Purpose: Patient data management systems (PDMS) are widely used in intensive care units (ICUs) to improve care traceability. Verbal orders are still used for prescriptions requiring immediate execution but should be subsequently recorded in the system. We assessed the rapid sequence induction (RSI) traceability for endotracheal intubation in an ICU dedicated PDMS.
Materials and methods: A retrospective study was conducted on anonymous databases in 21 ICUs. Endotracheal tube insertions performed during one year were compared to the number of RSI registered in the PDMS.
Results: We listed 5516 endotracheal tube insertions. A suxamethonium injection was registered in 829 cases and a rocuronium administration in 909 cases. The RSI traceability rate in the overall cohort was 31.5% and was greater in the units where nurses were allowed to record a drug administration before the computerized physician order entry.
Conclusions: PDMS are supposed to improve prescription completeness and traceability, but our study suggests an opposite result. A co-responsibility policy between physicians and nurses should be promoted to improve care traceability. PDMS ergonomic improvements and enhanced integration in clinical workflow might also result in better compliance with documentation requirements. In each centre, indicators of PDMS correct use should be defined and periodically monitored.
Keywords: Computerized critical care information system; Computerized physician order entry; Intensive care unit; Patient data management system; Traceability.
Copyright © 2019. Published by Elsevier Inc.