Observation Chart Research Articles

The effectiveness of the paediatric early warning tool (PEWT) in identifying children requiring admission to a critical care unit

Introduction The Paediatric Early Warning Trigger (PEWT) Tool is used at our hospital to aid early identification of clinical deterioration and promote effective escalation of care. Our hospital is a teaching hospital, with inpatient general, respiratory, haematology, surgery, neurosurgery, hepatology and gastroenterology beds and a paediatric critical care unit (CCU). Method The use of PEWT was prospectively audited during July 2010 for all Paediatric admissions, excluding critical care or NICU admissions. All observation charts included a PEWT scoring system that assessed 5 physiological parameters. The data were collected twice daily using a standard proforma including demographics, documentation of triggering, frequency of triggering and admission to CCU. Results Data was collected on 331 children (age [range] 6.3 [0.01-18.6] years), 62 (19%) children triggered. Seven children (all of whom triggered) were admitted to CCU. The children admitted to CCU were more likely to have triggered in more than one time period (median [range] number of triggers 3 [1-7] v 0 [0-16], p Conclusion Triggering PEWT is strongly associated with CCU admission. However, given its low positive predictive value, PEWT has poor efficacy for establishing the need for critical care based on triggering scores alone. Therefore, CCU admission may not be the most appropriate outcome measure for evaluating the effectiveness of PEWT, instead effectiveness of interventions would be more appropriate but more difficult to measure. If a national paediatric scoring system is to be developed it will need to be designed to detect effectiveness of interventions.

Antibiotic use for febrile neutropaenia in children with cancer

ObjectivesTo assess if the antibiotic regimens being instituted are according to the NUH febrile neutropaenia guideline. To determine if gentamicin levels are being taken appropriately and are within recommended limits....

A before and after study assessing the impact of a new model for recognizing and responding to early signs of deterioration in an acute hospital

To evaluate the impact of a new model for the detection and management of deteriorating patients on knowledge and confidence of nursing staff in an acute hospital. International evidence shows that clinical deterioration is not always recognized or acted on by nurses. The use of physiological track and trigger scoring systems accompanied by a graded response strategy has been recommended to monitor all adult patients in acute UK hospitals. However, little is known about the impact of these new systems in practice. A single centre, mixed methods before-and-after study. A mixed methods before-and-after study, set in a district general hospital in England, in 2009, including a survey (n = 213) and qualitative interviews (n = 15) with nursing staff. The questionnaire examined knowledge and confidence in recognition and management of deteriorating patients 6 weeks before and after an intervention which included training, new observation charts and a new track and trigger system. Interviews further explored participants' perspectives. Comparisons were made between registered and unregistered nurses. Following the intervention, knowledge, and confidence to recognize and manage deteriorating patients increased; the number of concerns were reduced. Scores were higher for registered than unregistered nurses before and after the intervention. Interviews confirmed these findings and provided detail on how nurses felt the new system had improved practice. The new model had a positive impact on the self-assessed knowledge and confidence of registered and unregistered nurses. Similar initiatives should take into account the clinical context and tailor training packages accordingly.

The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients

The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients

Designing observation charts to optimize the detection of patient deterioriation: Reliance on the subjective preferences of healthcare professionals is not enough

Observation charts are critical to detecting patient deterioration. Research suggests their design has a dramatic impact on user performance in terms of failure rates for detecting abnormal vital signs and how quickly users can interpret recorded observations. In this study, we examined the design preferences of professional chart users to assess their alignment with objective performance data. In addition, we tested the assumptions of prior knowledge that chart designers appear to have made about chart users. We conducted an online survey of health professionals (n=347). Participants answered questions about their observation chart design preferences in general, and were randomly assigned to evaluate one of nine specific charts. Chart users' preferences for design features were not always consistent with objective performance data. While some views concurred with empirical findings (e.g., participants preferred to plot observations on a graph with graded colouring, where the colours corresponded with degrees of abnormality), others did not (e.g., participants preferred plotting blood pressure and pulse together on the same chart area, which the objective data suggest is problematic). Additionally, a substantial proportion of respondents were unfamiliar with some of the assumed knowledge required to interpret many charts (e.g., particular abbreviations). It is dangerous to rely solely on subjective opinions - even those of experienced health professionals - when developing patient observation charts, as optimal design may be counterintuitive and some preferences may merely reflect familiarity. Objective performance data is also required. In addition, the level of assumed knowledge required to use a chart should be minimized.

Supporting the detection of patient deterioration: Observation chart design affects the recognition of abnormal vital signs

AimTo evaluate the effect of observation chart design on the ability of health professionals and novice chart users to recognise patient deterioration. MethodsParticipants were 45 health professionals (doctors and nurses) and 46 novices. Each participant completed 48 trials in which they viewed realistic patient observations recorded on six hospital observation charts of differing design quality. Each chart design was used on eight trials, four times with normal data and four times with abnormal data. On each trial, the participant's task was to identify any abnormal observation or else to indicate that all observations were normal (based on normal physiological ranges given in the instructions). The main outcome measures were participants’ error rates and response times for detecting abnormal observations on each of the six charts. ResultsThere was a significant effect of chart type on error rates (p<0.001), but health professionals made the same number of errors as novices (p=0.43). Chart type also had a significant effect on response times (p<0.001). Health professionals responded faster overall than novices (p=0.006); however, a significant interaction between chart type and participant group (p=0.02) indicated that the health professionals’ advantage was confined to the two most rudimentary charts. No significant differences were found between doctors and nurses on either measure. ConclusionsOur findings suggest that observation chart design has a substantial impact on the decision accuracy and response times of both health professionals and novices in recognising abnormal patient observations.

The Effectiveness of the Paediatric Early Warning Tool (PEWT) in Identifying Children Requiring Admission To a Critical Care Unit

Introduction: The Paediatric Early Warning Trigger (PEWT) Tool is used to aid early identification of clinical deterioration and promote effective escalation of care. PEWT is a trigger tool rather than an integer score.Method: The use of PEWT was prospectively audited during July 2010 at our hospital for all Paediatric admissions, excluding critical care (CCU) or NICU admissions. All observation charts included a PEWT scoring system that assessed 5 physiological parameters. The data were collected twice daily, including demographics, triggering frequency and admission to CCU.Results: 331 children were admitted (age [range] 6.3 [0.01-18.6] years), 62 (19%) children triggered. Seven children (all of whom triggered) were admitted to CCU. These seven were more likely to have triggered in more than one time epoch (median [range] number of triggers 3 [1-7] v 0 [0-16], p< 0.0001). Triggering PEWT detected CCU admission with a sensitivity of 100% and a specificity of 11% with a positive predictive value of 100% and a negative predictive value of 83%. Area under receiver operated curve (AUC) analysis showed that triggering PEWT was highly predictive of CCU admission (AUC 0.91) as was the number of triggering epochs (AUC 0.92).Conclusion: Triggering PEWT is strongly associated with CCU admission. However, given its low specificity, PEWT is poorly predictive for establishing the need for critical care based on triggering scores alone. Therefore, CCU admission may not be the best measure for evaluating the effectiveness of PEWT, instead effectiveness of interventions would be more appropriate but more difficult to measure.

Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department

Inpatient paediatric clinical observation charts that have predefined physiological criteria, which when reached might generate a mandatory medial review, are to be introduced into EDs in New South Wales. The present study estimated the increased workload of introducing these charts. The present study was carried out in the ED of The Children's Hospital at Westmead, Sydney, Australia. All patients admitted directly to the inpatient wards or to the Emergency Medical Unit for a 2 week period in April 2010 were included. The last set of clinical observations prior to the child being transferred out of the ED were recorded. These data were compared to the review criteria defined by the observation charts. The primary outcome was a possible activation of a review. Secondary outcomes were an attempt to quantify the extra time in the ED required before the review would be completed and the patient would be ready for transfer. There were 1822 presentations. Two hundred and fifty-three were admitted to the wards and 109 to the Emergency Medical Unit. There were 126 possible activations. Fifty-seven (52%) of Emergency Medical Unit patients and 69 (28%) of ward patients met review criteria at the time of transfer. The review activations might have generated an extra 7060 min of additional workload. Individual units must decide where in the patient journey to introduce the charts for acute paediatric admissions based on the number of acute paediatric admissions and their severity as well as the availability and ability of staff to respond to calls.

The safe use of spinal drains in thoracic aortic surgery

Paraplegia is a devastating complication which may occur following surgery on the thoracic aorta. The use of a cerebrospinal fluid drain (CSFD) has helped reduce the incidence of neurological deficit; however, the management of patients with a CSFD postsurgery requires nurses and doctors to have expertise and awareness of the associated complications. The National Patient Safety Agency (UK) has highlighted a number of cases involving inadvertent spinal injections throughout the UK National Health Service (NHS). To this end we have introduced a protocol or 'care bundle' for safe CSFD care as well as drain management. The protocol was developed by medical and nursing staff at our institution based on clinical experience and literature reviews over a two-year period (2008-2010). Interventions undertaken during the development of the protocol included discussion with the UK National Patient Safety Agency (NPSA). Content of the protocol was reviewed by internal regulatory bodies within the hospital prior to ratification and general dissemination. Clear guidance is given within the policy on the standards expected when caring for the line and managing drainage according to agreed parameters of spinal cord perfusion pressure. The protocol constitutes five documents which guide staff in the care of CSFD, its routine management, documentation and interventions necessary once neurological deficit is detected. Document 1 which is a checklist, communication tool and aide-memoire was developed to ensure effective management, when the patient arrives in intensive care unit (ICU) from theatre. Document 2 ensures that early detection of a neurological deficit is noted and with Document 3 is acted upon immediately to reverse the injury. Document 4 provides information on the safe administration of analgesia via the spinal drain and has reference to the Glasgow Coma Scale. Document 5 is a bespoke observation chart for documenting CSFD pressure and cerebrospinal fluid drainage. In conclusion, the protocol acts as a guide for safe management of the CSFD and directs staff in reacting to detection of neurological deficit.

Dying in acute care

The demography of dying in Australia, as in other developed countries, has shifted dramatically in a single generation. Cause of death, place of death and mode of dying are all...

The development of the Suicidal Patient Observation Chart (SPOC): Delphi study

Constant observation is a method used to insure the safety of suicidal inpatients. It involves structure and control as well as flexibility and the development of a relationship between the observer and the patient. It has been found that important observations may go unnoticed by the observer or fail to be communicated to the multidisciplinary team because of a lack of sufficient training and systematic documentation. We therefore conducted a Delphi survey to collect opinions on what would be important to observe during constant observation of suicidal patients. A panel of experienced clinicians, service users and researchers reached consensus on 37 of 40 observation items (92%). Of these, 28 were rated as the most important. As a result, we developed a form for systematic observer documentation in clinical practice, the Suicidal Patient Observation Chart. The Suicidal Patient Observation Chart includes the 28 items and covers 24 separate observation periods.

Low-flow oxygen therapy in intensive care: An observational study

There is scant published evidence that explains how ICU nurses' manage low-flow oxygen therapy; and, hence little is known about how low-flow oxygen therapy is delivered on a daily basis. The aims of this study were first to observe how ICU nurses' manage low-flow oxygen therapy and then to compare observed nursing practice on the management of oxygen therapy with patients' documented measures of oxygen saturation (SpO2) and respiratory rate (RR). From May to July 2009, eight 2h observation periods were conducted in one ICU of a metropolitan hospital in Melbourne, Victoria. Data were collected at using a structured observation tool, field notes and chart review. Quantitative data were analysed using descriptive and frequency statistics, and textual data were reviewed using a content analysis procedure. Over the 16 h of observed nursing practice, there were 96 points of measurement involving 16 patients and 16 ICU nurses. The management of low-flow oxygen therapy varied between nurses and data revealed that nurses did not always promote effective oxygenation. Documented SpO2 was 98.0% (SD 2.8%) and observed SpO2 was 96.3% (SD 1.8%). Documented RR was 19.6 breaths/min (SD 3.5) and observed RR was 21.0 breaths/min (SD 16.8). Episodes of hypoxaemia and tachypnoea occurred while patients were receiving oxygen and nurses did not always respond appropriately. ICU nurses' management of low-flow oxygen therapy was suboptimal and documentation of oxygenation and respiratory rate was inaccurate. Further exploration of how ICU nurses manage low-flow oxygen therapy is a necessary prelude to the conduct of interventional studies and the development of better guidance to support low-flow oxygen therapy in the ICU.

Charted observations and the use of a paediatric early warning tool did not predict the majority of cardio-respiratory arrest calls in a paediatric hospital

AimTo asses whether the routine use of observation charts incorporating a Paediatric Early Warning Tool (PEWT) are effective for screening inpatients, predicting those at risk of acute deterioration, in a...

Introduction of a new observation chart and education programme is associated with higher rates of vital-sign ascertainment in hospital wards

IntroductionLocal and national awareness of the need to improve the recognition and response to the clinical deterioration of hospital inpatients is high. The authors designed and implemented a programme to...

Review of standard & individualised parenteral nutrition (PN) prescribing in neonates

ObjectivesPrimarily, the review was carried out to look at the appropriateness of parenteral nutrition (PN) prescribing in neonates against ESPGHAN guidelines using both standard and individually manufactured bags.1 Secondly, to...

Grau de dependência de idosos hospitalizados para realização das atividades básicas da vida diária

Este estudo objetivou identificar o grau de dependência de idosos hospitalizados para a realização das Atividades Básicas da Vida Diária. Trata-se de estudo quantitativo, transversal e descritivo, desenvolvido na Enfermaria de Adultos do Pronto-Socorro do Hospital das Clínicas de Botucatu. A coleta de dados ocorreu mediante entrevistas, observação e consulta nos prontuários individuais. Os dados foram analisados com pacote estatístico SAS for Windows, versão 9.2, utilizando regressão logística. A amostra foi constituída por 71 sujeitos, com idade média de 74,30 anos. Verificou-se que 30,99% dos idosos se apresentaram independentes na realização das atividades propostas, 22,53%, parcialmente dependentes e 46,48% totalmente dependentes. O cuidado em gerontologia deve estar voltado para a manutenção do estado funcional, promovendo-se a independência e preservando a dignidade dos sujeitos.

Point prevalence of patients fulfilling MET criteria in ten MET equipped hospitals. The methodology of the RESCUE study

Objective The RESCUE study examined the prevalence of patients at risk of a medical emergency in acute care settings by assessing the prevalence of cases where patients fulfil the hospital-specific criteria for MET activation. This article will detail the study methodology including the ethics applications and approvals process, organisational preparation, research staff training, tools for data collection, as well as barriers encountered during the conduct of the study. Design and Setting A point prevalence design conducted at 10 hospitals, comprising of private and public, secondary and tertiary referral, ICU equipped, metropolitan and regional settings. Patients All inpatients were eligible except intensive care and psychiatric patients. Measurement and main results On a single day consenting inpatients in each hospital had a single set of vital signs obtained, their observation chart reviewed and followed up for MET activations, unplanned ICU admissions, cardiac arrests and 30 and 60 day mortality. Of 2199 eligible patients, 1688 (76.76%) were assessed, 175 (7.95%) refused consent and 336 (15.28%) were unavailable. Access to patients was refused in some wards despite ethics approval. Data collection required 2 student nurses approximately 14 min per patient assessment. Conclusion In conducting a large multi-site point prevalence study, critical organisational processes were shown to influence the access to patients. This study demonstrated the impact of variation in Human Research Ethics Committee interpretations of protocols on consenting processes and the importance of communication and leadership at ward level to promote access to patients.

Daily physiological goal-setting: medical prescription and nursing adherence in a London teaching hospital ICU

Individual, clearly defined physiological goal-setting can help to optimize patient care [1]. At our ICU, eight physiological goals can be prescribed on the daily ICU observation chart. These include Hb, MAP, ICP, CPP, pO2, pCO2, fluid balance and sedation scores. We performed a prospective audit assessing doctors' compliance with goal-setting, nursing adherence to these, and what goals nurses used when none were documented.

Isolated sphenoid sinus pathologies – the problem of delayed diagnosis

SummaryBackgroundIsolated sphenoid sinus pathologies are relatively rare. In the majority of cases, symptoms do not arise in the early stages of the disease or are non-specific, therefore making diagnosis difficult. The aim of this study was to investigate the diagnostic process and the reasons for development of complications in patients with isolated sphenoid sinus pathology.Material/MethodsThe clinical data and observation charts of 32 patients were investigated to determine how long the main symptoms of sphenoid pathology had been present before the patients were referred for medical treatment, and the time that elapsed from the first ambulatory medical assessment to the initial diagnosis.ResultsComplaints and symptoms of sphenoid sinus pathology had been present for 10.2 months before the diagnosis was established. Although the duration of complaints in “ORL” (diagnosed by otorhinolaryngologist) and “non-ORL” (diagnosed by other specialists) group of patients was similar (10.8 and 9.5 months on average, respectively), unexpectedly, in the “non-ORL” group of patients, the time necessary for making the initial diagnosis was actually shorter than in the “ORL” group (1.8 vs 4.1 months). At the time of hospital admission, endoscopic examination revealed no abnormalities in 31.2% of patients. In 28.1% of patients the pathological process in the sphenoid sinus was diagnosed only after the onset of complications.ConclusionsThe occult character of the disease and the lack of severe and specific symptoms, rather than the delay in getting extensive diagnostic tests, are responsible for the delayed diagnosis and treatment.

468 Making a Difference: Introducing Paediatric Critical Care Outreach Supports Effectiveness of An Early Warning Scoring System Improving Patient Safety

Nottingham Children's Hospital has recently developed and introduced an integrated Paediatric Early Warning Scoring tool and Observation Chart. To support this development and to enable the structured escalation plan to be instigated, a PCCOT team was also introduced and trialled for one month. The aim of the trial was to find out what added benefit the PCCOT Nurse contributed to the PEWS system in the recognition and management of evolving critical illness thus enhancing patient safety. Other aims included improvement to the patient treatment pathway, to assess the types/range of skills the PCCOT Nurse needs and the level of activity of the PCCOT Nurse. Utilising a service redesign model the project has moved through the following stages: Problem Identification Identifying issues surrounding ‘failure to rescue’ Proposed initiative PEWS and PCOTT. Development of Tool - PEWS, observation chart and escalation plan. Pilot Stage The trial of PCOTT and new charts took place over 1 month. Results: Total Number of patients 137. Average Number of PCCOT episodes per day 20 Time spent per episode 15 min - 6 hours Average PCCOT episodes per patient 5 Patients admitted to PICU/PHDU had higher PEWS score. Of 15 patients admitted to a higher level of care the transfers were controlled and timely. During the trial there were no cardiac arrests on the wards and only one ‘collapse’ needing ITU admission from a ward where PCOTT had not been involved. Conclusion: Paediatric Critical Care Outreach supports the effectiveness of a PEWS System improving patient safety.