EHR Alerts Support Dosing, Sedation, and Shock Recognition in Cardiac Care

Electronic health record alerts can add to clinician workload when they are poorly targeted. In critical cardiac care, however, delayed decisions can affect treatment timing, sedation exposure, and escalation to specialized teams. These pressures are especially important in emergency departments and cardiac intensive care units, where clinicians must act quickly. To support timely decision-making in these settings, researchers have developed and evaluated targeted digital alerts for critically ill cardiac patients.

Michigan Medicine investigators assessed electronic health record (EHR)-based clinical decision support tools across three studies involving acute decompensated heart failure, sedation in intensive care, and normotensive cardiogenic shock. The studies were conducted in settings that included the U-M Health Emergency Department and cardiac and medical intensive care units. The findings were published in Heart & Lung, the Journal of Cardiac Failure - Intersections, and JACC: Case Reports.

One EHR alert helped clinicians choose intravenous loop diuretic dosing for patients with acute decompensated heart failure. Guidelines recommend that these patients receive at least twice their home diuretic dose when they arrive in the emergency department. At the U-M Health Emergency Department, the alert was triggered for fluid overload or kidney dysfunction in 223 patient encounters, and clinicians followed the recommended diuretic dosing in nearly three-quarters of cases. Use of the alert did not delay treatment, with median time from arrival to diuretic administration remaining roughly two hours in both groups.

A second EHR intervention focused on limiting deep sedation in more than 1,600 ventilated patients in cardiac and medical intensive care units. After implementation, the average time that patients spent deeply sedated during the first 48 hours after intubation decreased in the cardiac ICU from 16.8 hours to 12.4 hours. Nurses also reduced the continuous dose of sedatives, including fentanyl, propofol, midazolam, and dexmedetomidine, in 23% of cases when an alert was generated.

The third study evaluated an alert for normotensive cardiogenic shock, a condition in which the heart cannot pump enough blood to the organs despite normal blood pressure. The alert identified additional physiological signs and facilitated communication with a shock team in the cardiac ICU. Clinicians engaged with the alert in 14% of cases, and those encounters were associated with higher rates of cardiac ICU consultation within 12 hours.

“These clinical decision support (CDS) tools are most useful when they help clinicians make the right decision in the moment, rather than adding more noise to their busy workflows. These findings suggest that well-designed EHR CDS tools have potential to improve clinical decision-making, even in the fast-paced environments of the emergency department and cardiac intensive care unit,” said Scott Ketcham, M.D., cardiologist at the University of Michigan Health Frankel Cardiovascular Center.

Related Links
University of Michigan Health Frankel Cardiovascular Center.
Michigan Medicine