Electronic Vital Signs Research Articles

The application of health information technology for the elderly care in the emergency department: a conceptual model

IntroductionIn the emergency departments (EDs), usually the longest waiting time for treatment and discharge belongs to the elderly patients. Moreover, the number of the ED admissions for the elderly increases every year. It seems that the use of health information technology in geriatric emergency departments can help to reduce the burden of the healthcare services for this group of patients. This research aimed to develop a conceptual model for using health information technology in the geriatric emergency department.MethodsThis study was conducted in 2021. The initial conceptual model was designed based on the findings derived from the previous research phases (literature review and interview with the experts). Then, the model was examined by an expert panel (n = 7). Finally, using the Delphi technique (two rounds), the components of the conceptual model were reviewed and finalized. To collect data, a questionnaire was used, and data were analyzed using descriptive statistics.ResultsThe common information technologies appropriate for the elderly care in the emergency departments included emergency department information system, clinical decision support system, electronic health records, telemedicine, personal health records, electronic questionnaires for screening, and other technologies such as picture archiving and communication systems (PACS), electronic vital sign monitoring systems, etc. The participants approved all of the proposed systems and their applications in the geriatric emergency departments.ConclusionThe proposed model can help to design and implement the most useful information systems in the geriatric emergency departments. As the application of technology accelerates care processes, investing in this field would help to support the care plans for the elderly and improve quality of care services. Further research is recommended to investigate the efficiency and effectiveness of using these technologies in the EDs.

Implementation of early warning system in the clinical teaching unit to reduce unexpected deaths

BackgroundEarly detection of patients with clinical deterioration admitted to the hospital is critical. The early warning system (EWS) is developed to identify early clinical deterioration. Using individual patient’s vital sign...

Removing modifications to the New Zealand Early Warning Score- does ethnicity matter? A multimethod research design

BackgroundPrevious research on a modified New Zealand Early Warning Score (M-NZEWS) used in predominately medical ward patients identified removing the modifications would significantly reduce the number of M-NZEWSs triggering the medical emergency team (MET), particularly in Māori patients. AimTo firstly, explore the impact of removing the modifications from the M-NZEWS on medical and surgical ward patients’ early warning score MET triggers and secondly, determine if the M-NZEWS MET triggers resulted in MET activations and if the MET activations were a result of M-NZEWS MET triggers. MethodThe study used a multimethod research design. Phase one analysed ward electronic vital sign data and phase two analysed MET and critical care outreach data from the critical care outreach data base. ResultsData of 353 patients and 1004 M-NZEWS MET triggers were analysed. Removing the modifications would result in 26.9% fewer patients with MET triggers, with the biggest impact on Māori. Only 45.8% of M-NZEWS MET triggers were escalated to the MET with 58.9% escalated to critical care outreach. Review of the MET activations identified only 59.2% had M-NZEWSs triggering the MET recorded in the electronic vital sign system; however the critical care outreach data base identified most of the MET activations were because of M-NZEWS MET triggers. ConclusionRemoving the modifications would significantly reduce the number of MET triggers, particularly in Māori patients. Analysing solely electronic vital sign data may not reflect the number of medical emergency team triggers or activations.

Improving Hospitalized Patient Sleep: It Is Easier Than It Seems.

Improving Hospitalized Patient Sleep: It Is Easier Than It Seems.

436 POSTOPERATIVE SYSTOLIC HYPOTENSION IN FRACTURED NECK OF FEMUR PATIENTS

Abstract Introduction Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP 2) found an association between reduced intraoperative systolic arterial pressure (SAP) and postoperative mortality at five and 30 days. We sought to determine the incidence of hypotension in the postoperative period, rather than just intraoperatively, in a small sample of patients with fractured neck of femur. Method We performed a retrospective review of the notes, electronic vital signs and electronic general practice records from 40 patients with fractured neck of femur. We identified the latest SAP performed at their general practice (if done within one year before admission). We noted the pre-operative baseline SAP reading from the ward as well as the lowest SAP during several time periods: the pre-operative period; the fracture surgery; the recovery room; and during each 24-h period postoperatively until the fifth postoperative day. Results A SAP recording from general practice within the previous year was only accessible in 21 (53%) of patients, but where it was accessible, it was within 20% of the immediate preoperative SAP in 14 (66%) of patients. The incidence of relative hypotension (< 80% preoperative SAP) was 54% in the operating theatre, 41% in the recovery room, 65% on the ward during the remainder of the first postoperative 24 h, 55% during postoperative day 2, 53% during day 3, 33% during day 4 and 41% during day 5. Conclusions Postoperative hypotension was common in our sample. In our analysis, the highest incidence was on the ward during the first 24 hours postoperatively. However, 41% of patients still had hypotension 5 days postoperatively.

How long do nursing staff take to measure and record patients’ vital signs observations in hospital? A time-and-motion study

IntroductionMonitoring vital signs in hospital is an important part of safe patient care. However, there are no robust estimates of the workload it generates for nursing staff. This makes it difficult to plan adequate staffing to ensure current monitoring protocols can be delivered. ObjectiveTo estimate the time taken to measure and record one set of patient's vital signs; and to identify factors associated with the time required to measure and record one set of patient's vital signs. MethodsWe undertook a time-and-motion study of 16 acute medical or surgical wards across four hospitals in England. Two trained observers followed a standard operating procedure to record the time taken to measure and record vital signs. We used mixed-effects models to estimate the mean time using whole vital signs rounds, which included equipment preparation, time spent taking vital signs at the bedside, vital signs documentation, and equipment storing. We tested whether our estimates were influenced by nurse, ward and hospital factors. ResultsAfter excluding non-vital signs related interruptions, dividing the length of a vital signs round by the number of vital signs assessments in that round yielded an estimated time per vital signs set of 5 min and 1 second (95% Confidence Interval (CI) = 4:39–5:24). If interruptions within the round were included, the estimated time was 6:26 (95% CI = 6:01–6:50). If only time taking each patient's vital signs at the bedside was considered, after excluding non-vital signs related interruptions, the estimated time was 3:45 (95% CI = 3:32–3:58). We found no substantial differences by hospital, ward or nurse characteristics, despite different systems for recording vital signs being used across the hospitals. DiscussionThe time taken to observe and record a patient's vital signs is considerable, so changes to recommended assessment frequency could have major workload implications. Variation in estimates derived from previous studies may, in part, arise from a lack of clarity about what was included in the reported times. We found no evidence that nurses save time when using electronic vital signs recording, or that the grade of staff measuring the vital signs influenced the time taken. ConclusionsMeasuring and recording vital signs is time consuming and the impact of interruptions and preparation away from the bedside is considerable. When considering the nursing workload around vital signs assessment, no assumption of relative efficiency should be made if different technologies or staff groups are deployed.

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

ABSTRACT 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.

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

IntroductionLimited research exists on the effectiveness of the New Zealand Early Warning Score (NZEWS). AimTo determine the impact of a modified NZEWS (M–NZEWS) and NZEWS on ward patients’ medical emergency team activation triggers. Research designMixed methods sequential design. MethodsThree 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. Results1255 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. ConclusionChanging 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.

Implementation of a Vital Sign Alert System to Improve Outcomes.

Patients at risk for clinical deterioration often show changes in vital signs up to 24 hours before a critical event. Use of modified early warning scores has demonstrated effectiveness in identifying patients at risk for clinical deterioration and improving outcomes. Documentation of vital signs, timely recognition of clinical deterioration, and compliance with the sepsis bundles remained a challenge. An interprofessional team developed an electronic vital sign alert (VSA) system with a concurrent running sepsis screen, along with clinical protocols. Education was provided and the VSA system was implemented on 3 nursing units. After implementation, the number of unplanned transfers to the intensive care unit increased. Mortality rate and length of stay in the intensive care unit for patients transferred for respiratory failure and sepsis significantly decreased. There was a 21% increase in identification of sepsis. The VSA system was an effective tool to identify patients at risk for clinical deterioration and help to improve outcomes.

Multiple vital signs analysis algorithm detects systemic inflammatory response in premature infants with late-onset sepsis and necrotising enterocolitis.

Commentary on: Mithal LB, Yogev R, Palac HL, Kaminsky D, Gur I, Mestan KK. Vital signs analysis algorithm detects inflammatory response in premature infants with late onset sepsis and necrotizing enterocolitis. Early Hum Dev. 2018 Feb; 117:83-89. https://doi.org/10.1016/j.earlhumdev.2018.01.008. Epub 2018 Jan 23. Neonatal sepsis substantially contributes to neonatal mortality and morbidity and presents a major public health challenge worldwide 1. Despite the decline in the incidence of late-onset sepsis (LOS) due to infection control measurements, it still disproportionately affects very low-birthweight (VLBW) infants causing significant morbidity, lifelong neurological impairments and prolonged hospitalisation 2, 3. The diagnosis of sepsis remains difficult due to its nonspecific clinical presentation which could be attributed to many other noninfectious aetiologies, as well as the lack of reliable laboratory biomarkers. Because of the potential dire consequences, clinicians have a low threshold for LOS treatment leading to antibiotic overuse in a large proportion of VLBW infants and its adverse effects such as increased antibiotic resistance, fungal infections, microbiota modification, necrotising enterocolitis (NEC) and death 4. NEC, defined as bowel infection, bacterial penetration and tissue destruction, presents with nonspecific signs at early stage, very often overlapping with sepsis 5. Both neonatal sepsis and NEC are associated with systemic inflammatory responses. The development of a reliable and specific method to detect an impending infection or systemic inflammatory response prior to the clinical deterioration has been of particular research interest in recent years 6, 7. Previous studies have shown that RALIS software with multiple vital signs monitoring was an effective tool in detecting sepsis 2.5 days earlier than the onset of the clinical suspicion of infection 8. The current study aimed to evaluate the performance of the revised RALIS algorithm in the detection of a systemic inflammatory response in LOS and NEC in preterm infants (23–32 GA). Vital sign data incorporated into the revised RALIS algorithm included heart rate, respiratory rate, temperature, desaturation events and bradycardia events. A score was generated (range: 0–10) and the clinical team was alerted if ≥5 for six consecutive hours. Premature infants with complete electronic vital sign data were included and classified according to the primary outcome into LOS, expanded LOS, NEC, culture-negative LOS or controls. This study consistently proved the effectiveness of the RALIS algorithm in detecting LOS and NEC with a mean alert of 33 hours before clinical suspicion, particularly emphasising its utility in excluding LOS with a high negative predictive value of 93%. Although sensitive, the positive diagnostic value in identifying LOS and NEC remained limited, showing a moderate PPV (67%) similar to that in previous reports 8. The authors note the study's limitations, mainly regarding the sample size and its retrospective nature. Thus, this study indicates the particular usefulness of the RALIS algorithm in identifying clinician concern ahead of clinical concern without consequence, which may more confidently aid the physician's decision-making with regard to withholding or discontinuing antibiotic treatment. This study adds additional data regarding the benefit of multiple sign monitoring algorithms in the prediction of neonatal infections; however, future prospective studies are warranted to investigate its association with existing or novel laboratory biomarkers, as well as its utility beyond the first month of life. https://ebneo.org/2019/05/late-onset-sepsis-necrotizing-enterocolitis/. The authors declare no financial or other conflict of interest.

Dentists by E. Less

Less, Emma. “Dentists.” Real-life Superheroes. Amicus Publishing, 2018.
 Aimed at emergent readers, this Real-life Superheroes series is intended to inform children of the ways community helpers do their jobs, understand what the jobs mean, inspire readers, and expose readers to vocabulary and action images specific to occupations in the spotlight. This is a review of three out of twelve Real-life Superheroes books. Other occupations in the series include chefs, librarians, construction workers, farmers, firefighters, mechanics, police officers, teachers, and veterinarians.
 Each book begins with the relevant job title and a purpose statement. The “Dentists” and “Doctors” books have health-promotion statements while the “Nurses” introductory statement is limited to an illness focus. Health promotion is a primary focus of these three professions and it is incorrect to limit nursing to an illness focus in the primary introduction. Also, on the first pages of the “Dentists” and “Doctors” books the author says “They [Dentists/Doctors] are busy,” while the “Nurses” book does not include the same statement. Further, the “Doctors” book includes a “Maybe you will be a Doctor” statement, while the “Dentists,” and “Nurses” books do not. These statements should be included in all the books. 
 The books adequately introduce subject specific vocabulary and use child-centered action images. The images are high quality, and feature real-world tools (needles, syringes, stethoscopes, electronic vital signs monitors, etc.). Regarding the pictures of the professionals, there could have been greater effort to demonstrate diversity, to ensure all children could see themselves reflected in the images. For example, only one of seven nurses shown is male, reinforcing gender stereotypes related to this profession. In the “Dentists” and “Doctors” books the images show a more diverse picture of the professions, when race and gender is considered. The last page of each book is dedicated to tools seen in the workplace and these would encourage curious readers to ask questions about the profession. 
 As a tool to introduce early readers to health care jobs and inspire them to think of themselves in these roles, the books fall short; specifically, they do not give a full and accurate account of job tasks and job relationships. For example, the books mention the nurse-doctor team but do not mention the dentist-dental hygienist team. Overall, these books are of limited use as they do little to inspire children to imagine themselves in these roles, and they lack accurate job descriptions. 
 Not Recommended: 1 out of 4 StarsReviewer: Tabatha Plesuk
 Tabatha Plesuk, is a first year MLIS Student at the University of Alberta (who spends free time teaching dance to children ages three to fourteen) with an enthusiasm for children’s books.

Electronic recording of vital signs for mental health inpatients

The use of electronic monitoring of vital signs is becoming increasingly widespread in general hospital settings in the National Health Service (NHS) in the United Kingdom, and numerous advantages when compared to using paper charts have been shown. However, electronic systems are not yet widely used within mental health inpatient care. We present a pilot implementation of a novel system of electronic vital signs monitoring introduced in two adult mental health inpatient wards, designed to assess feasibility and acceptability to staff and patients. Development and implementation of the new system, adapted from a system designed for use in acute medical nursing, has presented challenges. However, over the course of the 10-month period presented here, nursing compliance, measured by percentage of observations recorded on time, improved by 72.7%. Service users and clinical staff both reported positively to the new system. Efforts to improve monitoring psychiatirc inpatients’ physical health are of increasing importance. Implementing electronic recording of observations is practical, affordable and feasible within the mental health inpatient setting, and offers many potential advantages over the use of paper charts.

Bag Valve Mask Ventilation as a Perceptual-Cognitive Skill.

Objective This study used a high-fidelity infant mannequin to examine the relationship between the quality of bag valve mask ventilation (BVMV) and how providers of varying levels of experience use visual feedback (e.g., electronic vital signs) to guide their performance. Background BVMV is a common and critical procedure for managing pediatric respiratory emergencies. However, providers do not consistently deliver effective BVMV. Efforts to improve BVMV have ignored the question of how providers effectively use feedback often available during BVMV. Method Six expert and six novice respiratory therapists completed two simulations of an infant requiring BVMV. In one, the technology failed to display SpO2, an important but somewhat redundant visual cue. Eye movements, verbal reports, and ventilation rate (in breaths per minute) were measured in each simulation. Results Regardless of SpO2 availability, eye movements and verbal reports suggested that novices depended strongly on electronic vital signs and when SpO2 was absent ventilated at a faster rate (exceeding the recommended range of ventilation rates) than when SpO2 was present. Experts' ventilation rates were comparable and within the recommended range in both conditions. When SpO2 was absent, experts emphasized information from direct observation of the patient that novices neglected. Conclusion Individual differences in the use of feedback during BVMV contribute to the quality of BVMV. This work bears on the theoretical discussions involving the use of automation and nontechnological cues to guide performance. Application These results have the potential to expand the current understanding of factors underlying effective BVMV with implications for training novice providers.

Maternal heart rate during the first 48 h postpartum: a retrospective cross sectional study

Objectives1) Describe the distribution of heart rate in the first 48h postpartum in women with no evidence of sepsis, anaemia or haemorrhage. 2) Investigate the relationship between postpartum heart rate and other maternal factors. Study designA retrospective cross-sectional study of postpartum women who delivered between July 2012 and June 2015 in a tertiary hospital. Data was analysed from the local maternity system and electronic vital signs database. The main outcome measures: Heart rate at 6, 12, 24 and 48h postpartum. ResultsData were obtained on 11401 women. After exclusion of women with possible sepsis, anaemia or haemorrhage, 7627 heart rate readings from 5164 women were analysed. Mean heart rate (+2SD/+3SD) at 6h was 83.6 (108.2/120.6), 12h 84.5 (109.4/121.9), 24h 85.4 (110.4/122.9), and 48h 84.3 (109.7/122.4). There was statistical correlation of post partum heart rate with body mass index (BMI), age and discharge haemoglobin. ConclusionThis study describes the distribution of maternal heart rate in the early postpartum period, in women with no evidence of sepsis, anaemia or major haemorrhage. This will facilitate identification and appropriate investigation of women with abnormal heart rates. Although correlation with BMI, age and discharge haemoglobin was demonstrated, the differences were small and not clinically meaningful. Further work investigating the relationship between postpartum heart rate and poor maternal outcomes is required.

Health technologies

A report by the Nuffield Trust explores some of the possibilities to transform health care through digital technologies, ranging from clinical decision support tools and electronic vital signs monitors, to remote monitoring and digital patient networks. Download the report at tinyurl.com/h5eb2tv

Hamilton Early Warning Score: predict, prevent and protect

This study determined the pattern of decline prior to an inpatient arrest. We implemented the Hamilton Early Warning Score (HEWS) within our electronic vital signs documentation to track and trigger care for deteriorating patients. Other EWS have been described in the literature with varying success [1]. In contrast to previous observational studies, we chose to implement a score modified from published EWS using the consensus opinion of a steering committee and evaluate the score in real time.

Eliminating Errors in Vital Signs Documentation

This study compared two methods of documenting vital signs: a traditional method where staff wrote vital signs on paper then keyed into an electronic medical record and a wireless system that downloaded vital signs directly into an electronic medical record. The study design was pretest and posttest. Sixty-four sets of vital signs were evaluated prior to the implementation of a wireless download system and 66 sets of vital signs were evaluated after. To compare the error rates for the two methods, χ tests were used, and t tests were used to compare the elapsed time. Questionnaires relating to the clinicians' experiences were analyzed qualitatively. The paper vital signs recording had an error rate of 18.75% and the wireless system has an error rate of 0% (P < .001). The mean (SD) elapsed time from when the vital signs were taken until they were available in the electronic medical record was 38.53 (32.87) minutes for the paper method and 5.06 (6.59) minutes for the wireless method (P < .001). The electronic vital signs documentation system resulted in significantly fewer errors and shorter elapsed time when compared with the paper system.

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients

We conducted a randomised controlled trial of mandated five-channel physiological monitoring vs standard care, in acute medical and surgical wards in a single UK teaching hospital. In all, 402 high-risk medical and surgical patients were studied. The primary outcome was the proportion of patients experiencing one or more major adverse events, including urgent staff calls, changes to higher care levels, cardiac arrests or death, in 96 h following randomisation. Secondary outcomes were the proportion of patients requiring acute treatment changes, and the 30-day and hospital mortality. In the 96 h following randomisation, 113 (56%) patients in the monitored arm and 116 (58%) in the control arm (OR 0.94, 95% CI 0.63-1.40, p = 0.76) had a major event. An acute change in treatment was necessary in 107 (53%) monitored patients and 101 (50%) control patients (OR 0.55, 95% CI 0.87-1.29). Thirty-four (17%) monitored patients and 35 (17%) control patients died within 30 days. Thirteen patients in the control group received full five-channel monitoring at the request of the ward staff. We conclude that mandated electronic vital signs monitoring in high risk medical and surgical patients has no effect on adverse events or mortality.