'Errors' and omissions in paper-based early warning scores: the association with changes in vital signs--a database analysis

Wearable wireless continuous vital signs monitoring on the general ward

PURPOSE OF REVIEW

Wearable wireless sensors for continuous vital signs monitoring (CVSM) offer the potential for early identification of patient deterioration, especially in low-intensity care settings like general wards. This study aims to review advances in wearable CVSM - with a focus on the general ward - highlighting the technological characteristics of CVSM systems, user perspectives and impact on patient outcomes by exploring recent evidence.

RECENT FINDINGS

The accuracy of wearable sensors measuring vital signs exhibits variability, especially notable in ambulatory patients within hospital settings, and standard validation protocols are lacking. Usability of CMVS systems is critical for nurses and patients, highlighting the need for easy-to-use wearable sensors, and expansion of the number of measured vital signs. Current software systems lack integration with hospital IT infrastructures and workflow automation. Imperative enhancements involve nurse-friendly, less intrusive alarm strategies, and advanced decision support systems. Despite observed reductions in ICU admissions and Rapid Response Team calls, the impact on patient outcomes lacks robust statistical significance.

SUMMARY

Widespread implementation of CVSM systems on the general ward and potentially outside the hospital seems inevitable. Despite the theoretical benefits of CVSM systems in improving clinical outcomes, and supporting nursing care by optimizing clinical workflow efficiency, the demonstrated effects in clinical practice are mixed. This review highlights the existing challenges related to data quality, usability, implementation, integration, interpretation, and user perspectives, as well as the need for robust evidence to support their impact on patient outcomes, workflow and cost-effectiveness.

Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done

BACKGROUND

Appropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process.

METHODS

Thirty Applied Cognitive Task Analysis interviews were conducted with clinical experts (>4 years' experience) including Ward Nurses (n = 7), Outreach or Sepsis Nurses (n = 8), Nurse Manager or Consultant (n = 6), Physiotherapists (n = 4), Advanced Practitioners (n = 4), and Doctor (n = 1) from two National Health Service hospitals and analysed using Framework Analysis. Task-related elements of care escalation were identified and represented in a Functional Resonance Analysis Model.

FINDINGS

The NEWS2's clinical escalation response constitutes eight unique tasks and illustrates work-as-prescribed, but our interview data uncovered an additional 24 tasks (n = 32) pertaining to clinical judgement, decisions or processes reflecting work-as-done. Over a quarter of these tasks (9/32, 28 %) were identified by experts as cognitively challenging with a high likelihood of performance variability. Three out of the nine variable tasks were closely coupled and interdependent within the Functional Resonance Analysis Model ('synthesising data points', 'making critical decision to escalate' and 'identifying interim actions') so representing points of potential escalation failure. Data assimilation from different clinical information systems with poor usability was identified as a key cognitive challenge.

CONCLUSION

Our data support the emphasis on the need to retain clinical judgement and suggest that future escalation protocols and audit guidance require in-built flexibility, supporting staff to incorporate their expertise of the patient condition and the clinical environment. Improved information systems to synthesise the required data surrounding an unwell patient to reduce staff cognitive load, facilitate decision-making, support the referral process and identify actions are required. Fundamentally, reducing the cognitive load when assimilating core escalation data allows staff to provide better and more creative care. Study registration (ISRCTN 38850) and ethical approval (REC Ref 20/HRA/3828; CAG-20CAG0106).

PREDICT-GTN 2: Two-factor streamlined models match FIGO performance in gestational trophoblastic neoplasia

OBJECTIVE

The International Federation of Gynecology and Obstetrics (FIGO) scoring system uses the sum of eight risk-factors to predict single-agent chemotherapy resistance in Gestational Trophoblastic Neoplasia (GTN). To improve ease of use, this study aimed to generate: (i) streamlined models that match FIGO performance and; (ii) visual-decision aids (nomograms) for guiding management.

METHODS

Using training (n = 4191) and validation datasets (n = 144) of GTN patients from two UK specialist centres, logistic regression analysis generated two-factor models for cross-validation and exploration. Performance was assessed using true and false positive rate, positive and negative predictive values, Bland-Altman calibration plots, receiver operating characteristic (ROC) curves, decision-curve analysis (DCA) and contingency tables. Nomograms were developed from estimated model parameters and performance cross-checked upon the training and validation dataset.

RESULTS

Three streamlined, two-factor models were selected for analysis: (i) M1, pre-treatment hCG + history of failed chemotherapy; (ii) M2, pre-treatment hCG + site of metastases and; (iii) M3, pre-treatment hCG + number of metastases. Using both training and validation datasets, these models showed no evidence of significant discordance from FIGO (McNemar's test p > 0.78) or across a range of performance parameters. This behaviour was maintained when applying algorithms simulating the logic of the nomograms.

CONCLUSIONS

Our streamlined models could be used to assess GTN patients and replace FIGO, statistically matching performance. Given the importance of imaging parameters in guiding treatment, M2 and M3 are favoured for ongoing validation. In resource-poor countries, where access to specialist centres is problematic, M1 could be pragmatically implemented. Further prospective validation on a larger cohort is recommended.

Evaluating the performance of the National Early Warning Score in different diagnostic groups

BACKGROUND

The National Early Warning Score (NEWS) is used in hospitals across the UK to detect deterioration of patients within care pathways. It is used for most patients, but there are relatively few studies validating its performance in groups of patients with specific conditions.

METHODS

The performance of NEWS was evaluated against 36 other Early Warning Scores, in 123 patient groups, through use of the area under the receiver operating characteristic (AUROC) curve technique, to compare the abilities of each Early Warning Score to discriminate an outcome within 24hrs of vital sign recording. Outcomes evaluated were death, ICU admission, or a combined outcome of either death or ICU admission within 24 hours of an observation set.

RESULTS

The National Early Warning Score 2 performs either best or joint best within 120 of the 123 patient groups evaluated and is only outperformed in prediction of unanticipated ICU admission. When outperformed by other Early Warning Scores in the remaining 3 patient groups, the performance difference was marginal.

CONCLUSIONS

Consistently high performance indicates that NEWS is a suitable early warning score to use for all diagnostic groups considered by this analysis, and patients are not disadvantaged through use of NEWS in comparison to any of the other evaluated Early Warning Scores.

The quality of vital signs measurements and value preferences in electronic medical records varies by hospital, specialty, and patient demographics

We aimed to assess the frequency of value preferences in recording of vital signs in electronic healthcare records (EHRs) and associated patient and hospital factors. We used EHR data from Oxford University Hospitals, UK, between 01-January-2016 and 30-June-2019 and a maximum likelihood estimator to determine the prevalence of value preferences in measurements of systolic and diastolic blood pressure (SBP/DBP), heart rate (HR) (readings ending in zero), respiratory rate (multiples of 2 or 4), and temperature (readings of 36.0 °C). We used multivariable logistic regression to investigate associations between value preferences and patient age, sex, ethnicity, deprivation, comorbidities, calendar time, hour of day, days into admission, hospital, day of week and speciality. In 4,375,654 records from 135,173 patients, there was an excess of temperature readings of 36.0 °C above that expected from the underlying distribution that affected 11.3% (95% CI 10.6-12.1%) of measurements, i.e. these observations were likely inappropriately recorded as 36.0 °C instead of the true value. SBP, DBP and HR were rounded to the nearest 10 in 2.2% (1.4-2.8%) and 2.0% (1.3-5.1%) and 2.4% (1.7-3.1%) of measurements. RR was also more commonly recorded as multiples of 2. BP digit preference and an excess of temperature recordings of 36.0 °C were more common in older and male patients, as length of stay increased, following a previous normal set of vital signs and typically more common in medical vs. surgical specialities. Differences were seen between hospitals, however, digit preference reduced over calendar time. Vital signs may not always be accurately documented, and this may vary by patient groups and hospital settings. Allowances and adjustments may be needed in delivering care to patients and in observational analyses and predictive tools using these factors as outcomes or exposures.

The impact of continuous wireless monitoring on adverse device effects in medical and surgical wards: a review of current evidence

Novel technologies allow continuous wireless monitoring systems (CWMS) to measure vital signs and these systems might be favorable compared to intermittent monitoring regarding improving outcomes. However, device safety needs to be validated because uncertain evidence challenges the clinical implementation of CWMS. This review investigates the frequency of device-related adverse events in patients monitored with CWMS in general hospital wards. Systematic literature searches were conducted in PubMed and Embase. We included trials of adult patients in general hospital wards monitored with CWMS. Our primary outcome was the frequency of unanticipated serious adverse device effects (USADEs). Secondary outcomes were adverse device effects (ADEs) and serious adverse device effects (SADE). Data were extracted from eligible studies and descriptive statistics were applied to analyze the data. Seven studies were eligible for inclusion with a total of 1485 patients monitored by CWMS. Of these patients, 54 patients experienced ADEs (3.6%, 95% CI 2.8-4.7%) and no USADEs or SADEs were reported (0%, 95% CI 0-0.31%). The studies of the SensiumVitals® patch, the iThermonitor, and the ViSi Mobile® device reported 28 (9%), 25 (5%), and 1 (3%) ADEs, respectively. No ADEs were reported using the HealthPatch, WARD 24/7 system, or Coviden Alarm Management. Current evidence suggests that CWMS are safe to use but systematic reporting of all adverse device effects is warranted.

Assessment of Remote Vital Sign Monitoring and Alarms in a Real-World Healthcare at Home Dataset

The importance of vital sign monitoring to detect deterioration increases during healthcare at home. Continuous monitoring with wearables increases assessment frequency but may create information overload for clinicians. The goal of this work was to demonstrate the impact of vital sign observation frequency and alarm settings on alarms in a real-world dataset. Vital signs were collected from 76 patients admitted to healthcare at home programs using the Current Health (CH) platform; its wearable continuously measured respiratory rate (RR), pulse rate (PR), and oxygen saturation (SpO₂). Total alarms, alarm rate, patient rate, and detection time were calculated for three alarm rulesets to detect changes in SpO₂, PR, and RR under four vital sign observation frequencies and four window sizes for the alarm algorithms' median filter. Total alarms ranged from 65 to 3113. The alarm rate and early detection increased with the observation frequency for all alarm rulesets. Median filter windows reduced alarms triggered by normal fluctuations in vital signs without compromising the granularity of time between assessments. Frequent assessments enabled with continuous monitoring support early intervention but need to pair with settings that balance sensitivity, specificity, clinical risk, and provider capacity to respond when a patient is home to minimize clinician burden.

Artificial Intelligence for the Prediction of In-Hospital Clinical Deterioration: A Systematic Review

To analyze the available literature on the performance of artificial intelligence-generated clinical models for the prediction of serious life-threatening events in non-ICU adult patients and evaluate their potential clinical usage.

Quick Sequential Organ Failure Assessment Score and the Modified Early Warning Score for Predicting Clinical Deterioration in General Ward Patients Regardless of Suspected Infection

BACKGROUND

The quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection.

METHODS

The predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea.

RESULTS

Of 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777; 95% confidence interval [CI], 0.770-0.781) was higher than that for qSOFA (AUC, 0.684; 95% CI, 0.676-0.686; P < 0.001). In addition, MEWS was better for prediction of IHCA (AUC, 0.792; 95% CI, 0.781-0.795 vs. AUC, 0.640; 95% CI, 0.625-0.645; P < 0.001) and unexpected ICU transfer (AUC, 0.767; 95% CI, 0.760-0.773 vs. AUC, 0.716; 95% CI, 0.707-0.718; P < 0.001) than qSOFA. Using the MEWS at a cutoff of ≥ 5 would correctly reclassify 3.7% of patients from qSOFA score ≥ 2. Most patients met MEWS ≥ 5 criteria 13 hours before the composite outcome compared with 11 hours for qSOFA score ≥ 2.

CONCLUSION

MEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.

Key Factors and Modeling of Interprofessional Management of Clinical Deterioration in Hospital Units: A Scoping Review

BACKGROUND AND PURPOSE

Situations of clinical deterioration compromise patient safety, and their management can be a challenge for professionals. In this review, we synthesize the problematic factors for clinicians during the collective management of patient clinical deterioration in hospital units, and we provide a modeling of the action processes involved in patient safety.

METHODS

Electronic databases MEDLINE, CINAHL, EMBASE, and ERIC were systematically searched, and studies were critically appraised with MMAT. Seventeen articles were identified from 1222 for full-text screening. Data were deductively coded according to the Systems Analysis of Clinical Incidents model developed by Taylor-Adams and Vincent (2004), and results were consolidated using a narrative synthesis.

RESULTS

Faced with these uncertain and rapidly changing situations, great adaptability is essential, and the quality of social interactions is a central issue for the effectiveness of teamwork. Interprofessional management of patients in clinical deterioration is complex due to multiple factors related to patients, professionals, tasks, environment, and teamwork. Caregivers' sense of worry about the patient's evolution is a key factor in early detection and therefore in the implementation of interventions.

IMPLICATIONS FOR PRACTICE

The model of four action processes proposed (Evaluation-Solicitation-Articulation-Composition) constitutes the points of attention for patient safety. It aims to guide the activities of the interprofessional collective involved.

The impact of wearable continuous vital sign monitoring on deterioration detection and clinical outcomes in hospitalised patients: a systematic review and meta-analysis

BACKGROUND

Timely recognition of the deteriorating inpatient remains challenging. Wearable monitoring systems (WMS) may augment current monitoring practices. However, there are many barriers to implementation in the hospital environment, and evidence describing the clinical impact of WMS on deterioration detection and patient outcome remains unclear.

OBJECTIVE

To assess the impact of vital-sign monitoring on detection of deterioration and related clinical outcomes in hospitalised patients using WMS, in comparison with standard care.

METHODS

A systematic search was conducted in August 2020 using MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL, Health Technology Assessment databases and grey literature. Studies comparing the use of WMS against standard care for deterioration detection and related clinical outcomes in hospitalised patients were included. Deterioration related outcomes (primary) included unplanned intensive care admissions, rapid response team or cardiac arrest activation, total and major complications rate. Other clinical outcomes (secondary) included in-hospital mortality and hospital length of stay. Exploratory outcomes included alerting system parameters and clinical trial registry information.

RESULTS

Of 8706 citations, 10 studies with different designs met the inclusion criteria, of which 7 were included in the meta-analyses. Overall study quality was moderate. The meta-analysis indicated that the WMS, when compared with standard care, was not associated with significant reductions in intensive care transfers (risk ratio, RR 0.87; 95% confidence interval, CI 0.66-1.15), rapid response or cardiac arrest team activation (RR 0.84; 95% CI 0.69-1.01), total (RR 0.77; 95% CI 0.44-1.32) and major (RR 0.55; 95% CI 0.24-1.30) complications prevalence. There was also no statistically significant association with reduced mortality (RR 0.48; 95% CI 0.18-1.29) and hospital length of stay (mean difference, MD - 0.09; 95% CI - 0.43 to 0.44).

CONCLUSION

This systematic review indicates that there is no current evidence that implementation of WMS impacts early deterioration detection and associated clinical outcomes, as differing design/quality of available studies and diversity of outcome measures make it difficult to reach a definite conclusion. Our narrative findings suggested that alarms should be adjusted to minimise false alarms and promote rapid clinical action in response to deterioration. PROSPERO Registration number: CRD42020188633 .

Physiological deterioration in the Emergency Department: The SNAP40-ED study

Continuous novel ambulatory monitoring may detect deterioration in Emergency Department (ED) patients more rapidly, prompting treatment and preventing adverse events. Single-centre, open-label, prospective, observational cohort study recruiting high/medium acuity (Manchester triage category 2 and 3) participants, aged over 16 years, presenting to ED. Participants were fitted with a novel wearable monitoring device alongside standard clinical care (wired monitoring and/or manual clinical staff vital sign recording) and observed for up to 4 hours in the ED. Primary outcome was time to detection of deterioration. Two-hundred and fifty (250) patients were enrolled. In 82 patients (32.8%) with standard monitoring (wired monitoring and/or manual clinical staff vital sign recording), deterioration in at least one vital sign was noted during their four-hour ED stay. Overall, the novel device detected deterioration a median of 34 minutes earlier than wired monitoring (Q1, Q3 67,194; n=73, mean difference 39.48, p<0.0001). The novel device detected deterioration a median of 24 minutes (Q1, Q3 2,43; n=42) earlier than wired monitoring and 65 minutes (Q1, Q3 28,114; n=31) earlier than manual vital signs. Deterioration in physiology was common in ED patients. ED staff spent a significant amount of time performing observations and responding to alarms, with many not escalated. The novel device detected deterioration significantly earlier than standard care.

A Chest Patch for Continuous Vital Sign Monitoring: Clinical Validation Study During Movement and Controlled Hypoxia

BACKGROUND

The standard of care in general wards includes periodic manual measurements, with the data entered into track-and-trigger charts, either on paper or electronically. Wearable devices may support health care staff, improve patient safety, and promote early deterioration detection in the interval between periodic measurements. However, regulatory standards for ambulatory cardiac monitors estimating heart rate (HR) and respiratory rate (RR) do not specify performance criteria during patient movement or clinical conditions in which the patient's oxygen saturation varies. Therefore, further validation is required before clinical implementation and deployment of any wearable system that provides continuous vital sign measurements.

OBJECTIVE

The objective of this study is to determine the agreement between a chest-worn patch (VitalPatch) and a gold standard reference device for HR and RR measurements during movement and gradual desaturation (modeling a hypoxic episode) in a controlled environment.

METHODS

After the VitalPatch and gold standard devices (Philips MX450) were applied, participants performed different movements in seven consecutive stages: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia was then induced, and the participants' oxygen saturation gradually reduced to 80% in a controlled environment. The primary outcome measure was accuracy, defined as the mean absolute error (MAE) of the VitalPatch estimates when compared with HR and RR gold standards (3-lead electrocardiography and capnography, respectively). We defined these as clinically acceptable if the rates were within 5 beats per minute for HR and 3 respirations per minute (rpm) for RR.

RESULTS

Complete data sets were acquired for 29 participants. In the movement phase, the HR estimates were within prespecified limits for all movements. For RR, estimates were also within the acceptable range, with the exception of the sit-to-stand and turning page movements, showing an MAE of 3.05 (95% CI 2.48-3.58) rpm and 3.45 (95% CI 2.71-4.11) rpm, respectively. For the hypoxia phase, both HR and RR estimates were within limits, with an overall MAE of 0.72 (95% CI 0.66-0.78) beats per minute and 1.89 (95% CI 1.75-2.03) rpm, respectively. There were no significant differences in the accuracy of HR and RR estimations between normoxia (≥90%), mild (89.9%-85%), and severe hypoxia (<85%).

CONCLUSIONS

The VitalPatch was highly accurate throughout both the movement and hypoxia phases of the study, except for RR estimation during the two types of movements. This study demonstrated that VitalPatch can be safely tested in clinical environments to support earlier detection of cardiorespiratory deterioration.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN61535692; https://www.isrctn.com/ISRCTN61535692.

The global elements of vital signs' assessment: a guide for clinical practice

The assessment of vital signs is critical for safe, high-quality care. Vital signs' data provide valuable insight into the patient's condition, including how they are responding to medical treatment and, importantly, whether the patient is deteriorating. Although abnormal vital signs have been associated with poor clinical outcomes, research has consistently found that vital signs' assessment is often neglected in clinical practice. Factors contributing to this include nurses' knowledge, clinical judgement, culture, tradition and workloads. To emphasise the importance of vital signs' assessment, global elements of vital signs' assessment are proposed. The elements reflect key principles underpinning vital signs' assessment and are informed by evidence-based literature.

Adherence to the bedside paediatric early warning system (BedsidePEWS) in a pediatric tertiary care hospital

Background

The aim of this study is to describe the adherence to the Bedside Pediatric Early Warning System (BedsidePEWS) escalation protocol in children admitted to hospital wards in a large tertiary care children’s hospital in Italy.

Methods

This is a retrospective observational chart review. Data on the frequency and accuracy of BedsidePEWS score calculations, escalation of patient observations, monitoring and medical reviews were recorded.

Two research nurses performed weekly visits to the hospital wards to collect data on BedsidePEWS scores, medical reviews, type of monitoring and vital signs recorded. Data were described through means or medians according to the distribution. Inferences were calculated either with Chi-square, Student’s t test or Wilcoxon-Mann–Whitney test, as appropriate (P < 0.05 considered as significant).

Results

A total of 522 Vital Signs (VS) and score calculations [BedsidePEWS documentation events, (DE)] on 177 patient clinical records were observed from 13 hospital inpatient wards. Frequency of BedsidePEWS DE occurred < 3 times per day in 33 % of the observations. Adherence to the BedsidePEWS documentation frequency according to the hospital protocol was observed in 54 % of all patients; in children with chronic health conditions (CHC) it was significantly lower than children admitted for acute medical conditions (47 % vs. 69 %, P = 0.006). The BedsidePEWS score was correctly calculated and documented in 84 % of the BedsidePEWS DE. Patients in a 0–2 BedsidePEWS score range were all reviewed at least once a day by a physician. Only 50 % of the patients in the 5–6 score range were reviewed within 4 h and 42 % of the patients with a score ≥ 7 within 2 h.

Conclusions

Escalation of patient observations, monitoring and medical reviews matching the BedsidePEWS is still suboptimal. Children with CHC are at higher risk of lower compliance. Impact of adherence to predefined response algorithms on patient outcomes should be further explored.

A systematic review of rapid response applications based on early warning score for early detection of inpatient deterioration

AIM

The aim of this study was to investigate the effectiveness of current rapid response applications available in acute care settings for escalation of patient deterioration. Current challenges and barriers, as well as key recommendations, were also discussed.

METHODS

We adopted PRISMA review methodology and screened a total of 559 articles. After considering the eligibility and selection criteria, we selected 13 articles published between 2015 and 2019. The selection criteria were based on the inclusion of studies that report on the advancement made to the current practice for providing rapid response to the patient deterioration in acute care settings.

RESULTS

We found that current rapid response applications are complicated and time-consuming for detecting inpatient deterioration. Existing applications are either siloed or challenging to use, where clinicians are required to move between two or three different applications to complete an end-to-end patient escalation workflow - from vital signs collection to escalation of deteriorating patients. We found significant differences in escalation and responses when using an electronic tool compared to the manual approach. Moreover, encouraging results were reported in extensive documentation of vital signs and timely alerts for patient deterioration.

CONCLUSION

The electronic vital signs monitoring applications are proved to be efficient and clinically suitable if they are user-friendly and interoperable. As an outcome, several key recommendations and features were identified that would be crucial to the successful implementation of any rapid response system in all clinical settings.

Protocol for a systematic review assessing ambulatory vital sign monitoring impact on deterioration detection and related clinical outcomes in hospitalised patients

INTRODUCTION

Ambulatory monitoring systems (AMS) can facilitate early detection of clinical deterioration, and have the potential to improve hospitalised patient outcomes. The objective of this systematic review is to assess the impact of vital signs monitoring on detection of deterioration and related outcomes in hospitalised patients using AMS, in comparison with standard care.

METHODS AND ANALYSIS

A systematic search was conducted on 27 August 2020 in MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL and Health Technology Assessment databases, as well as grey literature. Search results will be reviewed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist for systematic reviews. Studies comparing the use of ambulatory monitoring devices against standard care for deterioration detection and related clinical outcomes in hospitalised patients will be included and further clinical and other outcomes will also be explored. Deterioration-related outcomes may include (but not limited to) unplanned intensive care admissions, rapid response team activation and unscheduled emergency interventions, as defined by the included studies. Two reviewers will independently extract study data and assess the quality and risk of bias of included studies. Where possible, a meta-analysis will be conducted and quantitative results presented. Alternatively, a narrative synthesis will be reported.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as no primary data will be collected. This study is part of our virtual High Dependency Unit project and will be disseminated through peer-reviewed publications, public and scientific conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020188633.

The EMS Modified Early Warning Score (EMEWS): A Simple Count of Vital Signs as a Predictor of Out-of-Hospital Cardiac Arrests

Objective: For patients at risk for out-of-hospital cardiac arrest (OHCA) after Emergency Medical Services (EMS) arrival, outcomes may be mitigated by identifying impending arrests and intervening before they occur. Tools such as the Modified Early Warning Score (MEWS) have been developed to determine the risk of arrest, but involve relatively complicated algorithms that can be impractical to compute in the prehospital environment. A simple count of abnormal vital signs, the "EMS Modified Early Warning Score" (EMEWS), may represent a more practical alternative. We sought to compare to the ability of MEWS and EMEWS to identify patients at risk for EMS-witnessed OHCA.Methods: We conducted a retrospect analysis of the 2018 ESO Data Collaborative database of EMS encounters. Patients without cardiac arrest before EMS arrival were categorized into those who did or did not have an EMS-witnessed arrest. MEWS was evaluated without its temperature component (MEWS-T). The performance of MEWS-T and EMEWS in predicting EMS witnessed arrest was evaluated by comparing receiver-operating characteristic curves.Results: Of 369,064 included encounters, 4,651 were EMS witnessed arrests. MEWS-T demonstrated an area under the curve (AUC) of 0.79 (95% CI: 0.79 - 0.80), with 86.8% sensitivity and 51.0% specificity for MEWS-T ≥ 3. EMEWS demonstrated an AUC of 0.74 (95% CI: 0.73 - 0.75), with 81.3% sensitivity and 53.9% specificity for EMEWS ≥ 2.Conclusions: EMEWS showed a similar ability to predict EMS-witnessed cardiac arrest compared to MEWS-T, despite being significantly simpler to compute. Further study is needed to evaluate whether the implementation of EMEWS can aid EMS clinicians in anticipating and preventing OHCA.

Human factors in escalating acute ward care: a qualitative evidence synthesis

Background

Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.

Methods

We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality.

Results

Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient’s condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff’s ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies).

Conclusions

Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills.

PROSPERO registration number

CRD42018104745.

[Postoperative remote monitoring]

During the course of surgical interventions, complications mostly occur in the postoperative period. Slight clinical indications can be observed, which precede a significant deterioration of the patient's condition. On the general ward vital parameters, such as heart and breathing frequencies are measured every 4-8 h. Even if the monitoring of critically ill patients is increased to every 2 h and the measurement of vital functions takes 10 min, the patient is only monitored for 120 min in a 24 h period and remains postoperatively on the general ward without monitoring for 22 out of 24 h. New wireless monitoring systems are available to continuously register some vital functions with the aid of wearable sensors. These systems can alert and alarm ward personnel if the patient's condition deteriorates. Although the optimal monitoring system does not yet exist and implementation of these new wireless monitoring systems might involve some risks, these new methods offer a great opportunity to optimize surveillance of postoperative patients on the general ward.

Update on early warning scores

Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.

Wearability Testing of Ambulatory Vital Sign Monitoring Devices: Prospective Observational Cohort Study

Background

Timely recognition of patient deterioration remains challenging. Ambulatory monitoring systems (AMSs) may provide support to current monitoring practices; however, they need to be thoroughly tested before implementation in the clinical environment for early detection of deterioration.

Objective

The objective of this study was to assess the wearability of a selection of commercially available AMSs to inform a future prospective study of ambulatory vital sign monitors in an acute hospital ward.

Methods

Five pulse oximeters (4 with finger probes and 1 wrist-worn only, collecting pulse rates and oxygen saturation) and 2 chest patches (collecting heart rates and respiratory rates) were selected to be part of this study: The 2 chest-worn patches were VitalPatch (VitalConnect) and Peerbridge Cor (Peerbridge); the 4 wrist-worn devices with finger probe were Nonin WristOx2 3150 (Nonin), Checkme O2+ (Viatom Technology), PC-68B, and AP-20 (both from Creative Medical); and the 1 solely wrist-worn device was Wavelet (Wavelet Health). Adult participants wore each device for up to 72 hours while performing usual “activities of daily living” and were asked to score the perceived exertion and perception of pain or discomfort by using the Borg CR-10 scale; thoughts and feelings caused by the AMS using the Comfort Rating Scale (CRS); and to provide general free text feedback. Median and IQRs were reported and nonparametric tests were used to assess differences between the devices’ CRS scores.

Results

Quantitative scores and feedback were collected in 70 completed questionnaires from 20 healthy volunteers, with each device tested approximately 10 times. The Wavelet seemed to be the most wearable device (P<.001) with an overall median (IQR) CRS score of 1.00 (0.88). There were no statistically significant differences in wearability between the chest patches in the CRS total score; however, the VitalPatch was superior in the Attachment section (P=.04) with a median (IQR) score of 3.00 (1.00). General pain and discomfort scores and total percentage of time worn are also reflective of this.

Conclusions

Our results suggest that adult participants prefer to wear wrist-worn pulse oximeters without a probe compressing the fingertip and they prefer to wear a smaller chest patch. A compromise between wearability, reliability, and accuracy should be made for successful and practical integration of AMSs within the hospital environment.

The impact of a modified New Zealand Early Warning Score (M-NZEWS) and NZEWS on ward patients triggering a medical emergency team activation: A mixed methods sequential design

INTRODUCTION

Limited research exists on the effectiveness of the New Zealand Early Warning Score (NZEWS).

AIM

To determine the impact of a modified NZEWS (M-NZEWS) and NZEWS on ward patients' medical emergency team activation triggers.

RESEARCH DESIGN

Mixed methods sequential design.

METHODS

Three phases included: 1) review of M-NZEWS electronic data to determine the effect of a M-NZEWS and NZEWS on ward patients; 2) an in-depth review of 20 Māori patients allocated to lower escalation zones if the NZEWS were adopted and 3) the number of electronic medical emergency team activation triggers compared to the number of actual medical emergency team activations.

RESULTS

1255 patients and 3505 vital sign data sets were analysed. Adopting the NZEWS would result in 396 (26.8%) fewer patients triggering a medical emergency team activation. The biggest impact would be on Māori, with 38.6% of Māori allocated to a lower escalation zone. Only 51.2% of patients with a medical emergency team activation had vital signs triggering the response electronically documented.

CONCLUSION

Changing from the M-NZEWS to NZEWS will reduce the number of medical emergency team activation triggers, with the biggest impact on Māori. Electronic vital sign data does not accurately reflect the number of ward medical emergency team triggers or activations.

A qualitative exploration of escalation of care in the acute ward setting

BACKGROUND

"Failure to Rescue" includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes.

AIMS AND OBJECTIVE

The aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable.

DESIGN

A total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust.

METHODS

Observations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care.

RESULTS

Clinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re-escalate low-level scores. Patient and non-patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover.

CONCLUSION

This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re-escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.

RELEVANCE TO CLINICAL PRACTICE

This service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways.

Leveraging Clinical Expertise as a Feature - not an Outcome - of Predictive Models: Evaluation of an Early Warning System Use Case

Identifying patients at risk of deterioration in the hospital and intervening more quickly to prevent adverse events is a top patient safety priority. Early warning scores (EWS) identify at risk patients, but there is much opportunity for improvement particularly related to increasing lead time - the time from an alert trigger to adverse event (e.g., cardiac arrest, death). Our team develops healthcare process models of clinical concern (HPM-CC) and in this work has identified documentation signals that are proxies of nurses concern and can be used to predict patient risk earlier than current EWS systems that rely only on physiological data. We compared the performance of a validated EWS - the MEWS - to our novel model (MEWS-CC) comprised of MEWS criteria plus 3 proxy variables of nursing concern. MEWS-CC performed similarly to MEWS, with the added benefit of increased the time from EWS trigger to event by 5-26 hours.

Missed opportunities: incomplete and inaccurate recording of paediatric early warning scores

BACKGROUND

Paediatric early warning scores (PEWS) are widely used as an adjunct to support staff in recognising deterioration in hospitalised children. Relatively little is known about how staff use these systems.

OBJECTIVE

To examine the completeness and accuracy of PEWS recording in hospitalised children in a tertiary specialist children's hospital.

DESIGN

This is a secondary analysis of retrospective, case-controlled study data. Case patients suffering from a critical deterioration event were matched with controls present on the same ward at the same time and matched for age. Data were extracted from the PEWS chart for the 48 hours before the critical deterioration event for case patients and the corresponding 48 hours period for the control. Observation sets were assessed for completeness and accuracy of PEWS scoring.

RESULTS

In total 297 case events in 224 patients were available for analysis. Overall 13 816 observations sets were performed, 8543 on cases and 5273 on controls. Only 4958 (35.9%) of observation sets contained a complete set of vital sign parameters and a concurrent PEWS. Errors were more prevalent in the observation sets of case patients versus controls (19.5% vs 14.1%). More errors resulted in the PEWS value being underscored rather than overscored for all observation sets (p<0.0001). 9.1% of inaccuracies for case patients were clinically significant, as the accurately calculated PEWS would have prompted a different escalation from the documented value.

CONCLUSION

Failure to record complete and accurate PEWS may jeopardise recognition of children who are deteriorating. Technology may offer an effective solution.

Physiological abnormalities in patients admitted with acute exacerbation of COPD: an observational study with continuous monitoring

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) may rapidly require intensive care treatment. Evaluation of vital signs is necessary to detect physiological abnormalities (micro events), but patients may deteriorate between measurements. We aimed to assess if continuous monitoring of vital signs in patients admitted with AECOPD detects micro events more often than routine ward rounds. In this observational pilot study (NCT03467815), 30 adult patients admitted with AECOPD were included. Patients were continuously monitored with peripheral oxygen saturation (SpO₂), heart rate, and respiratory rate during the first 4 days after admission. Hypoxaemic events were defined as decreased SpO₂ for at least 60 s. Non-invasive blood pressure was also measured every 15-60 min. Clinical ward staff measured vital signs as part of Early Warning Score (EWS). Data were analysed using Fisher's exact test or Wilcoxon rank sum test. Continuous monitoring detected episodes of SpO₂ < 92% in 97% versus 43% detected by conventional EWS (p < 0.0001). Events of SpO₂ < 88% was detected in 90% with continuous monitoring compared with 13% with EWS (p < 0.0001). Sixty-three percent of patients had episodes of SpO₂ < 80% recorded by continuous monitoring and 17% had events lasting longer than 10 min. No events of SpO₂ < 80% was detected by EWS. Micro events of tachycardia, tachypnoea, and bradypnoea were also more frequently detected by continuous monitoring (p < 0.02 for all). Moderate and severe episodes of desaturation and other cardiopulmonary micro events during hospitalization for AECOPD are common and most often not detected by EWS.

Smoothing Effect in Vital Sign Recordings: Fact or Fiction? A Retrospective Cohort Analysis of Manual and Continuous Vital Sign Measurements to Assess Data Smoothing in Postoperative Care

BACKGROUND:

Data smoothing of vital signs has been reported in the anesthesia literature, suggesting that clinical staff are biased toward measurements of normal physiology. However, these findings may be partially explained by clinicians interpolating spurious values from noisy signals and by the undersampling of physiological changes by infrequent manual observations. We explored the phenomenon of data smoothing using a method robust to these effects in a large postoperative dataset including respiratory rate, heart rate, and oxygen saturation (Spo₂). We also assessed whether the presence of the vital sign taker creates an arousal effect.

METHODS:

Study data came from a UK upper gastrointestinal postoperative ward (May 2009 to December 2013). We compared manually recorded vital sign data with contemporaneous continuous data recorded from monitoring equipment. We proposed that data smoothing increases differences between vital sign sources as vital sign abnormality increases. The primary assessment method was a mixed-effects model relating continuous-manual differences to vital sign values, adjusting for repeated measurements. We tested the regression slope significance and predicted the continuous-manual difference at clinically important vital sign values. We calculated limits of agreement (LoA) between vital sign sources using the Bland–Altman method, adjusting for repeated measures. Similarly, we assessed whether the vital sign taker affected vital signs, comparing continuous data before and during manual recording.

RESULTS:

From 407 study patients, 271 had contemporaneous continuous and manual recordings, allowing 3740 respiratory rate, 3844 heart rate, and 3896 Spo₂ paired measurements for analysis. For the model relating continuous-manual differences to continuous-manual average vital sign values, the regression slope (95% confidence interval) was 0.04 (−0.01 to 0.10; P = .11) for respiratory rate, 0.04 (−0.01 to 0.09; P = .11) for heart rate, and 0.10 (0.07–0.14; P < .001) for Spo₂. For Spo₂ measurements of 91%, the model predicted a continuous-manual difference (95% confidence interval) of −0.88% (−1.17% to −0.60%). The bias (LoA) between measurement sources was −0.74 (−7.80 to 6.32) breaths/min for respiratory rate, −1.13 (−17.4 to 15.1) beats/min for heart rate, and −0.25% (−3.35% to 2.84%) for Spo₂. The bias (LoA) between continuous data before and during manual observation was −0.57 (−5.63 to 4.48) breaths/min for respiratory rate, −0.71 (−10.2 to 8.73) beats/min for heart rate, and −0.07% (−2.67% to 2.54%) for Spo₂.

CONCLUSIONS:

We found no evidence of data smoothing for heart rate and respiratory rate measurements. Although an effect exists for Spo₂ measurements, it was not clinically significant. The wide LoAs between continuous and manually recorded vital signs would commonly result in different early warning scores, impacting clinical care. There was no evidence of an arousal effect caused by the vital sign taker.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

OBJECTIVE

To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.

DESIGN

Systematic review.

DATA SOURCES

British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.

ELIGIBILITY CRITERIA

We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered.

DATA EXTRACTION AND SYNTHESIS

Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.

RESULTS

36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.

CONCLUSION

There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

[Benefits of medical emergency teams : Mortality on normal wards and readmission to intensive care wards]

Medical emergency teams (MET) were implemented in many hospitals worldwide in order to identify patients at risk on normal wards and to initiate diagnostics and therapy without delay. Ideally, the implementation leads to prevention of cardiac arrests and unexpected deaths on normal wards, reduced rates of admissions to intensive care units and hospital mortality. Various track and trigger systems are available to identify such patients and for them to be assessed and treated within 30-45 min by the MET. The ideal personnel composition of METs has not yet been established. Whether the implementation of an MET generally leads to an improvement of treatment on normal wards or to a reduction in mortality in hospitals has not been finally clarified. Mortality and morbitidy (M&M) conferences can help to analyze if an individual clinic is likely to profit from the introduction of a MET.

The Impact of an Electronic Patient Bedside Observation and Handover System on Clinical Practice: Mixed-Methods Evaluation

Background

Patient safety literature has long reported the need for early recognition of deteriorating patients. Early warning scores (EWSs) are commonly implemented as “track and trigger,” or rapid response systems for monitoring and early recognition of acute patient deterioration. This study presents a human factors evaluation of a hospital-wide transformation in practice, engendered by the deployment of an innovative electronic observations (eObs) and handover system. This technology enables real-time information processing at the patient’s bedside, improves visibility of patient data, and streamlines communication within clinical teams.

Objective

The aim of this study was to identify improvement and deterioration in workplace efficiency and quality of care resulting from the large-scale imposition of new technology.

Methods

A total of 85 hours of direct structured observations of clinical staff were carried out before and after deployment. We conducted 40 interviews with a range of clinicians. A longitudinal analysis of critical care audit and electronically recorded patient safety incident reports was conducted. The study was undertaken in a large secondary-care facility in the United Kingdom.

Results

Roll-out of eObs was associated with approximately 10% reduction in total unplanned admissions to critical care units from eObs-equipped wards. Over time, staff appropriated the technology as a tool for communication, workload management, and improving awareness of team capacity. A negative factor was perceived as lack of engagement with the system by senior clinicians. Doctors spent less time in the office (68.7% to 25.6%). More time was spent at the nurses’ station (6.6% to 41.7%). Patient contact time was more than doubled (2.9% to 7.3%).

Conclusions

Since deployment, clinicians have more time for patient care because of reduced time spent inputting and accessing data. The formation of a specialist clinical team to lead the roll-out was universally lauded as the reason for success. Staff valued the technology as a tool for managing workload and identified improved situational awareness as a key benefit. For future technology deployments, the staff requested more training preroll-out, in addition to engagement and support from senior clinicians.

Use of National Early Warning Score for observation for increased risk for clinical deterioration during post-ICU care at a surgical ward

Purpose

Patients transferred from an intensive care unit (ICU) to a general ward are at risk for clinical deterioration. The aim of the study was to determine if an increase in National Early Warning Score (NEWS) value predicted worse outcomes in surgical ward patients previously treated in the ICU.

Patients and methods

A retrospective observational study was conducted in a cohort of gastrointestinal surgery patients after transfer from an ICU/high dependency unit (HDU). NEWS values were collected throughout the ward admission. Clinical deterioration was defined by ICU readmission or death. The ability of NEWS to predict clinical deterioration was determined using a linear mixed effect model.

Results

We included 124 patients, age 65.9±14.5, 60% males with an ICU Simplified Acute Physiology Score II 33.8±12.7. No patients died unexpectedly at the ward and 20 were readmitted to an ICU/HDU. The NEWS values increased by a mean of 0.15 points per hour (intercept 3.7, P<0.001) before ICU/HDU readmission according to the linear mixed effect model. NEWS at transfer from ICU was the only factor that predicted readmission (OR 1.32; 95% CI 1.01–1.72; P=0.04) at the time of admission to the ward.

Conclusion

Clinical deterioration of surgical patients was preceded by an increase in NEWS.

Impact of Electronic Versus Paper Vital Sign Observations on Length of Stay in Trauma Patients: Stepped-Wedge, Cluster Randomized Controlled Trial

Background

Electronic recording of vital sign observations (e-Obs) has become increasingly prevalent in hospital care. The evidence of clinical impact for these systems is mixed.

Objective

The objective of our study was to assess the effect of e-Obs versus paper documentation (paper) on length of stay (time between trauma unit admission and “fit to discharge”) for trauma patients.

Methods

A single-center, randomized stepped-wedge study of e-Obs against paper was conducted in two 26-bed trauma wards at a medium-sized UK teaching hospital. Randomization of the phased intervention order to 12 study areas was computer generated. The primary outcome was length of stay.

Results

A total of 1232 patient episodes were randomized (paper: 628, e-Obs: 604). There were 37 deaths in hospital: 21 in the paper arm and 16 in the e-Obs arm. For discharged patients, the median length of stay was 5.4 (range: 0.2-79.0) days on the paper arm and 5.6 (range: 0.1-236.7) days on the e-Obs arm. Competing risks regression analysis for time to discharge showed no difference between the treatment arms (subhazard ratio: 1.05; 95% CI 0.82-1.35; P=.68). A greater proportion of patient episodes contained an Early Warning Score (EWS) ≥3 using the e-Obs system than using paper (subhazard ratio: 1.63; 95% CI 1.28-2.09; P<.001). However, there was no difference in the time to the subsequent observation, “escalation time” (hazard ratio 1.05; 95% CI 0.80-1.38; P=.70).

Conclusions

The phased introduction of an e-Obs documentation system was not associated with a change in length of stay. A greater proportion of patient episodes contained an EWS≥3 using the e-Obs system, but this was not associated with a change in “escalation time.”

Trial Registration

ISRCTN Registry ISRCTN91040762; http://www.isrctn.com/ISRCTN91040762 (Archived by WebCite at http://www.webcitation.org/72prakGTU)

Short National Early Warning Score - Developing a Modified Early Warning Score

INTRODUCTION

Early Warning Score (EWS) systems have been developed for detecting hospital patients clinical deterioration. Many studies show that a National Early Warning Score (NEWS) performs well in discriminating survival from death in acute medical and surgical hospital wards. NEWS is validated for Portugal and is available for use. A simpler EWS system may help to reduce the risk of error, as well as increase clinician compliance with the tool.

OBJECTIVES

The aim of the study was to evaluate whether a simplified NEWS model will improve use and data collection.

METHODS

We evaluated the ability of single and aggregated parameters from the NEWS model to detect patients' clinical deterioration in the 24h prior to an outcome. There were 2 possible outcomes: Survival vs Unanticipated intensive care unit admission or death. We used binary logistic regression models and Receiver Operating Characteristic Curves (ROC) to evaluate the parameters' performance in discriminating among the outcomes for a sample of patients from 6 Portuguese hospital wards.

RESULTS

NEWS presented an excellent discriminating capability (Area under the Curve of ROC (AUCROC)=0.944). Temperature and systolic blood pressure (SBP) parameters did not contribute significantly to the model. We developed two different models, one without temperature, and the other by removing temperature and SBP (M2). Both models had an excellent discriminating capability (AUCROC: 0.965; 0.903, respectively) and a good predictive power in the optimum threshold of the ROC curve.

CONCLUSIONS

The 3 models revealed similar discriminant capabilities. Although the use of SBP is not clearly evident in the identification of clinical deterioration, it is recognized as an important vital sign. We recommend the use of the first new model, as its simplicity may help to improve adherence and use by health care workers.

Make vital signs great again - A call for action

Vital signs are the simplest, cheapest and probably the most important information gathered on patients in hospital. In this narrative review we present a large amount of evidence that vital signs are currently little valued, not regularly or accurately recorded, and frequently not acted on appropriately. It is probable that few hospitals would keep their accreditation with regulatory bodies if they collected and acted on their laboratory results in the same way that they collect and act on vital signs. Professional societies and regulatory bodies need to address this issue: if vital signs were more accurately and frequently measured, and acted on promptly and appropriately hospital care would be safer, better and cheaper.

A ward-based time study of paper and electronic documentation for recording vital sign observations

OBJECTIVE

To investigate time differences in recording observations and an early warning score using traditional paper charts and a novel e-Obs system in clinical practice.

METHODS

Researchers observed the process of recording observations and early warning scores across 3 wards in 2 university teaching hospitals immediately before and after introduction of the e-Obs system. The process of recording observations included both measurement and documentation of vital signs. Interruptions were timed and subtracted from the measured process duration. Multilevel modeling was used to compensate for potential confounding factors.

RESULTS

In all, 577 nurse events were observed (281 paper, 296 e-Obs). The geometric mean time to take a complete set of vital signs was 215 s (95% confidence interval [CI], 177 s-262 s) on paper, and 150 s (95% CI, 130 s-172 s) electronically. The treatment effect ratio was 0.70 (95% CI, 0.57-0.85, P  < .001). The treatment effect ratio in ward 1 was 0.37 (95% CI, 0.26-0.53), in ward 2 was 0.98 (95% CI, 0.70-1.38), and in ward 3 was 0.93 (95% CI, 0.66-1.33).

DISCUSSION

Introduction of an e-Obs system was associated with a statistically significant reduction in overall time to measure and document vital signs electronically compared to paper documentation. The reductions in time varied among wards and were of clinical significance on only 1 of 3 wards studied.

CONCLUSION

Our results suggest that introduction of an e-Obs system could lower nursing workload as well as increase documentation quality.

'The Score Matters': wide variations in predictive performance of 18 paediatric track and trigger systems

OBJECTIVE

To compare the predictive performance of 18 paediatric early warning systems (PEWS) in predicting critical deterioration.

DESIGN

Retrospective case-controlled study. PEWS values were calculated from existing clinical data, and the area under the receiver operator characteristic curve (AUROC) compared.

SETTING

UK tertiary referral children's hospital.

PATIENTS

Patients without a 'do not attempt resuscitation' order admitted between 1 January 2011 and 31 December 2012. All patients on paediatric wards who suffered a critical deterioration event were designated 'cases' and matched with a control closest in age who was present on the same ward at the same time.

MAIN OUTCOME MEASURES

Respiratory and/or cardiac arrest, unplanned transfer to paediatric intensive care and/or unexpected death.

RESULTS

12 'scoring' and 6 'trigger' systems were suitable for comparative analysis. 297 case events in 224 patients were available for analysis. 244 control patients were identified for the 311 events. Three PEWS demonstrated better overall predictive performance with an AUROC of 0.87 or greater. Comparing each system with the highest performing PEWS with Bonferroni's correction for multiple comparisons resulted in statistically significant differences for 13 systems. Trigger systems performed worse than scoring systems, occupying the six lowest places in the AUROC rankings.

CONCLUSIONS

There is considerable variation in the performance of published PEWS, and as such the choice of PEWS has the potential to be clinically important. Trigger-based systems performed poorly overall, but it remains unclear what factors determine optimum performance. More complex systems did not necessarily demonstrate improved performance.