Desired characteristics of a clinical decision support system for early sepsis recognition: Interview study among hospital-based clinicians

BACKGROUND: Sepsis is a major burden for health care systems in the United States, with over 750,000 cases annually and a total cost of approximately US $20 billion. The hallmark of sepsis treatment is early and appropriate initiation of antibiotic therapy. Although sepsis clinical decision support (CDS) systems can provide clinicians with early predictions of suspected sepsis or imminent clinical decline, such systems have not reliably demonstrated improvements in clinical outcomes or care processes. Growing evidence suggests that the challenges of integrating sepsis CDS systems into clinical workflows, gaining the trust of clinicians, and making sepsis CDS systems clinically relevant at the bedside are all obstacles to successful deployment. However, there are significant knowledge gaps regarding the achievement of these implementation and deployment goals.

OBJECTIVE: We aimed to identify perceptions of predictive information in sepsis CDS systems based on clinicians’ past experiences, explore clinicians’ perceptions of a hypothetical sepsis CDS system, and identify the characteristics of a CDS system that would be helpful in promoting timely recognition and management of suspected sepsis in a multidisciplinary, team-based clinical setting.

METHODS: We conducted semistructured interviews with practicing bedside nurses, advanced practice providers, and physicians at a large academic medical center between September 2020 and March 2021. We used modified human factor methods (contextual interview and cognitive walkthrough performed over video calls because of the COVID-19 pandemic) and conducted a thematic analysis using an abductive approach for coding to identify important patterns and concepts in the interview transcripts.

RESULTS: We interviewed 6 bedside nurses and 9 clinicians responsible for ordering antibiotics (advanced practice providers or physicians) who had a median of 4 (IQR 4-6.5) years of experience working in an inpatient setting. We then synthesized critical content from the thematic analysis of the data into four domains: clinician perceptions of prediction models and alerts; previous experiences of clinician encounters with predictive information and risk scores; desired characteristics of a CDS system build, including predictions, supporting information, and delivery methods for a potential alert; and the clinical relevance and potential utility of a CDS system. These 4 domains were strongly linked to clinicians’ perceptions of the likelihood of adoption and the impact on clinical workflows when diagnosing and managing patients with suspected sepsis. Ultimately, clinicians desired a trusted and actionable CDS system to improve sepsis care.

CONCLUSIONS: Building a trusted and actionable sepsis CDS alert is paramount to achieving acceptability and use among clinicians. These findings can inform the development, implementation, and deployment strategies for CDS systems that support the early detection and treatment of sepsis. This study also highlights several key opportunities when eliciting clinician input before the development and deployment of prediction models.

Jasmine A Silvestri, Tyler E Kmiec, Nicholas S Bishop, Susan H Regli, Gary E Weissman