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Volume of Clinical Information Generated in the ICU
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: This 6-year study of the volume of clinical information documented in the medical record during the care of patients in the pediatric ICU of a university-affiliated hospital found that a median of 1348 separate items were generated each day, and that the amount increased by 26% from 2000 to 2005.
Source: Manor-Shulman O, et al. Quantifying the volume of documented clinical information in critical illness. J Crit Care 2008;23:245-250.
This study from the University of Toronto sought to quantify the number of individual pieces of clinical information entered into the medical record on each patient in the ICU each day. The authors performed a 6-year retrospective cohort study in the pediatric ICU of a university-affiliated hospital, and included data from every patient who was admitted to the ICU for at least 24 hours between January 2000 and December 2005. The same computerized health record system was used throughout the study period. Additional information in handwritten notes by physicians, nurses, and pharmacists, verbally communicated information, and records of medication orders and administration were not included.
During the 6-year study period, 10,533 patients were admitted to the ICU for a total of 61,450 patient-days. A total of 5623 admissions with at least one complete 24-hour patient-day was analyzed. The median number of documented clinical data for each complete 24-hour ICU day was 1348 (interquartile range, 1018-1664; mean, 1341), which represented an average of 56 items per patient-hour. This information was composed of items from fluid balance (34%), respiratory and ventilation (21%), vital signs (17%), nursing care (15%), laboratory results (6%), neurologic assessment (4%), and dialysis or ECMO (0.7%). Significantly more information was documented on patients who received conventional mechanical ventilation, high-frequency oscillatory ventilation, inotropes or vasoactive medications, hemodialysis, or ECMO, as compared to patients who did not receive these interventions.
There was a 26% increase in the number of items documented per day during the 6-year observation period, from 1165 in 2000 to 1471 in 2005 (P < 0.0001). A median of 24 patients were discussed on clinical rounds each day, and a median of 27,559 items were documented in the medical record each day. A 20-minute hand-over between nurses on 1:1 assignments would have included discussion summarizing an average of 674 items documented during the previous 12-hour shift.
It will come as no surprise to anyone who works in today's ICU environment that the quantity of clinical information generated and documented for each patient over the course of a day is enormous — although the sheer numbers revealed by this study are staggering, they do not include data from continuous oximetry, electrocardiography, vascular pressure tracings, and numerous other forms of information that clinicians use. Of note, substantially more information was documented for patients receiving pressors, ventilatory support, and other high-tech interventions. This study's findings support the general impression that the overall workload for clinicians in the ICU is high and increasing, and the implications of the avalanche of data it documents with respect to hand-offs and the potential for clinical error should be obvious.