EHR Sampling Interval Bias Detection and Burden of Blood Pressure Excursions: Implications for Clinical Decision Support and Model Validity in Pediatric ECMO

Routine Electronic Health Record (EHR) blood pressure charting under-samples dynamic physiology, risking missed hemodynamic instability. This study quantifies how HER-like down-sampling changes the detection and burden of hypo- and hypertension versus continuous monitoring and articulates the consequences for clinical decision support and machine learning label quality. We retrospectively analyzed 78 ECMO-supported pediatric patients (2019-2023). The continuous mean arterial pressure (MAP) captured every 5 s was resampled at intervals from 5 s to 1 h. We screened for 3 min windows of hypotension or hypertension at 10th/90th age-normed thresholds, comparing the per-patient event frequency and burden with EHR-derived recordings. At 10th/90th thresholds, hypotension events fell from 13,936 (5 s) to 3803 (15 min; -72.7%); the EHR captured 3471. Hypertension events dropped from 1573 to 410 (-73.9%); the EHR registered 1587. The EHR data overstated hypertension burden, indicating preferential documentation during prolonged instability while missing brief excursions. Standard EHR sampling significantly under-reports blood pressure derangements in pediatric ECMO. This underreporting of brief events may limit the accuracy of clinical decision support tools and machine learning algorithms in high-acuity patients. High-frequency data acquisition improves event capture and should be prioritized for clinical decision support and machine learning development.