Vanderbilt experts guide Epic in integrating a proven clinical protocol.

Over the past two decades, studies at Vanderbilt University Medical Center by pulmonary and critical care specialist Wes Ely, M.D., and colleagues have drawn attention to the long-term health impacts of ICU delirium. The resulting body of evidence has come to inform critical care guidelines endorsed by medical societies in several countries. Now, Ely and team are designing tools for hospital EHR systems to improve prevention and management of delirium within intensive care.

One of the nation’s largest health information technology companies, Epic Systems Corporation, has released an update that aims to prevent ICU delirium and improve patient outcomes. Ely and his team assisted Epic with the update.

“New support from a major EHR company like Epic means that fewer patients stand to undergo ICU delirium and its harrowing consequences,” said Ely, who is also professor of medicine and co-director of the Critical Illness, Brain Dysfunction, and Survivorship Center at Vanderbilt.

Whole Person Approach

Ely served as the principal investigator for a project sponsored by the Society of Critical Care Medicine to improve patient outcomes in U.S. hospitals using a clinical protocol called the ICU Liberation Bundle, also known as ABCDEF. This protocol is the basis for the Epic software update.

The protocol includes well-calibrated pain management with prompt discontinuation of analgesics and sedatives, daily spontaneous awakening trials, daily spontaneous breathing trials, delirium assessments throughout the day, early mobility and exercise, and family engagement. Protocol checklists and other tools are publicly available for download.

“What this bundle does is stop people from just looking at one organ at a time.”

“What this bundle does is stop people from just looking at one organ at a time,” Ely said. “It takes the overall person and says, ‘This is a whole human being and we’re going to pay attention to how their brain is working, and their liver and lungs and kidneys, all at once.’ It makes us take a step back and help people avoid injury that might otherwise occur in intensive care.”

Streamlining Implementation

The new EHR build allows streamlined implementation and better compliance, Ely said, “which, according to more than 20,000 patients worth of data we’ve published, yields less time on the ventilator, shorter ICU stays, reduced costs and improved survival.”

The system update and associated ICU workflows – involving nurses, pharmacists, physicians, physical therapists, occupational therapists, respiratory therapists and family members – are in use at Vanderbilt and other centers that assisted Epic with the update.

“The implications for patient outcomes are stark, and so is the improvement opportunity,” said Kevin Johnson, M.D., professor and chair of the Department of Biomedical Informatics. “We’re very pleased that our colleagues at Epic have fully embraced this opportunity to promote new workflows in the ICU.”

Collaborating on Design

Epic developers, led by Jeff Wolanin, worked closely with Ely’s team both to design what the workflows would look like in Epic and to craft recommendations to help hospitals operationalize the protocol in the ICU.

Other collaborators on the update included Vanderbilt pharmacist Joanna Stollings, Pharm.D., medical ICU nurse Charlotte Garwood, R.N., and colleagues from the University of Colorado, the University of California San Francisco and California-based Sutter Health.

With Epic’s next software release in February, the ICU Liberation Bundle will become a standard part of the company’s EHR system, and it is now available as an add-on. Ely’s team and Epic are now working together on information systems support for ICU patient outcomes monitoring.

About the Expert

E. Wesley Ely, M.D.

Wesley Ely, M.D., M.P.H., is the Grant W. Liddle Chair in Medicine, a professor of medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine, and co-director of the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center. His research focuses on improving the care and outcomes of critically ill patients with ICU-acquired brain disease.

Kevin Johnson, M.D.

Kevin Johnson, M.D., M.S., is Cornelius Vanderbilt Professor and Chair of Biomedical Informatics, Vanderbilt University Medical Center’s Informatician in Chief, and a professor of pediatrics at Vanderbilt. He serves as lead of the National Library of Medicine's Board of Scientific Counselors and was recently appointed to the NIH Council of Councils.