Observation Chart Research Articles

Development of a Functional Analytical Nurse Observation Chart (FANOC)

There has been little evaluation or development of nurse observation charts on psychiatric in-patient units since they were first introduced. We aimed to develop a new nursing chart that adds a functional and contextual assessment of the observed behaviour. We describe its initial evaluation in an in-patient setting. A member of the staff coded a participant's behaviour as either an instance of an individual's daily life problem; or an improvement; or a non-clinically relevant behaviour. We evaluated the charts in 14 in-patients and compared the coding of the behaviour against that of one of the investigators. After brief training the inter-rater agreement resulted in Kappa = 0.496 with p < .001. Removal of a rating of neutral behaviours resulted in a higher Kappa = 0.546 with p < .001. The inter-rater reliability was only moderate for the Functional Analytical Nurse Observation Charts. Frequent training and support from management and therapy staff is required to maintain a psychologically informed environment and observation in an in-patient setting. An area for further research is to explore the impact that a FANOC has on staff satisfaction and an individual's experience of care, and whether it can assist in determining mediators of change before an improvement in symptoms.

Retrospective Evaluation of a New Neonatal Trigger Score

To design and validate an objective clinical scoring system to identify unwell neonates, by using routinely collected bedside observations. A Neonatal Trigger Score (NTS) was designed by using local expert consensus and incorporated into a new observation chart. All neonates >35 weeks' gestation admitted to the NICU over an 18-month period, and an age-matched "well" cohort, were retrospectively scored by using the newly constructed NTS and all established pediatric early warning system (PEWS) scores. Scores were calculated for 485 neonates. The NTS score area under the receiver operating characteristic curve was 0.924 with a score of 2 or more predicting need for admission to the NICU with 77% sensitivity and 97% specificity. Neonates scoring ≥2 had increased odds of needing intensive care (odds ratio [OR] 48.7, 95% confidence interval [CI] 27.5-86.3), intravenous fluids (OR 48.1, 95% CI 23.9-96.9), and continuous positive airway pressure (OR 29.5, 95% CI 6.9-125.8). The NTS was more sensitive than currently established PEWS scores. The NTS observation chart acts as an adjunct to clinical assessment, highlighting unwell neonates. Its simplicity allows successful and safe use by nonpediatric specialists. NTS out-performed PEWS, with significantly better sensitivity, particularly in neonates who deteriorated within the first 12 hours after birth (P < .001) or in neonates with sepsis or respiratory symptoms (P < .001). Neonates with a score of 1 should be reviewed and those scoring ≥2 should be considered for NICU admission for further management.

2025 – Audit of monitoring for metabolic syndrome in medium secure forensic wards in roseberry park hospital, middlesbrough, UK

Persons receiving care in forensic settings face unique challenges. Long hospital stay combined with other factors such as reduced physical activity, unhealthy diets, smoking, serious mental illness, antipsychotic medications, all add up to increase their risk of acquiring metabolic syndrome, thereby increasing morbidity and mortality. Practice of monitoring for metabolic effects of an atypical antipsychotic- Clozapine was audited with the Maudsley Guideline as standard in 2 medium secure wards with 25 patients. It was conducted in 2011. We checked whether blood lipids and body weight were monitored at baseline, at 3 months and then yearly; whether blood glucose and blood pressure were checked at baseline, at 4–6 months and then yearly. Various sources of information were used including: paper medical records, electronic clinical entries, physical observation charts, medication prescription charts, Clozapine charts and acute hospital laboratory results 24 patients (96%) were on antipsychotic medication. Of these, 23 patients were on atypicals. Of the latter, 8 persons were on Clozapine. No patient on Clozapine achieved a 100% monitoring on indices. Baseline monitoring for cholesterol, weight, blood glucose and blood pressure were 88%, 50%, 75% and 88% respectively. At midterm they were 50%, 100%, 38%, and 25% respectively. There were variable compliance with other indices at stipulated times. Lack of supporting infrastructure to facilitate compliance was identified. There was a need to adhere to existing guidelines which were also embodied in Trust policy to help manage metabolic syndrome.

1112 – Every contact counts: audit investigating extent psychiatry trainees maximise opportunity for physical health assessment when admitting patients to psychiatric hospital

Patients with severe mental illness have significantly reduced lifespans. Excepting suicide, cardiovascular risk is the biggest cause. The problem is exacerbated by psychotropic medication and poor primary care engagement. Therefore psychiatrists should maximise every opportunity to promote physical health. We audited physical examination, investigations, and documentation of past medical history (PMH) & assessments in inpatients. We used the Royal College of Psychiatrist's Physical Health in Mental Health Scoping Group 2009 guidelines as our standard. We audited notes of all 125 patients admitted to four wards at Ladywell unit over two months (01/07/2011- 31/08/2011). We surveyed trainees to identify training and resource needs and facilitate focussed interventions. Physical Examination: 102/125(82%) received physical examination, 60/125(48%) on admission. Average delay before examination 12 days. Blood tests/Investigations: 89/125(71%) received blood tests: 50/125(40%) thyroid function, 67/125(54%) liver function, 28/125(22%) glucose, 1/125(0.8%) HbA1c, 38/125(30%) lipid profile. 48/125(38%) had urine drug screening, 55/125(44%) ECG. Documentation: The following was documented: 102/125(82%) PMH, 82/125(66%) allergies, 90/125(72%) smoking status. The following was scanned into records: 23/55(42%) ECG, 72/125(58%) physical observation chart. Survey : The trainee survey highlighted need for training updates on physical health and problems in equipment provision. Physical assessment is inconsistent, neglecting metabolic screening. Admission is a vital window for screening/modifying physical health. Focussed assessment guidelines should be formulated. Following the survey, teaching led by consultant physicians has been organised on identified topics including metabolic syndrome. Lack of equipment will be addressed by creation of comprehensive equipment lists, to be distributed to ward administrators.

Applying heuristic evaluation to observation chart design to improve the detection of patient deterioration

A key goal for patient safety is to improve the early recognition and management of patients whose conditions deteriorate whilst in hospital. Paper-based observation charts are the main means of recording and monitoring patients' physiological stability, yet observations (e.g., blood pressure, heart rate, and respiratory rate) are not always correctly recorded or appropriately acted upon. No prior published study has applied usability heuristics to systematically compare the usability of multiple observation chart designs. In this study, five evaluators with human factors, applied psychology, or medical expertise inspected 25 observation charts for usability problems. Every chart was found to have substantial usability problems, potentially affecting the ability of hospital staff to accurately record observations or recognize patient deterioration. We proposed a new observation chart design, which avoids many of the previously observed usability problems.

P45 Audit of Oxygen Management on Nine Medical Wards Using Electronic Prescribing Systems

Nationwide UK audits by the British Thoracic Society have shown that more than half of UK hospital patients who are using oxygen do not have a prescription for this drug...

A human factors approach to observation chart design can trump health professionals’ prior chart experience

AimTo determine whether experienced health professionals recognise patient deterioration more accurately and efficiently using (a) novel observation charts, designed from a human factors perspective, or (b) chart designs with which they have long-term experience. MethodsParticipants were 101 health professionals experienced in using either a multiple parameter track-and-trigger chart or a graphical chart with no track-and-trigger system. Participants were presented with realistic abnormal and normal patient observations recorded on six hospital observation charts of varying design quality, including the chart that participants were familiar with (or a very similar design). Across 48 trials, the participant was asked to specify if any of the vital sign observations were abnormal, or if all of the observations were normal. Participants’ overall error rates (i.e., proportion of incorrect responses) and response times, the main outcome measures, were calculated for each observation chart. ResultsParticipants made significantly fewer errors and responded significantly faster when using a novel user-friendly chart compared with all the other designs, including the charts that they were experienced with in a clinical setting. ConclusionsThe findings suggest that, at least in the contexts examined, superior observation chart design appears to trump familiarity. Hence, hospitals motivated to improve the detection of patient deterioration should implement charts designed from a human factors perspective, rather than simply maintaining the status quo of reliance on clinical experience.

The importance of observation chart design for identifying clinical deterioration

The importance of observation chart design for identifying clinical deterioration

1568 Burton Neonatal track and Trigger Observation Chart

BackgroundThe use of early warning system scores and track & trigger charts is widespread in adult and paediatric hospitalised patients. Its use in neonatal group is not well recognized. Lack...

Overcoming Barriers to Recruitment in Care of the Dying Research in Hospitals

ContextApproximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging. ObjectivesWe designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives. MethodsA study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, “Is this patient so unwell that you feel they could die on this admission?” to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died. ResultsIn total, 6642 patients were screened. The ward staff answered “yes” to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate. ConclusionWe have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.

Response to “A cross-sectional study of constipation and laxative use in advanced cancer patients: insights for revision of current practise”

To the Editor: It was with interest that we read the recent article by Cheng et al. published in Supportive Care in Cancer [1]. The study highlighted very well the importance of understanding patient’s subjective constipation experiences as little correlation was observed in this work between people’s reports, the frequency with which bowels were opened, and the stool form. Reporting stool form requires greater exploration as recording this information has been recommended as an aid to titrating laxatives. Observation charts such as the Bristol Stool Chart have been suggested to provide guidance to patients and health professionals [2]. This is based on previous observations that have identified stool form as a way to predict colon transit time [3]. However, this work was undertaken in a healthy population. Scant attention so far paid to understanding how such observations could be extrapolated to people with cancer who are likely to have several contributing factors for disturbed bowel habits occurring simultaneously. Recent work by Dinning et al. is relevant to consider [4]. The aim of this work was to objectively assess the effects of laxatives on people’s constipation symptoms. This included a review of people’s stool form charts (n094) all of whom had scintigraphically confirmed functional slow transit (>72 h). Eighty percent of this cohort were taking laxatives either daily (n028) or intermittently (n049). The results showed that despite proven slow transit constipation, people continued to pass soft to lose frequent stools whilst taking laxatives with 75 % of the people studied falling into the normal bowel habit category (i.e. passing a bowel action more than three times per week or more than every 3 days). However, subjects self-reported severe symptoms related to pain, bloating and a need to strain when attempting to pass a bowel motion. The main conclusion of this work was that whilst laxatives aid defecation in non-cancer populations with functional constipation, these medications have little effect to improve self-reported symptoms. More work is needed as it is likely that the underlying problems experienced by people with cancer are more complex than just functional slow transit constipation. Cancer patients are exposed to many other factors that could contribute to slow colonic transit including medications, reduced functional status, impaired appetite and electrolyte disturbances. They are also at high risk of developing problems that could hinder normal defecation such as muscle wasting of the pelvic floor [5]. There is a real need to try and classify cancer patients with constipation according to the underlying problems (pre-existing bowel dysfunction, slow transit and problems of defecation). This work requires well-tolerated and easy to perform physiological function tests of colon transit and defecation. Until such work is undertaken, it remains difficult to understand the optimal approaches to assessing and palliating bowel problems. K. Clark (*) Department of Palliative Care, Calvary Mater Newcastle, Edith St., Waratah, NSW 2298, Australia e-mail: Katherine.Clark@calvarymater.org.au

Making Pain Visible: An Audit and Review of Documentation to Improve the Use of Pain Assessment by Implementing Pain as the Fifth Vital Sign

Pain has been promoted as the fifth vital sign for a decade, but there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain. This was a three-stage audit of pain assessment in one large teaching hospital in the Northwest of England. Stage one measured the baseline pain assessment activity on surgical and medical wards and identified that the pain assessment tool was not visible to nurses. Stage two redesigned the patient observation charts held at the end of the bed and piloted two versions for clinical utility. Version 2 which had pain assessment alongside the early warning score was adopted and introduced throughout the hospital. Stage three audited pain assessment and management 8 months after the introduction of the new charts. Pain was assessed more regularly at the stage three audit than at the baseline audit. On average, pain was assessed alongside other routine observations 70% of the time across surgical and medical wards. Medical wards appeared to improve their pain assessment using the philosophy of pain being the fifth vital sign better than surgical wards, because they assessed pain alongside routine observations in >90% of cases. Stage three identified that where a high pain score was recorded, analgesia was delivered in the majority of cases (88%). Introducing the philosophy of pain as the fifth vital sign and making pain assessment more visible on the patient observation chart improved the uptake of pain assessment. Pain management strategies were stimulated when high pain scores were identified.

Intravenous fluid prescribing practices by foundation year one doctors – a questionnaire study

ObjectivesFoundation Year Ones (FY1s) are the most junior doctors in the UK who are often required to prescribe intravenous fluid to patients not under their regular care, during on-call or out-of-hours ward cover. This study aimed to investigate FY1s’ practice and decision-making process of intravenous fluid prescribing to these patients.DesignQuestionnaire survey.SettingSurvey on Practices during on-calls and out-of-hours ward covers.ParticipantsFY1s of five National Health Service (NHS) hospitals in England and Scotland.ResultsAll 149 FY1s responded to survey. Eighty-six percent have been taught intravenous fluid prescribing during medical school, compared with only 48% in FY1 induction. More than half always/often checked the patient's urea and electrolytes (U&Es) (72%), read the fluid balance (58%) and observation charts (80%), discussed the case with nursing staff (75%), enquired about oral status (82%), identified the main diagnosis/operation (75%) and indication for intravenous fluid (72%) of the patient when prescribing intravenous fluid. However, less than half often/always read the medical notes (43%) or performed clinical examinations on patients (16%). Most FY1s (94%) always/often checked patient's U&Es when prescribing potassium.ConclusionsThe questionnaire study demonstrated variations among FY1s in the practice and decision-making process of intravenous fluid prescribing to patients unknown to them, during on-calls or out-of-hours ward covers. Such variations in practice should be addressed especially by medical and foundation schools, and NHS hospitals to improve patient care.

Effect of the Raga Ananda Bhairavi in Post Operative Pain Relief Management

Music is considered as an universal language and has influences the human existence at various levels.In recent years music therapy has evolved as a challenge of research with a clinical approach involving science and art. Music therapy has been used for various therapeutic reasons like Alzheimer's disease,Hypertension and mental disorders to name a few. We conducted a study to establish the effect of the classical ragam Anandhabhairavi on post operative pain relief. A randomized controlled study involving 60 patients who were to undergo surgery was conducted at PSG Institute of Medical Sciences and Research,Coimbatore.30 patients selected at random and were exposed to the ragam Anandhabhairavi which was played in their room pre operatively (from the day they got admitted for surgery) and 3days post operatively. The control group did not listen to the music during their stay in the hospital. An observation chart was attached in which the requirement of analgesics by the patient was recorded. On completion of the study and on analysis,the ragam Anandhabhairavi had a significant effect in post operative pain management which was evidenced by the reduction in analgesic requirement by 50% in those who listened to the ragam.A significant p value of <0.001 was obtained.

Single patient-observation chart could save 6,000 lives a year

Hundreds of different patient observation charts used across the country may be scrapped in favour of a single colour-coded system that could save an estimated 6,000 lives a year.

Impact of a standardized nurse observation protocol including MEWS after Intensive Care Unit discharge

BackgroundAnalysis of in-hospital mortality after serious adverse events (SAE's) in our hospital showed the need for more frequent observation in medical and surgical wards. We hypothesized that the incidence of SAE's could be decreased by introducing a standard nurse observation protocol. AimTo investigate the effect of a standard nurse observation protocol implementing the Modified Early Warning Score (MEWS) and a color graphic observation chart. MethodsPre- and post-intervention study by analysis of patients records for a 5-day period after Intensive Care Unit (ICU) discharge to 14 medical and surgical wards before (n=530) and after (n=509) the intervention. ResultsFor the total study population the mean Patient Observation Frequency Per Nursing Shift (POFPNS) during the 5-day period after ICU discharge increased from .9993 (95% C.I. .9637–1.0350) in the pre-intervention period to 1.0732 (95% C.I. 1.0362–1.1101) (p=.005) in the post-intervention period. There was an increased risk of a SAE in patients with MEWS 4 or higher in the present nursing shift (HR 8.25; 95% C.I. 2.88–23.62) and the previous nursing shift (HR 12.83;95% C.I. 4.45–36.99). There was an absolute risk reduction for SAE's within 120h after ICU discharge of 2.2% (95% C.I. −0.4–4.67%) from 5.7% to 3.5%. ConclusionThe intervention had a positive impact on the observation frequency. MEWS had a predictive value for SAE's in patients after ICU discharge. The drop in SAE's was substantial but did not reach statistical significance.

Orofacial functions and oral health associated with Treacher Collins syndrome

Objective. The aim of this study was to describe orofacial features and functions and oral health associated with Treacher Collins syndrome (TCS) in relation to the variable phenotypic expression of the condition. Materials and methods. The Nordic Orofacial Test-Screening (NOT-S), MHC Questionnaire, MHC Observation chart and clinical examinations of nasal and pharyngeal conditions and chewing and swallowing function were used to assess 19 individuals aged 5–74 years (median 34 years). TCS severity scores were calculated by a clinical geneticist. Results. Orofacial features characterizing the study group were altered profile, increased mandibular angle, narrow hypopharynx and facial asymmetry. Basic orofacial functions such as breathing, eating, facial expression and speech were affected in all subjects demonstrating orofacial dysfunction in at least two NOT-S domains (median NOT-S total score 4/12, range 2–7). Significant correlation was found between the TCS severity scores reflecting phenotypic expression and the NOT-S total scores reflecting orofacial function. Self-reported experience of dry oral mucosa was common. Overall, dental health was good with few carious lesions diagnosed, but considerable need for orthodontic treatment was documented. Conclusions. Altered orofacial features and functions in TCS are common and often persist into late adolescence and adulthood. The functional level was correlated with the phenotypic variability of the condition. The standard of oral health was satisfactory. The findings indicated that individuals with TCS are likely to require lifelong health services related to their oral condition.

Adoption of an Electronic Observation Chart With an Integrated Early Warning Scoring System on Pilot Wards

The charting of physiological variables in hospital inpatients allows for recognition and treatment of deteriorating patients. The use of electronic records to capture patients' vital signs is still in its infancy in the United Kingdom. The main objective of this article was to describe the adoption of an electronic observation charting function integrated into an established bedside e-prescribing record system on acute wards in a large English university hospital. This new function also has the capability of contacting Critical Care Outreach and clinical staff when patients deteriorate. Data captured over a 4-month period from the pilot wards showed that 80% of observation sets were completed sufficiently to produce early warning scores over the time period. A daily average of 419 Standardized Early Warning Score produced 74 alerts to clinical staff, and two critical alarms per day were e-mailed to the Outreach team. The wards showed different levels of completeness of observations (from 69% to 92%). Although a good overall rate of completeness of physiological data was found, traditional gaps in observation recording documented in the literature (eg, recording of respiratory rate) were still apparent. This system can be used for audit for targeted staff education and to evaluate the Critical Care Outreach service.

The effect of implementing a modified early warning scoring (MEWS) system on the adequacy of vital sign documentation

Early recognition of deteriorating patients results in better patient outcomes. Modified early warning scores (MEWS) attempt to identify deteriorating patients early so timely interventions can occur thus reducing serious adverse events. We compared frequencies of vital sign recording 24h post-ICU discharge and 24h preceding unplanned ICU admission before and after a new observation chart using MEWS and an associated educational programme was implemented into an Australian Tertiary referral hospital in Brisbane. Prospective before-and-after intervention study, using a convenience sample of ICU patients who have been discharged to the hospital wards, and in patients with an unplanned ICU admission, during November 2009 (before implementation; n=69) and February 2010 (after implementation; n=70). Any change in a full set or individual vital sign frequency before-and-after the new MEWS observation chart and associated education programme was implemented. A full set of vital signs included Blood pressure (BP), heart rate (HR), temperature (T°), oxygen saturation (SaO2) respiratory rate (RR) and urine output (UO). After the MEWS observation chart implementation, we identified a statistically significant increase (210%) in overall frequency of full vital sign set documentation during the first 24h post-ICU discharge (95% CI 148, 288%, p value <0.001). Frequency of all individual vital sign recordings increased after the MEWS observation chart was implemented. In particular, T° recordings increased by 26% (95% CI 8, 46%, p value=0.003). An increased frequency of full vital sign set recordings for unplanned ICU admissions were found (44%, 95% CI 2, 102%, p value=0.035). The only statistically significant improvement in individual vital sign recordings was urine output, demonstrating a 27% increase (95% CI 3, 57%, p value=0.029). The implementation of a new MEWS observation chart plus a supporting educational programme was associated with statistically significant increases in frequency of combined and individual vital sign set recordings during the first 24h post-ICU discharge. There were no significant changes to frequency of individual vital sign recordings in unplanned admissions to ICU after the MEWS observation chart was implemented, except for urine output. Overall increases in the frequency of full vital sign sets were seen.

Admission pack for newly diagnosed diabetes: help or hindrance?

Aims In order to improve communication and reduce insulin errors, a new admission pack was introduced in 2010 in a tertiary paediatric centre, for children newly diagnosed with diabetes. The aim of this study was to assess how well this pack is being used and what changes may improve it. We also asked for staff opinions about its use. Method A retrospective study of all children aged 0-18 years presenting with newly diagnosed type 1 diabetes between June 2010 and April 2011. Notes were audited to establish which pages of the pack were being completed appropriately. Questionnaires were distributed amongst staff to determine their awareness of the pack, the sections they found most useful and changes they felt should be made. Results 24 admissions were included. 66.7% of initial assessments and 70.8% of the nursing actions on admission were completed. Blood glucose (BG) charts were used in 96%, observation charts in 66.7% and food diaries in 45.8%. 75% of the history and examination sheets were used and the insulin dose calculation sheet was complete in 79.2%. Hypoglycaemia management was documented in only 29.2% of cases and the discharge checklist used in 25%. The dietitian section was completed in 45.8% of cases and the diabetes specialist nurse checklist in 79.2%. 19 staff with varying expertise received questionnaires. The majority of those who had completed the pack found the nursing checklist and care plan, BG chart, food diary, history sheets and insulin dose calculation particularly useful. However, awareness and completion of the pack differed amongst wards and staff. Of the general paediatricians, 4/5 had not completed it and 60% were unaware where to find copies. Conclusion The admission pack has been introduced successfully and is highly rated by staff, although some parts are completed better than others. Staff awareness could be improved at MDT meetings and induction training. Alterations could also be made to ease its use but it provides a framework to ensure that management is safe and clear on the ward, discharge is planned, and it prevents duplication of patient information.