Post on 25-Dec-2015
Data marts. Intensive care experience
Vitaly Herasevich, MD, PhD, MSc
Assistant Professor of Medicine and Anesthesiology,Department of Anesthesiology,Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.)
herasevich.vitaly@mayo.eduJun 2012
Why we need Datamart?
April 2011 56 Hospitals worldwide
Including Mayo Clinic
©2011 MFMER | slide-4
http://mayoweb.mayo.edu/it-operations/supported-systems.html
EHR
Data volume before and in ICU
Microbiology, labs, medications, chest X-ray, Nurses flowsheet, Clinical notes (history and impression/plan) – Vitals excluded
“Datapoints” in acute setting
Routine noninvasive monitoring
• EKG• Arterial blood pressure• Heart rate• Respiratory rate• Temperature
Fluid balance
• Fluid IN• Fluid OUT• Urine output
Laboratory blood
• Hemoglobin• Serum electrolytes• Blood chemistry
Invasive hemodynamic monitoring
• Central venous pressure• Arterial blood gases and pH• Pulmonary arterial pressure• Oxygen transport variables• Intra-arterial blood pressure
Natural contexts
• Demographic data• Chronic diseases history• Allergies• Stress• Pain
Tissue perfusion / oxygenation monitoring
• Pulse oximetry• Transcutaneous oxygen and carbon dioxide monitoring
Ventilator monitoring
• FiO2
• PIP• PEEP/CPAP• Mean Airway Pressure• Tidal Volume
Brain function monitoring
• Electroencephalography• Intracranial pressure
Routine cardiac monitoring
• Cardiac output • Hemodynamic variables• Blood volume• Colloidal osmotic pressure
Average data points per dayPer Patient Per 24 bedded ICU
Labs 60 1440Drug Orders 10 240Microbiology 2 48X ray 2 48Vitals 1950 46800
FOCUS ON TOPIC OF INTEREST
ICU Datamart (METRIC Datamart)
Radiology Reports
RIMS
Nursing Flow Sheet
MICS Lastword
Clinical notes
MCLS Lastword
APACHE
APACHE
Historical
REP
CPOE
Enterprise orders
ICD-9
DSS
Past history
PPI
OR Data mart
HL7
Microbiology Reports
HRBS
Labs
HRBS
Monitored data
Chart+
Transfusion Orders
MYSIS
Drug orders
HRBS
ICU demographics
HRBS
Fluids: in/out
Chart+
Emergency acute area
YES
Surgical schedule
Surgical
ICU Data mart
SQL sto
red p
roce
dures
SQ
L sto
red p
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ures
Key Facts
• ~ 15,000 admissions per year• ~ 1,000,000 vital records per week• Data available from 2003• Updated every hour in average (15 min for vitals)• Near real-time• ED critical area
Anesthesia Datamart (OR Datamart)
Anesthesia locations included in OR Data mart
©2011 MFMER | slide-14
Available data (Apr 2012)
1998 ….. 2012 Yearly average Monthly average
Total1998-2011
Demographics 750,000 65,000 5,400,000
Events 20,000,000 1,600,000 144,000,000
Procedures 300,000 26,000 2,500,000
Fluids 7,900,000 650,000 87,000,000
OR Medications 5,000,000 400,000 50,000,000
Vital signs 190,000,000 16,000,000 1,600,000,000
Documents 3,200,000 250,000 27,300,000
Procedures 330,000 28,000 2,500,000
Teams 620,000 50,000 4,600,000
Near real time (5 min delay)
Approach
Rule one: lego bricks
Rule two: UNIX- no user interface• No formal web/query Interface• ODBC connection allows query from any app (JMP, Excel, SAS…)
Rule three: raw data
Approach: technically• SQL server with institutional support
• Tables divided by years
• In “Current tables” only patients who in currently in anesthesia location or ICU
• EAV (entity – attribute – value) structure
• Continuously “Testing – production”
• Test –> production DBs
Real time monitoringStatistical control
Currently: no institutional 24/7 support
Data integrity
Herasevich V, Pickering BW, Dong Y, et al. Informatics infrastructure for syndrome surveillance, decision support, reporting, and modeling of critical illness. Mayo Clin Proc 2010;85(3):247-254. (PMID: 20194152)
Herasevich V, Kor D, Li M, et al. ICU Data Mart: A Non-IT Approach. Healthcare Informatics 2011;28(11):42-45. (PMID: pending)
Areas of implementation
APACHE replacement
Reports1994 - 2009
APACHE replacement project
APACHE IV
Free text search for medical admission diagnoses
Clinical reports
Effective management
Joint Commission on Healthcare Organizations (JCAHO) measurement
of ICU performance.• Mortality report
• Length of Stay Review
• ICU Death Review
• ICU admission Low Risk Monitor Review
• ICU Readmission Review
METRIC Reports
• Monthly reports• Ad-hock reports• Customized reports
1. Hospital Length of Stay for ICU Graduates – Unadjusted
2. ICU Length of Stay – Unadjusted
3. ICU Length of Stay – Adjusted
4. ICU Readmission Rate
5. ICU Admissions
6. ICU Admission Source and Service
7. Duration of Mechanical Ventilation
8. ICU Mortality Rate – Unadjusted
9. Hospital Mortality Rate – Adjusted
10. ICU Admissions for Low-Risk Monitoring
11. ICU Census - Hourly Utilization
Reports
Dashboards
Value of this data?
INFORMATIONOVERLOAD
orLACK OF
INFORMATION
2010©2011 MFMER | slide-34
1985
DashboardsThe Stability and Workload Index for Transfer (SWIFT score)
Daily APACHE
Dashboards: administrative and clinical
©2011 MFMER | slide-36
EXAMPLE
Anti MicrobialAB admin YesCultures Taken YesSource Control No
O2 0.68.0 ETT Easy IMV VC
Fluid Bolus 4LNE 0.80aVP 0.03
RR 28SpO2 92PaO2/FiO2 200
HR 118 SRMAP 65ST ∆ No
ToC 38.9WBC 15
IHDCCFHypertension
Surgery-Stent
ObeseCOPDSmoker
Alcoholism
CVS
Renal
CNS
Respiratory
Hematologic
GIT
Sepsis
EKG NormalECHO N/ATroponin 0.02
CXR InfiltratepH 7.28pCO2 55PO2 80HCO3 24
HB 10g/dLBlood Loss 0 mlHct 0.27X Match DoneIV Access 2x20G
Possible SepsisMAP
<65HR
>90T
>38.4WBC
>12
Syndrome Advisory
Treatment GoalsMAP
>65SvO2
>70AB
<1hr
StatusCVP
10Lactate
3.0SvO2
68AB GivenYesX-Match
Done
Date SourceOrganism
03.08 BloodPending
03.08 BALPending
03.08 UrinePending
Name: Age: Source:
AWARE
Sniffers
Sniffers – rule based DSS
Notable sniffers
Herasevich V, Pieper MS, Pulido J, et al. Enrollment into a time sensitive clinical study in the critical care setting: results from computerized septic shock sniffer implementation. J Am Med Inform Assoc 2011. (PMID: 21508415)
Herasevich V, Tsapenko M, Kojicic M, et al. Limiting ventilator-induced lung injury through individual electronic medical record surveillance. Crit Care Med 2011;39(1):34-39. (PMID: 20959788)
Herasevich V, Yilmaz M, Khan H, et al. Validation of an electronic surveillance system for acute lung injury. Intensive Care Med 2009;35(6):1018-1023. (PMID: 19280175)
ALI VILI Septic Shock
Data retrieval for research
Olmsted county
Olmsted county
admission
METRICdatamart
Clinical studies
• Enrollment to time sensitive trials
• Retrospective studies for Quality Improvement an research
Future
Facilitate 3 distinct data use scenarios
• Point of care novel user interfaces, alerts and decision supports
• Reporting
• Research
Team
/co
nta
cts
Data integrity Greg Wilson, RRT
Clinical leadership Daryl Kor, MD
Medical informatics leadership Vitaly Herasevich, MD, PhD
ICU/OR datamart programming lead
Man Li, MD
OR datamart programming
Nageswar Madde
SAS programmingAndrew Hanson
Clinical ExpertiseArun Subramanian, MBBS
Clinical Expertise Brian Pickering, MD
Vision/Mentoring Ognjen Gajic, MD
Data requestsRahul Kashyap, MBBS
2 FTE
Department ChairBradly J. Narr, MD
When the machines that men invented over time would now even function: what pleasant life this would be!
Kurt Tucholsky, German writer and satirist,
1890-1935
©2011 MFMER | slide-47
herasevich.vitaly@mayo.edu
http://mayoresearch.mayo.edu/mayo/research/clinical-informatics-in-intensive-care/