Barriers to implementation of an automated severe sepsis alert system in the ICU setting 1

20 Background. Electronic Health Record (EHR)-based sepsis alert systems have failed to 21 demonstrate improvements in clinically meaningful endpoints. However, the effect of 22 implementation barriers on the success of new sepsis alert systems is rarely explored. 23 Objective. To test the hypothesis time to severe sepsis alert acknowledgement by critical care 24 clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement 25 system compared to a text paging-based system. 26 Study Design. In one arm of this simulation study, real alerts for patients in the medical ICU 27 were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts 28 were delivered through text paging. The primary outcome was time to alert acknowledgement. 29 The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal 30 group interview. 31 Results. The alert acknowledgement rate from the severe sepsis alert system was 3% (N=148) 32 and 51% (N=156) from simulated severe sepsis alerts through traditional text paging. Time to 33 alert acknowledgement from the severe sepsis alert system was median 274 minutes (N=5) and 34 median 2 minutes (N=80) from text paging. The response rate from the EHR-based alert system 35 was insufficient to compare primary measures. However, secondary measures revealed 36 important barriers. 37 Conclusion. Alert fatigue, interruption, human error, and information overload are barriers to 38 alert and simulation studies in the ICU setting. 39 Word count: 215 40 Deleted: Automated, electronic medical record 41 Deleted: EMR 42 Deleted: an automated, EMR-based 43 Deleted: system 44 Deleted: time to 45 Deleted: by critical care clinicians in the intensive care unit 46 (ICU) setting 47