients stay on ventilators, the longer they stay in the ICU,” said Dr. Barry Fuchs, medical director of the medical ICU and the respiratory care department at the Hospital of the University of Pennsylvania, Penn Medicine’s largest hospital. 

Weaning patients from ventilators involves gradually reducing their support from the machine, a process that accounts for nearly 40% of a patient’s time on ventilator support, according to some studies. Providers track data related to blood pressure, sedation and more to determine when to wean patients—and that’s a lot of data to synthesize.

If a patient isn’t ready after being screened by a respiratory therapist, they’ll often stay on the same level of support until they are evaluated again the following morning, Fuchs said. Penn Medicine found that’s partly why patients remained on ventilators for 12 to 24 hours longer than expected.

To improve the process, a team from Penn Medicine’s ICU; information technology and data science departments; and its Center for Health Care Innovation, among other sections of the health system, created an app that manages streams of relevant patient data in real time. Fuchs served as the clinical lead for the project.

Called the Awakening and Breathing Coordination, or “ABC” app, it pulls data from ventilators and the health system’s electronic health record into a clinical dashboard, so clinicians can continuously evaluate whether patients are eligible for weaning from the ventilator. The app also includes an alert system, which suggests interventions that respiratory and nursing staff can take to move patients along the weaning process.

On average, the app has helped to cut the time patients spend on ventilator support by more than 24 hours, according to internal data from Penn Medicine. And that’s resulted in two fewer days on average in the ICU for patients on ventilator support.

Those outcomes earned Penn Medicine’s app the ECRI Institute’s Health Devices Achievement Award for 2019.

“EHRs may be looked at as repositories for data, kind of stagnant and for historical purposes,” said Rob Schluth, senior project officer for the ECRI Institute’s health devices group. But Penn Medicine was “able to get the data out so that caregivers could make decisions in real time.”

Still, there are concerns when developing a clinical alert system.

As early as 2013, the Joint Commission issued a warning to hospitals about the dangers of alert fatigue, a phenomenon that occurs when clinicians—who are increasingly bombarded with computerized alerts—become desensitized to these pings. There’s a potential to harm patient safety, should alarm fatigue lead clinicians to unintentionally gloss over important notifications.

That’s part of why communicating information in a way that didn’t feel like a “nuisance” was a big challenge to developing the app, Fuchs said. Penn Medicine leadership said the development team addressed these concerns head-on by engaging ICU nurses, physicians and respiratory therapists. “They directed where the dashboards would be more helpful and what data should reside on top,” said Michael Restuccia, Penn Medicine’s chief information officer.

For example, when the team first rolled out the app, they tested having an off-site telehealth team receive the alerts and call bedside providers to pass along relevant messages—but clinicians found that too intrusive. “People didn’t like being told by someone else, ‘You should do this now,’ ” Fuchs said.

The development team subsequently reconfigured the app to deliver text alerts directly to bedside providers, so they can assess potential interventions as they’re able. 

Dr. Lewis Kaplan, president-elect of the Society of Critical Care Medicine, said data tools like these are helpful for flagging unexpected changes in patients’ health. Kaplan, a surgery professor at the Perelman School of Medicine at the University of Pennsylvania, said he had used the ABC app’s clinical dashboard, but not the alert system.

He said the tool has proved useful as a “supplement” to clinical judgment for clinicians in the health system’s ICUs, without replacing it. “It’s a cue, and another tool for you to use,” he said.

David Jamison, the ECRI Institute’s executive director for selection and evaluation, said the key to developing a successful alert system is to ensure clinical staff feel they can use these notifications to intervene in a valuable way.

“People have to be judicious in adding additional alerts, and make sure they’re attacking a problem that’s a real problem,” he said. “Penn did that.”