EHR Alerts Steer Faster, Evidence-Based Care for Critically Ill Cardiac Patients

For clinicians working in emergency departments and intensive care units, the electronic health record is often described as a burden rather than a benefit: an endless stream of clicks, pop-ups and prompts that competes for attention during moments when every second counts. Yet a trio of new studies from Michigan Medicine, the academic medical center of the University of Michigan, suggests that when alerts are designed with care and embedded directly into digital workflows, they can change what actually happens at the bedside of critically ill cardiac patients. The research, published in Heart & Lung, the Journal of Cardiac Failure – Intersections and JACC: Case Reports, examined electronic health record alerts at two decisive moments in the trajectory of critical cardiac illness: the emergency department, where treatment is first initiated, and the cardiac intensive care unit, where deterioration can unfold rapidly and silently.

The central finding across all three investigations is that well-constructed clinical decision support tools can nudge clinicians toward evidence-based decisions without slowing them down. In the emergency department study, the research team evaluated a tool designed to help clinicians select an appropriate dose of an intravenous loop diuretic for patients arriving with acute decompensated heart failure. This class of medication removes excess fluid that accumulates when the failing heart cannot maintain adequate circulation, allowing the heart to pump more effectively and relieving the profound shortness of breath that drives these patients to seek emergency care in the first place. Clinical guidelines recommend that patients with acute decompensated heart failure receive at least twice the dose of diuretics they take at home when they arrive in the emergency department, a bolus strategy intended to achieve rapid decongestion. In practice, however, the relentless demands of a busy emergency department make it difficult for clinicians to quickly review home medication lists and adjust diuretic therapy accordingly, and recommended dosing is frequently missed.

To address this gap, the University of Michigan team implemented an interruptive alert within the electronic health record that fired when a patient showed signs of fluid overload or kidney dysfunction, prompting the treating clinician to consider guideline-recommended diuretic dosing. The alert was triggered in 223 patient encounters at the U-M Health Emergency Department. In nearly three-quarters of those cases, clinicians followed the recommended diuretic dosing after the alert appeared. Critically, the tool accomplished this without creating the kind of delay that often undermines the adoption of decision support systems: the median time from arrival at the emergency department to diuretic administration was roughly two hours in both groups, meaning the alert influenced the content of the treatment decision rather than its timing.

The researchers were careful to note the limits of what the study demonstrated. The investigation did not assess whether following the digital alerts improved downstream patient outcomes such as the amount of fluid removed or the length of hospital stay. Even so, the results establish something foundational for the field: the tools are easily used in a real clinical setting and measurably affect treatment decisions. As Sarah Adie, Pharm.D., a clinical cardiology pharmacy specialist at U-M Health and an author on all three studies, explained, this is a critical first step toward broad clinical adoption in settings that treat critically ill cardiac patients. Demonstrating feasibility and behavioral impact in a live emergency department environment is a prerequisite for the larger outcome trials that would justify deployment across many institutions.

The second study shifted the setting to the intensive care unit and examined sedation practices in more than 1,600 patients receiving mechanical ventilation in the cardiac and medical intensive care units. Deep sedation is common in intensive care, but leading cardiac and critical care society guidelines favor limiting its use, because prolonged heavy sedation may contribute to worse outcomes, including prolonged ventilator dependence and longer recovery. Changing sedation practice, however, is notoriously difficult, since it requires coordinated action from both physicians and nurses at the bedside, often under time pressure. The research team introduced an electronic health record-based intervention that encouraged the care team to use lighter sedation, surfacing the recommendation at the moment sedative decisions were being made.

The results were striking. After implementation, the average amount of time patients spent deeply sedated during the first 48 hours after intubation dropped in the cardiac intensive care unit from 16.8 hours to 12.4 hours, a reduction of more than four hours per patient. Nurses also reduced the continuous dose of commonly used sedatives, including fentanyl, propofol, midazolam and dexmedetomidine, in 23 percent of cases when the electronic health record generated an alert. These figures suggest that a well-timed digital prompt can shift entrenched practice patterns in an environment where clinicians are managing multiple simultaneous demands. As Anna Barker, M.D., Ph.D., a pulmonologist at University of Michigan Health and senior author of the light sedation paper, emphasized, the alerts are not designed to replace clinical judgment; rather, they are a tool delivered at high-pressure moments to assist clinicians with evidence-based guidance.

The third study tackled one of the most treacherous diagnostic challenges in cardiology: normotensive cardiogenic shock. This condition occurs when the heart cannot pump enough blood to the organs even though the patient’s blood pressure remains normal. Because cardiogenic shock is classically associated with low blood pressure, clinicians may fail to recognize that a normotensive patient is already in shock, and delays in diagnosis can be life threatening. The researchers implemented an electronic health record alert that identified patients displaying additional physiological signs of normotensive cardiogenic shock, such as subtle markers of hypoperfusion that might otherwise be overlooked, and facilitated direct communication with the shock team in the cardiac intensive care unit.

Clinicians engaged with the alert in 14 percent of cases, and those engagements were linked with higher rates of cardiac intensive care unit consultation within 12 hours. While the engagement rate may appear modest, the study illustrates a different design philosophy from the diuretic and sedation alerts: rather than prompting a medication decision, this alert functioned as a recognition and escalation tool, bridging the gap between a bedside clinician who may not suspect shock and a specialized team equipped to deploy advanced therapies. In conditions where early specialist involvement changes the trajectory of illness, even a low-frequency, high-value alert can be clinically meaningful.

Taken together, the three studies map how targeted electronic health record alerts can assist clinicians across the continuum of critical cardiac care, from the first hours in the emergency department through intensive care management. The design of each intervention differed according to the clinical problem. In the emergency department, the tool offered patient-specific recommendations at the moment the diuretic order was placed, embedding the guideline directly into the ordering workflow. In the two intensive care unit studies, alerts prompted clinicians to limit deep sedation or to escalate suspected shock cases to specialized critical care teams. In each case, the intervention respected the existing workflow rather than adding parallel tasks, which the researchers identify as a key principle: these clinical decision support tools are most useful when they help clinicians make the right decision in the moment, rather than adding more noise to already busy workflows, as Scott Ketcham, M.D., a cardiologist at the University of Michigan Health Frankel Cardiovascular Center and an author on all three studies, observed.

The researchers describe the work as proof of concept, and they are explicit that more must be done to ensure electronic alerts are beneficial without disrupting clinical workflow. Alert fatigue remains one of the most persistent problems in health information technology, as clinicians bombarded with low-value notifications learn to dismiss them reflexively, undermining even genuinely useful tools. The Michigan studies suggest a path forward: alerts that are triggered by specific clinical signals, deliver a single actionable recommendation, and arrive at the exact moment a decision is being made. The next step, according to Ketcham, is to evaluate these interventions across multiple health systems to better understand their impact on patient outcomes and determine how they can help improve the care of critically ill cardiac patients nationwide. If those multi-center evaluations confirm what these early studies hint at, the electronic health record, long criticized as a source of friction, may earn a new role as an active partner in the care of the sickest patients with heart disease.

Subject of Research: Electronic health record clinical decision support alerts for critically ill cardiac patients

Article Title: Digital alerts support timely treatment decisions of critically ill cardiac patients

Article References: Digital alerts support timely treatment decisions of critically ill cardiac patients. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: electronic health records, clinical decision support, acute decompensated heart failure, diuretics, cardiac intensive care, sedation, cardiogenic shock, emergency department, ventilators, alert fatigue, Michigan Medicine, patient outcomes