311 - EHR Integration of a NICU Emergency Code Sheet Is Associated With Improved Usability and Safety

Publication Number: 1295.311

Alex B. Ruan, Children's Hospital of Philadelphia, Drexel Hill, PA, United States; Osvaldo Mercado, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Lauren Heimall, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Anna O'Brien, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Janine Cockerham, children's hospital of philadelphia, East Norriton, PA, United States; Matthew Coyle, Childrens Hospital of Philadelphia, Springfield, PA, United States; Stan Krajewski, DTS Systems Analyst Supervisor, Cinnaminson, NJ, United States; Leah Carr, Childrens Hospital of Philadelphia, Philadelphia, PA, United States

Background: Our NICU has historically used paper emergency medication dosing sheets to support medication preparation during code events. These sheets were hosted on our institution's SharePoint with an embedded Excel file, bedside copies were printed for all admissions, and they were updated weekly by nursing staff to reflect changes in patient dosing weights. Over time, multiple safety and usability concerns were identified with this process.

Objective: To improve the safety and usability of emergency code sheet workflows through a multidisciplinary initiative involving clinical pharmacists, neonatal nurses, neonatologists, and clinical informaticists.

Design/Methods: Workflow analyses were conducted to map the existing process for maintaining bedside code sheets and to evaluate the possibility of electronic health record (EHR) integration. Our institution utilizes Epic (Verona, Wisconsin) as its EHR. A customized EHR code sheet template was created to align with unit-specific workflows (Figure 1). Routine bedside audits were conducted before and after EHR code sheet implementation to assess code sheet presence, dosing weight accuracy, and inclusion of a patient identifier. Bedside nurses completed a modified Post-Study System Usability Questionnaire (PSSUQ) before and after implementation of the EHR code sheet to assess usability. Additionally, nurses were timed on how long it took to print a code sheet using the old SharePoint and new EHR workflows.

Results: Post-implementation PSSUQ scores showed statistically significant improvements in information quality, interface quality, and system usefulness (Table 1). A majority of NICU nurses (162/175, 93%) preferred the Epic EHR workflow. Audits showed a significant increase in the presence of patient identifiers on code sheets (88% pre-implementation vs. 100% post-implementation; p = 0.004), while no significant differences were observed in the presence of code sheets at bedside (99% pre vs. 100% post; p = 0.50) or accuracy of dosing weight (97% pre vs. 99% post; p = 0.07). Time analysis revealed that generating a code sheet via the EHR was nearly one minute faster than the SharePoint method (p < 0.001; Figure 2).

Conclusion(s): Through multidisciplinary collaboration, a customized EHR-based emergency code sheet was implemented to align with NICU clinical workflows. Integration into the EHR improved usability, safety, and efficiency at the bedside. Moreover, this integration was strongly preferred by NICU nurses. These outcomes may be generalizable to other neonatal or pediatric care settings aiming to enhance emergency preparedness through a similar EHR-integrated tool.

Figure 1
Left: Screenshot of the customized code sheet for a test patient as viewed within the EHR. Right: Front side of the printed Epic EHR code sheet.

Table 1
Modified Post-Study System Usability Questionnaire (PSSUQ) results comparing SharePoint and Epic EHR workflows, with response rates of 28.1% (163/580) for SharePoint and 30.2% (175/580) for Epic. Responses were rated on a 7-point Likert scale (1 = Strongly Agree, 7 = Strongly Disagree), and analyzed using the Wilcox Rank Sum Test. The SharePoint survey was distributed approximately a month before implementation of the Epic EHR code sheet, while the Epic EHR survey was sent six weeks after implementation of the Epic EHR code sheet. Improvements were observed in the overall modified PSSUQ, and across the domains of system usefulness, information quality, and interface quality.

Figure 2
Violin plot depicting time to access and print a code sheet via SharePoint and Epic EHR methods. Both groups included 41 NICU nurses. Average time to print was 66 seconds for SharePoint and 14 seconds for Epic. A one-sided t-test showed a statistically significant difference (p < 0.001).