Abstract
BackgroundTraditional electronic medical record (EMR) interfaces mark laboratory tests as abnormal based on standard reference ranges derived from healthy, middle-aged adults. This yields many false positive alerts with subsequent alert-fatigue when applied to complex populations like hospitalized, critically ill patients. Novel EMR interfaces using adjusted reference ranges customized for specific patient populations may ameliorate this problem.ObjectiveTo compare accuracy of abnormal laboratory value indicators in a novel vs traditional EMR interface.MethodsLaboratory data from intensive care unit (ICU) patients consecutively admitted during a two-day period were recorded. For each patient, available laboratory results and the problem list were sent to two mutually blinded critical care experts, who marked the values about which they would like to be alerted. All disagreements were resolved by an independent super-reviewer. Based on this gold standard, we calculated and compared the sensitivity, specificity, positive and negative predictive values (PPV, NPV) of customized vs traditional abnormal value indicators.ResultsThirty seven patients with a total of 1341 laboratory results were included. Experts’ agreement was fair (kappa = 0.39). Compared to the traditional EMR, custom abnormal laboratory value indicators had similar sensitivity (77% vs 85%, P = 0.22) and NPV (97.1% vs 98.6%, P = 0.06) but higher specificity (79% vs 61%, P<0.001) and PPV (28% vs 11%, P<0.001).ConclusionsReference ranges for laboratory values customized for an ICU population decrease false positive alerts. Disagreement among clinicians about which laboratory values should be indicated as abnormal limits the development of customized reference ranges.
Highlights
Audiovisual notifications have widely been used in patient care areas to provide information about organ and device function in order to attract health-care providers’ attention to an abnormality for a possible immediate action.Early in the 1970s, laboratories started actively notifying health care providers about ‘‘critical’’ or ‘‘panic’’ values, indicating potential life-threatening conditions. [1] Since clinical laboratories have been required to list the normal ranges and develop notification procedures to alert clinicians [2].Early detection and response to abnormal laboratory values is crucial in critical care. [3] there are two main barriers that hinder early detection of abnormalities in critically ill patients
Reference ranges for laboratory values customized for an intensive care unit (ICU) population decrease false positive alerts
Disagreement among clinicians about which laboratory values should be indicated as abnormal limits the development of customized reference ranges
Summary
Audiovisual notifications have widely been used in patient care areas to provide information about organ and device function in order to attract health-care providers’ attention to an abnormality for a possible immediate action.Early in the 1970s, laboratories started actively notifying health care providers about ‘‘critical’’ or ‘‘panic’’ values, indicating potential life-threatening conditions. [1] Since clinical laboratories have been required to list the normal ranges and develop notification procedures to alert clinicians [2].Early detection and response to abnormal laboratory values is crucial in critical care. [3] there are two main barriers that hinder early detection of abnormalities in critically ill patients. [5] On the other hand normal ranges listed by clinical laboratories and traditional electronic medical (EMR) systems are often defined based on blood analyses of healthy men and non-pregnant women aged between 20–50 years. [6] these values may be normal or at least acceptable in specific populations like elderly patients or an ICU setting. Traditional electronic medical record (EMR) interfaces mark laboratory tests as abnormal based on standard reference ranges derived from healthy, middle-aged adults. This yields many false positive alerts with subsequent alertfatigue when applied to complex populations like hospitalized, critically ill patients. Novel EMR interfaces using adjusted reference ranges customized for specific patient populations may ameliorate this problem
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