title: Automated inhaled nitric oxide alerts for adult extracorporeal membrane oxygenation patient identification.
abstract: BACKGROUND
  Recently, automated alerts have been used to identify patients with respiratory failure based on set criteria, which can be gleaned from the electronic medical record (EMR). Such an approach may also be useful for identifying patients with severe adult respiratory distress syndrome (ARDS) who may benefit from extracorporeal membrane oxygenation (ECMO). Inhaled nitric oxide (iNO) is a common rescue therapy for severe ARDS which can be easily tracked in the EMR, and some patients started on iNO may have indications for initiating ECMO. This case series summarizes our experience with using automated electronic alerts for ECMO team activation focused particularly on an alert triggered by the initiation of iNO.
  
  
  METHODS
  After a brief trial evaluation, our Smart Alert system generated an automated page and e-mail alert to ECMO team members whenever a nonzero value for iNO appeared in the respiratory care section of our EMR. If iNO was initiated for severe respiratory failure, a detailed evaluation by the ECMO team determined if ECMO was indicated. For those patients managed with ECMO, we tabulated baseline characteristics, indication for ECMO, and outcomes.
  
  
  RESULTS
  From September 2012 to July 2013, 45 iNO alerts were generated on 42 unique patients. Six patients (14%) met criteria for ECMO. Of these, four were identified exclusively by the iNO alert. At the time of the alert, the median PaO₂-to-FIO₂ ratio was 64 mm Hg (range, 55-107 mm Hg), the median age-adjusted oxygenation index was 73 (range, 51-96), and the median Murray score was 3.4 (range, 3-3.75), indicating severe respiratory failure. Median time from iNO alert to ECMO initiation was 81 hours (range, -2-292 hours). Survival to hospital discharge was 83% in those managed with ECMO.
  
  
  CONCLUSIONS
  Automated alerts may be useful for identifying patients with severe ARDS who may be ECMO candidates.
  
  
  METHODS
  Diagnostic test, level V.
authors.affiliation: From the US Army Institute of Surgical Research (S.M.B., A.I.B., D.E.L., M.L.S.-M., L.C.C., K.K.C., J.S.); and Department of Surgery, San Antonio Military Medical Center, (T.S.P., J.C.P., J.W.C.) Fort Sam Houston, San Antonio, Texas; Uniformed Services University of the Health Sciences (J.C.P., K.K.C. J.W.C.), Bethesda, Maryland.
authors.forename: Slava M
authors.initials: SM
authors.lastname: Belenkiy
authors.forename: Andriy I
authors.initials: AI
authors.lastname: Batchinsky
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Park
authors.forename: David E
authors.initials: DE
authors.lastname: Luellen
authors.forename: Maria L
authors.initials: ML
authors.lastname: Serio-Melvin
authors.forename: Leopoldo C
authors.initials: LC
authors.lastname: Cancio
authors.forename: Jeremy C
authors.initials: JC
authors.lastname: Pamplin
authors.forename: Kevin K
authors.initials: KK
authors.lastname: Chung
authors.forename: Josè
authors.initials: J
authors.lastname: Salinas
authors.forename: Jeremy W
authors.initials: JW
authors.lastname: Cannon
mesh_terms: D000328:Adult; D056902:Clinical Alarms; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009569:Nitric Oxide / Q000032:analysis*; D012128:Respiratory Distress Syndrome / Q000175:diagnosis* / Q000628:therapy; D013997:Time Factors; D055815:Young Adult
chemical_list: D009569:Nitric Oxide