1. Who Cares to Know: Defining Neonatal Critical Laboratory Values Theodora Stavroudis, MD Johns Hopkins University tstavro1@jhmi.edu October 28, 2007 American Academy of Pediatrics Council on Clinical Information Technology I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

2. Background Medical errors are common in the NICU –NICU patients are eight more times likely to experience a medication error with the potential to cause harm than adults (Kaushal et al 2001) –Ten percent of medical errors result from either error or delay in diagnosis, delay in treatment, or in responding to an abnormal test (Suresh et al 2004) In adults, information technology solutions have been shown to help prevent these errors

3. Alerting Systems & Algorithms Clinical information systems can generate alert messages using a variety of media –Phone calls, computer terminal messages, e-mails, flashing lights, alpha-numeric pages, SMS messages Problems: –Resource-intensive –Signal-to-Noise Ratio

4. Signal-to-Noise Ratio White Blood Cell Count 35,000 –Do you care to be paged? Yesterday’s WBC was 37,000 –Do you still care?

5. Signal-to-Noise Ratio Total Bilirubin 10 mg/dl –Do you care to be paged? Patient is a five day old term infant –Do you still care?

6. Aims & Hypothesis Aims 1)To define what constitutes critical laboratory values (CLV) in the NICU.  MUST KNOW vs. MUST KNOW NOW 2)To determine if definitions of CLV vary among health care providers in the NICU. Hypothesis Definitions of CLV do not vary among health care providers in the NICU.

7. Methods Study Type Survey at a tertiary medical center conducted in 2006 CLV Evaluated: WBC, ANC, CRP, hematocrit, platelets, sodium, potassium, bicarbonate, calcium, creatinine, triglycerides Population Studied Senior residents, fellows and attendings in the NICU Analysis Descriptive statistics, chi-square

8. Sample Survey Question The current hematocrit is 65. In the last 24 hours, there has not been a hematocrit level ≥ 65. 1 2 34 5 67 8 91 2 34 5 67 8 9 What hematocrit do you prefer to be paged about? Lab Value ScenarioIs this important information to know? Circle only one number Would you like to be paged with this lab value? Circle only one number YesUncertainNoYesUncertainNo

9. Results ProviderSurveyedResponded nn% Attendings151067 Fellows66100 Residents543157

10. Results - Attendings

11. Results - Fellows

12. Results - Residents

13. CLVResidentsFellowsAttendingsP-value ITKPageITKPageITKPageITKPage ANC<5018664835088 0.980.30 Bands>20%93781008388500.660.25 Bicarb<156943835075430.760.95 CRP>45936675075290.680.72 Cr>1.59379674075380.140.04 iCa<0.89389100 63380.040.002 K>79786100 88500.470.03 Hct<2383688367100500.450.64 Hct>6586561008375380.420.23 Plt<509071100 880.460.24 Na<1295521836788130.140.05 Na>145724610083100130.090.03 Trig>200501950 75380.440.21 WBC>30,0008664675075380.470.37 WBC<5,000765783 88500.750.41

14. Conclusions Significant differences exist by role on what CLV should be paged to health care providers. Differences are not related to perceived importance of the data. Future studies are needed to determine the reasons behind the differences in desires to be paged by health care providers.

15. Future Directions Conduct a national survey of providers to promote national adoption of CLV among neonates Create further algorithms for CLV and links to other clinical decision support systems –Culture results –Blood gas results –Oxygen requirements –Fluid status (cc/kg/day, urine output) –Drug levels –Central line placement duration –Medication alerts Implement alpha-numeric pagers using CLV discovered in this study –Measure physician response time to therapy for CLV –Measure prevention of adverse consequences from this intervention

16. Study is Underway!

17. Acknowledgements Collaborators: –Anusha Hemachandra Streubel, MD, MPH –Christoph U. Lehmann, MD Johns Hopkins senior residents, NICU fellows, and NICU attendings Johns Hopkins Quality and Safety Research Group

18. CLVAllResidentsFellowsAttendingsP-value ITKPageITKPageITKPageITKPageITKPage ANC<50186678664835088 0.980.30 Bands>20%937393781008388500.660.25 Bicarb<1572446943835075430.760.95 CRP>463375936675075290.680.72 Cr>1.586669379674075380.140.04 iCa<0.888819389100 63380.040.002 K>795819786100 88500.470.03 Hct<23866483688367100500.450.64 Hct>65865686561008375380.420.23 Plt<5093799071100 880.460.24 Na<12965265521836788130.140.05 Na>1458145724610083100130.090.03 Trig>2005527501950 75380.440.21 WBC>30,00081578664675075380.470.37 WBC<5,0007960765783 88500.750.41