Rapid sequence induction traceability in an ICU dedicated patient data management system: a multicentric...

Area of Science:

• Critical Care Medicine
• Health Informatics

Background:

• Patient data management systems (PDMS) are essential for enhancing care traceability in intensive care units (ICUs).
• Verbal orders, though used for immediate prescriptions, require subsequent recording in PDMS for complete documentation.

Purpose of the Study:

• To assess the traceability of rapid sequence induction (RSI) for endotracheal intubation within an ICU-dedicated PDMS.
• Evaluate the completeness of RSI documentation in electronic health records.

Main Methods:

• A retrospective analysis of anonymous data from 21 ICUs over one year.
• Comparison of recorded endotracheal tube insertions with registered RSI events in the PDMS.

Main Results:

• Out of 5516 endotracheal tube insertions, RSI was documented in only 31.5% of cases.
• Traceability rates were higher in ICUs allowing nurses to record drug administration before physician order entry.

Conclusions:

• Current PDMS may hinder rather than improve prescription completeness and traceability.
• Promoting shared responsibility between physicians and nurses can enhance care documentation.
• PDMS usability improvements and better clinical workflow integration are needed for better compliance.