Clinical Informatics in the ICU in a Pandemic

Previously through the SSUAG website I’ve detailed some of the pros and cons of an electronic clinical information system (CIS). In North Cumbria we use such a system in both ICUs (38 miles apart!), the chosen system being IMDSoft’s “Metavision” system. The software and hardware enable electronic prescribing, multidisciplinary notekeeping and recording of vital signs imported from monitors and equipment. It operates as a standalone system in the trust though it integrates portals into radiology and pathology services. 

Our previously detailed major advantages prior to the pandemic were of accuracy and safety of prescribing, legibility of notes in chronologic order and ease of data retrieval for quality and governance purposes. Interhospital transfer between our two ICUs was not infrequent, mainly for repatriation or upgrade of care purposes, with additional non clinical transfers at times of bed pressure (we have a 9 and a 6 bedded ICU on our two sites, both with emergency departments). Inter-ICU transfer in terms of clinical information was seamless almost at the touch of a button, plus either site has the ability to view the other’s data ‘live’, with a ward layout and occupancy screen. 

Come the pandemic, along with all the other rapid learning points for clinical practice, there were significant implications for our clinical information system. 

The Good

For ICU consultants there has been an immense amount of ‘bed juggling’, partly to even load between the two units but also to protect elective surgery. Having visual live representations of occupancy can be extremely useful. The known advantage of seamless data transfer between sites was never more apparent than this era of an explosion of non-clinical transfers 

Access to the CIS can be remote, from any trust computer, including at home. This means that we were able to note keep and prescribe outside the ‘hot zone’ or covid area. This saves a lot of trips in and out for forgotten tasks, and therefore PPE and likely some glaciers and dolphins as well. 

Remote access was useful to allow some degree of management at home for a team on tight shift patterns and heavy workload. In conjunction with the explosion of TEAMS meetings this led to less avoidable on site work. 

Programming of the system allowed rapid adoption of ‘covid bundled’ care. This has included immune therapies, tailored anticoagulant regimes, feeding regimes and so on to be added. The continued utility of ‘one click’ prescribing saved time for the multiple sedatives used for nursing and medical teams. Stretched nursing ratios were helped by the speed of the prescribing process. 

Multidisciplinary teams were able to log in remotely – for example dietician support – enabling less traffic into the hot zone. 

The bad 

As can be inferred from the ‘good’ narrative, covid patients were managed within our ICU, whereas non-covid patients were managed in theatres. This meant this area was obliged to use paper - a fall-back system that we have always retained, for those usual winters of one or two patients in recovery. This presented an ‘invisible’ area to us, with the mass of paper leading to an unaccustomed filing problem. Two systems and extremely stretched nursing ratios led to abandonment of the CIS on one site at one point, since non ICU staff were not trained in use of the CIS. This was all a salutary reminder that we must never neglect the paper backup option! 

The ugly 

Buying into a CIS is a complex affair. Network cabling, Wi-Fi hotspots, provision of monitors and carts all go hand in hand with the process. To reliably run extra points for doubling ICU capacity into non critical care areas would run well into a 6 figure sum on each site, an amount which could be questioned versus supplying workforce manpower in stretched times. We have taken a compromised view of budgeting some additional capacity in theatres recovery although not sufficient to manage more than a few patients. 

A final viewpoint 

Not having complete access to the CIS for all patients brought its advantages home to us. Even staff who were ambivalent about it expressed thoughts of how they missed it. Having mixed paper systems was messy at times but nevertheless showed the value of rehearsing the backup. Overview of bed occupancy in the trust was valuable but ultimately in times of high surge this proved beyond the CIS as previously implemented since reserve provision in non-critical care areas is a costly solution! Those ICUs contemplating new CIS should bear these aspects in mind when implementing the system.