Appl Clin Inform 2016; 07(02): 560-572
DOI: 10.4338/ACI-2015-11-RA-0159
Research Article
Schattauer GmbH

Validation of test performance and clinical time zero for an electronic health record embedded severe sepsis alert

Joshua Rolnick
1  Santa Clara Valley Medical Center
,
N. Lance Downing
2  Stanford Hospital & Clinics
,
John Shepard
2  Stanford Hospital & Clinics
,
Weihan Chu
3  Stanford School of Medicine
,
Julia Tam
2  Stanford Hospital & Clinics
,
Alexander Wessels
4  Sagacious Consultants
,
Ron Li
2  Stanford Hospital & Clinics
,
Brian Dietrich
2  Stanford Hospital & Clinics
,
Michael Rudy
2  Stanford Hospital & Clinics
,
Leon Castaneda
2  Stanford Hospital & Clinics
,
Lisa Shieh
3  Stanford School of Medicine
› Author Affiliations
Further Information

Publication History

received: 15 November 2015

accepted: 10 April 2016

Publication Date:
16 December 2017 (online)

Summary

Bachground

Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management.

Objective

To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR.

Methods

he sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis.

Results

Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen.

Conclusion

We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.