Vital Signs Chart Research Articles

Vital signs and early warning score monitoring: perceptions of clinical staff about current practices and introducing an electronic rapid response system

Aims and objectivesThis study investigated clinical staff perceptions of learning about current monitoring practices and the planned introduction of an electronic system for patient monitoring. The aim of this research was to evaluate the perceptions of clinical staff (nurses and doctors) about the perceived strengths and weaknesses of the current state of the rapid response system (RRS) and how those strengths and weakness would be affected by introducing an electronic RRS. MethodsThis research applied a descriptive study methodology. Two detailed sessions on demonstration on the electronic RRS for measuring and recording vital signs and the electronic Early Warning System (EWS) were followed by two structured surveys administered through an online portal (SurveyMonkey) for nurses and doctors working at Taranaki District Health Board. The study was planned and conducted between October 2020 and May 2021 at Taranaki Base Hospital, New Plymouth, New Zealand. ResultsWe found that the perceptions of clinical staff were a combination of key practice issues with current manual monitoring, expectations of improved visibility of vital sign charts, better communication between staff and thus improved patient care with the introduction of an electronic system. A majority (24, 60%) of nurses reported that, when called to assess deteriorating patients, the responders arrive at bedside within 5–30 min and an additional 11 (27%) said the responders arrive within 5 min. That is a collective 87% responder arrival within 30 min ConclusionStaff believe that an electronic RRS could improve communication, speed up decision making and have a positive impact on patient outcomes.

Knowledge, Attitudes and Practice of Nurses in Assessing Patients using Early Warning Sign (EWS) Scoring in a teaching hospital in Kuantan Pahang, Malaysia

Introduction: Early Warning Sign (EWS) is a tool made up of vital signs chart and scoring to detect any changes in patient so that immediate and appropriate care can be further determined and provided. The objectives of the study are to assess the level of knowledge, attitudes, and practice of nurses in assessing patient using EWS scoring and to identify association between socio-demographic with knowledge, attitudes, and practice, as well as to determine the associations between knowledge with attitudes, attitudes with practice and knowledge of nurses in assessing patient using EWS scoring. Methods: A quantitative cross- sectional study with convenience sampling study was conducted on 132 nurses from medical, surgical and orthopedics wards in Sultan Ahmad Shah Medical Centre (SASMEC) from November 2020 until January 2021. Printed questionnaires were distributed to the nurses in English language. The questionnaire consisted of two parts. Part A was about socio-demographic data (area and on years of nursing practice, & service, area of practice, educational level, as well as whether holding post-basic/ advance course certificate, attending life support training and ICU outreach participant). Part B was about knowledge, attitudes, and practices of EWS. Data analysis was interpreted in descriptive and inferential analysis using Statistical Package for the Social Sciences (SPSS) version 20.0. Results: A total of 108 respondents involved in the study represents 82% response rate. Majority of respondents scored low in knowledge questions with grade F (n=106, 98.3%). One respondent scored grade D, correctly answering 8 over 13 questions (62%). Only one respondent obtained grade B with 85% score. Based on the result, there are more participants (n=58, 53.7%) achieving good attitudes while respondents with poor attitudes were (n=50, 46.3%). Moreover, 59 respondents (54.6%) have higher practice level than mean score, indicating good EWS practice. The remaining 49 respondents (45.4%) scored below the mean score cut off point indicating poor practice. The mean values are different depending on working areas in terms of attitudes and practice. The association between attitudes and practice (r= 0.641, p-value<0.01) is confirmed having a positive and strong correlation. Conclusion: The study revealed that despite having poor knowledge on EWS, the nurses have demonstrated good attitudes and practice in detecting patients’ progressive deteriorating conditions; thus, confirming that there are associations in area of practice with attitudes and practice. The results also shows that there is a significant difference between attitudes and practice of nurses in assessing patient using EWS with (p- value< 0.05).

Effectiveness of Warm Water Footbath on Temperature and Fatigue among Children with Fever

Contents: A fever can have various causes. Fever can be the only sign of a sick child. It may be combined with several problems. 
 Aim: Evaluate warm water footbath effectiveness on the temperature and fatigue level among children with fever.
 Methods: Quasi-experimental pre/post, study, and control groups design was used. A non-probability purposive sample composed of 100 children, 50 in each study and control groups, their age ranged from 6-12 years with fever. The study was conducted in the Medical and Surgical wards, Emergency Unit (ER), Oncology and Hematology Units, and Pediatric Intensive Care Unit (PICU) at Children Hospital affiliated to Ain Shams University. Four tools were used. A Structured Interviewing Questionnaire. It is composed of two parts; the first part was concerned with the socio-demographic characteristics of children. The second part was concerned with the child's medical history. The second tool was the Child's Vital Signs Chart (pre & post). It was used to assess the child's vital signs, especially temperature. The third tool was Fatigue Scale Child (FS-C), and the fourth tool was Fatigue Scale Staff (FS-S) (pre & post) were used to assess the fatigue level among children pre- and post-applying warm water footbath from child perceptions and researcher's evaluation as a staff. The intervention was a warm water footbath applied for 20-30 minutes.
 Results: The mean score level of children's age was 10±1.3 & 10±1.5 years for both the study and control groups, respectively. Nearly two-thirds of them (68% &62%) were boys in the study and control groups, respectively. There were significant differences in the temperature and fatigue score among children with a fever between the study and control groups after the application of warm water footbath therapy. Also, statistically significant differences between the children mean scores of temperature and fatigue pre- and post-footbath in the study group children.
 Conclusion: Warm water footbath is effective in reducing the temperature and fatigue level among children with fever. Recommendations: Warm water footbath should be involved in fever management protocol for children as a complementary therapy, and further studies with a large sample and another age group of children in another setting are also recommended.

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography.

To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. Observation was conducted for 300hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.

The interactive effect of preoperative consultation and operating room admission by a counselor on anxiety level and vital signs in patients undergoing Coronary Artery Bypass Grafting surgery. A clinical trial study.

Objective. The purpose of this study was to provide appropriate preoperative supportive conditions to improve anxiety and vital signs for patients undergoing Coronary Artery Bypass Grafting -CABG- surgery. Methods. This clinical trial study was performed on 90 patients undergoing CABG surgery in Farshchian Hospital of Hamadan, Iran in 2019. Sample was selected by convenience and were randomly divided into three groups: control (n=30), intervention1 (n=30), and intervention2 (n=30). The control group received only the routine preoperative counseling of ward and admitted to the operating room as usual; the intervention1 and intervention2 groups in addition received another two counseling sessions, then the intervention1 group was admitted in the operating room as usual, but the intervention2 group was admitted by the counselor in the operating room. Data were collected using a three-part questionnaire including demographic characteristics, vital signs chart, and the Spielberger's State-Trait Anxiety Inventory. Results. The results showed that there was a significant difference in the mean anxiety of the three groups after admission in the operating room (intervention2 was lower than intervention1 and control groups, p<0.001; and intervention 1 group was lower than control group, p<0.001) and also there was a significant difference between the mean systolic blood pressure, heart rate and respiratory rate of the three groups (p<0.001) but the mean of the variables of temperature and diastolic blood pressure in the three groups were not significantly different (p=0.59 and p=0.225, respectively). Conclusion. Our results revealed preoperative consultation and admission in the operating room by the consultant can reduce the level of anxiety and stability of vital signs of patients undergoing CABG.

The Impact of Emerging Simulation-Based Technologies on the Management of Deteriorating Patients: Aiming for a Gold Standard Educational Evaluation

BackgroundMeasuring the impact of patient safety interventions is challenging. This article aims to illustrate a “gold standard” model of program evaluation incorporating examples from two patient deterioration programs. MethodsAustralian nurses were trained in primary responses to emergencies in four hospitals using either face-to-face (F2F) or screen-based simulation versions of a simulation program. Evaluation outcomes were measured using Kirkpatrick's evaluation hierarchy covering participant ‘reaction’, ‘learning’, ‘behaviour’ change and ‘results’—based on 1,564 pre–post intervention vital signs chart reviews. ResultsSeventy-four nurses participated. Reaction—participant confidence/competence ratings and Learning improved significantly in both modalities (p < .001). Behaviour—oxygen delivery systems were used more appropriately after training in the F2F group (p = .037). Applicable recording of oxygen saturation (SpO2) improved significantly (p ≤ .008) in both modalities. Results—at least a two-fold increase in the overall initiation of a clinical review after training, in both modalities (p < .001; effect: d = 0.41 F2F and d = 0.35 screen-based simulation). ConclusionsKirkpatrick's evaluation model enables a suitable template for gold standard education evaluations.

Design errors in vital sign charts used in consultant-led maternity units in the United Kingdom

BackgroundPaper-based charts remain the principal means of documenting the vital signs of hospitalised pregnant and postnatal women. However, poor chart design may contribute to both incorrect charting of data and clinical responses. We decided to identify design faults that might have an adverse clinical impact. MethodsOne hundred and twenty obstetric early warning charts and escalation protocols from consultant-led maternity units in the United Kingdom and the Channel Islands were analysed using an objective and systematic approach. We identified design errors that might impede their successful use (e.g. generate confusion regarding vital sign documentation, hamper the recognition of maternal deterioration, cause a failure of the early warning system or of any clinical response). ResultsWe found 30% (n=36/120) of charts contained at least one design error with the potential to confuse staff, render the charts difficult to use or compromise patient safety. Amongst the most common areas were inadequate patient identification, poor use of colour, illogical weighting, poor alignment and labelling of axes, and the opportunity for staff to ‘game’ the escalation. ConclusionsWe recommend the urgent development of an evidence-based, standardised obstetric observation chart, which integrates ‘human factors’ and user experience. It should have a clear layout and style, appropriate colour scheme, correct language and labelling, and the ability for vital signs to be documented accurately and quickly. It should incorporate a suitable early warning score to guide clinical management.

Pain is vital in resuscitation in trauma.

Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.

The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward

PurposeRecording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score (MEWS) uses vital signs to categorise the severity of a patient's physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. MethodsVital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator-measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL. ResultsThe details of 181 newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88% for respiratory rate, 98% for blood pressure, 92% for temperature and 41% for GCS. The recorded heart rate was positively correlated with the investigator's measurement (Pearson's correlation coefficient of 0.76); while the respiratory rate did not correlate (Pearson's correlation coefficient of 0.02). In 59% of patients the recorded respiratory rate (RR) was exactly 20 breaths per minute and 27% had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15.The average MEWS was 2 for both the recorded (MEWS(R)) and investigator (MEWS(I)) vitals, with the range of MEWS(R) 0–7 and MEWS(I) 0–9. Analysis showed 59% of the MEWS(R) underestimated the physiological derangement (scores were lower than the MEWS(I)); 80% of patients had a MEWS(R) requiring 4 hourly checks which was only completed in 2%; 86% of patients had a MEWS(R) of less than three (i.e. not necessitating escalation of care), but 33% of these showed a MEWS(I) greater than three (i.e. actually necessitating escalation of care). ConclusionDocumentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients' physiological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts.

Validation of a modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool: A mixed methods study.

To develop and validate a modified Situation-Background-Assessment-Recommendation communication tool incorporating components of the Cape Town modified early warning score vital signs chart for reporting early signs of clinical deterioration. Reporting early signs of physiological and clinical deterioration could prevent "failure to rescue" or unexpected intensive care admission, cardiac arrest or death. A structured communication tool incorporating physiological and clinical parameters allows nurses to provide pertinent information about a deteriorating patient in a logical order. Mixed methods instrument development and validation. We used a sequential three-phase method: cognitive interviews, content validation and inter-rater reliability testing to validate a self-designed communication tool. Participants were purposively selected expert nurses and doctors in government sector hospitals in Cape Town. Cognitive interviews with five experts prompted most changes to the communication tool: 15/42 (35.71%) items were modified. Content validation of a revised tool was high by a predetermined ≥70% of 18 experts: 4/49 (8.2%) items were modified. Inter-rater reliability testing by two nurses indicated substantial to full agreement (Cohen's kappa .61-1) on 37/45 (82%) items. The one item achieving slight agreement (Cohen's kappa .20) indicated a difference in clinical judgement. The high overall percentage agreement (82%) suggests that the modified items are sound. Overall, 45 items remained on the validated tool. The first modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool developed in South Africa was found to be valid and reliable in a local context. Nurses in South Africa can use the validated tool to provide doctors with pertinent information about a deteriorating patient in a logical order to prevent a serious adverse event. Our findings provide a reference for other African countries to develop and validate communication tools for reporting early signs of clinical deterioration.

Vital signs and other observations used to detect deterioration in pregnant women: an analysis of vital sign charts in consultant-led UK maternity units

BackgroundObstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care. MethodsOne-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers. ResultsThere was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of ‘normal’ vital sign ranges were found, the most common being: heart rate=50–99beats/min; respiratory rate=11–20breaths/min; blood pressure, systolic=100–149mmHg, diastolic ≤89mmHg; SpO2=95–100%; temperature=36.0–37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency. ConclusionThe wide range of ‘normal’ vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding ‘normal’ vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Nurses Perception toward Using a New Eight Vital Signs Chart at ICUs

Background: Assessment of the traditional vital signs at ICUs as temperature, pulse, respiration, blood pressure and oxygen saturation are inadequate to determine patients’ clinical condition deteriorating; however assessment of eight vital signs should be included in a routine nursing assessment to improve patients’ outcomes for appropriate nursing diagnosis on proper time. Aim: To assess nurses’ perception toward using a new eight vital signs chart at ICUs Methods: Descriptive cross-sectional study design was used in this study composed of 45 nurses from all ICUs at the Beni-Suef University Hospital from November 2015 to January 2017, data were collected using structured interview to assess nurses’ perception toward using a new eight vital signs chart at ICUs. Results: The study findings demonstrate the distribution of all nurses’ perception items and found more than two third of the study sample (68.9%) were agreed to use eight vital signs, and almost all nurses had fantastic perception to eight vital signs, moreover about (84.4%) had adequate knowledge regarding assessment of pain, level of consciousness, urine output, as well as more than half of study sample reported the degree of importance is extremely important to assess additional three vital signs with basic vital signs (55.6%). However barrier may face nurses to assess pain, level of consciousness and urine output were reported high percentage (91.1%) and (97.8%) agreed to use the new eight vital signs chart at ICUs and defiantly it will help for better design of Nursing Diagnosis. Conclusion: ICUs’ nurses strongly agreed to apply new 8 vital signs chart at ICUs for meticulous designing of nursing diagnosis of patients’ clinically unstable. Recommendation: The study is recommended to consider the importance of application a new eight vital signs chart instead of traditional five vital signs and generalized it in the hospital documentation system.

CRITICAL APPRAISAL: ADEQUACY OF REPORTING STUDIES ON EARLY WARNING SCORE SYSTEMS

Background : Routine monitoring of patients’ clinical and physiological status by nurses includes the use of vital signs (observations) charts for recording findings. Charts that incorporate early warning score (EWS) systems are designed to ‘track’ signs of deterioration and ‘trigger’ a rapid response. Published studies of EWS systems are of limited benefit if reporting of these studies is inadequate. Reporting guidelines are recommended to improve the quality of reporting. Objective: To assess the adequacy of reporting studies on EWS systems. Methods: All study designs published between 1 May 2007 and 23 May 2015 describing the use of EWS systems for detecting deterioration in adult patients on general medical and surgical wards were included. Data extraction was undertaken by one researcher. Results: Of the 657 references identified from search terms, 596 articles were excluded leaving 61 articles for assessment. Most studies were published in non-nursing journals (47/61, 77.0%). Six of the 61 (9.8%) studies were reviews. The remaining 55 clinical studies on the use of EWS/MEWS systems were mostly observational (46/55, 83.6%) rather than experimental (9/55, 16.4%). Reporting guidelines were used in 9.8% (6/61) of reviewed studies. Only the reviews but no clinical studies reported a search strategy. Electronic searches included mostly CINAHL (5/6, 83.3%), MEDLINE and The Cochrane Library (4/6, 66.7%). No meta-analyses were performed. Inclusion and exclusion criteria and reasons for exclusion of references were well reported in the reviews. The most frequently reported range of physiological parameters (12/61, 19.7%) were respiratory rate, oxygen saturation, supplemental oxygen, heart rate, systolic blood pressure, temperature and level of consciousness. Conclusion: Reporting of published studies on EWS systems reviewed for this critical appraisal, with the exception of reviews, was inadequate as most did not use reporting guidelines, limiting the use of study findings for developing clinical guidelines and in further research.

G312(P) Improving neonatal mortality in an Ethiopian referral hospital

Ethiopia has one of the world’s poorest neonatal mortality rates. As a british paediatrician working for one year the main aim was to improve neonatal care in a referral hospital’s...

A Retrospective Study to Audit Nursing Documentation of Psychiatric Patients of Selected Hospital, Ludhiana, Punjab

Retrospective Study to Audit Nursing Documentation of Psychiatric Patients of Selected Hospital, Ludhiana, Punjab. The purpose of this study was to evaluate the nursing documentation through auditing with a view to prepare nursing documentation protocol. Objectives of the study were to audit nursing documentation of psychiatric patients’ bed side charts, to ascertain nursing documentation in relation to the variables like: duration of hospitalization, years of nursing documentation records and to prepare nursing documentation protocol. The present study was conducted to audit nursing documentation of psychiatric patients’ bed side charts. The area selected for the study was medical record office of Christian Medical College & Hospital, Ludhiana, Punjab. Retrospective approach was used in the study. Sample was selected using random sampling technique, time spent to audit each psychiatric patients’ bed side charts was of 15–20 min. Structured nursing documentation audit tool was used to collect required data. Reliability was 0.79. Try-out was conducted on four psychiatric patients’ bed side charts to find out the wording and clarity of the research tool. Pilot study was conducted on 20 psychiatric patients’ bed side charts to check the feasibility and practicability of the study. Final study was carried out on 200 psychiatric patients’ bed side charts in the month of December,2010-January,2011. Descriptive and inferential statistics were employed to analyse the data. Bar diagrams and pie charts were used to depict the findings. On the basis of mean score most deficit area of nursing documentation was treatment sheet and least deficit area was vital signs chart of psychiatric patients. Relationship of nursing documentation with duration of hospitalization and year of nursing documentation were not found statistically significant. Findings revealed that nursing documentation of psychiatric patients’ bed side charts need improvement and protocol for nursing documentation need to be administered.

A review of rapid response team activation parameters in New Zealand hospitals

ObjectiveTo review current systems for recognising and responding to clinically deteriorating patients in all New Zealand public hospitals. DesignA cross-sectional study of recognition and response systems in all New Zealand public hospitals was conducted in October 2011. Copies of all current vital sign charts and/or relevant policies were requested. These were examined for vital sign based recognition and response systems. The charts or policies were also used to determine the type of system in use and the vital sign parameters and trigger thresholds that provoke a call to the rapid response team. SettingAll New Zealand District Health Boards (DHBs). Main outcome measuresPhysiological parameters used to trigger rapid response, the weighting of any early warning score assigned to them, type of system used, values of physiological derangement that trigger maximal system response. ResultsAll DHBs use aggregate scoring systems to assess deterioration and respond. A total of 9 different physiological parameters were scored with most charts (21%) scoring 6 different parameters. All scored respiratory rate, heart rate, systolic blood pressure and conscious level. 86% scored oliguria, 14% polyuria, 33% oxygen saturation and 24% oxygen administration. All systems used either aggregate scores or a single extreme parameter to elicit a maximal system response. The extremes of physiological derangement to which scores were assigned varied greatly with bradypnoea having the greatest range for what was considered grossly abnormal. ConclusionA large variance exists in the criteria used to detect deteriorating patients within New Zealand hospitals. Standardising both the vital signs chart and escalation criteria is likely to be of significant benefit in the early detection of and response to patient deterioration.

Improving neonatal mortality in an Ethiopian referral hospital.

Ethiopia has one of the world's poorest neonatal mortality rates (1). As a British paediatrician working for one year, the main aim was to improve neonatal care in a referral hospital's neonatal unit. An initial project looking at all admissions to the unit over the month of October 2012, revealed the death rate within the unit was 21% of all admissions. Of the 55 admissions only 43 (75%) had a temperature recorded at admission. 29 (67%) of these were hypothermic, and of these 29 initially hypothermic babies, 19 (65%) remained hypothermic or did not have another temperature documented during their stay. Only 33 (56%) had a heart rate and respiratory rate recorded on admission and only 11 (19%) had any further vital signs recorded during their stay. 19 of the admitted infants had a diagnosis of low birth weight and 10 (53%) of these either died or left against medical advice.With this information regular basic neonatal care teaching sessions for doctors and nursing staff were initiated. Vital signs charts were introduced and unit specific protocols were written. Continuous Positive Airway Pressure (CPAP) was trialled and found to be effective, and CPAP training was given to all nurses and doctors on the unit. A room was set aside to be used solely as Kangaroo Mother Care (KMC). The nurses were taken to a very effective neonatal unit as an ‘experience sharing’ trip to help with motivation and a grant was also obtained for basic equipment.After 6 months the project was repeated for all the admissions during February 2013. The death rate had progressively fallen and was 10% in February. 54 patients (98%) had a temperature taken on admission and of these, 27 (49%) were hypothermic. 25 (93%) of these hypothermic infants had subsequent temperatures documented which were normal. 54 (98%) had heart rate and respiratory rate recorded on admission and 50 (90%) had them recorded at least daily during their stay. Of the 22 babies with low birth weight (40%), only 4 (18%) died/left against medical advice. 4 received CPAP and 6 were treated with KMC.

Automated calculation of ‘early warning scores’

Smith and Oakley [1] have described important problems with the use of a patient ‘track and trigger’ system, and the consequent errors that arise because of current methods of recording and charting raw data, and of deriving an early warning score (EWS). They describe considerable variability in the recording of patient vital signs, with only 65% of observations sets containing a full set of data (systolic blood pressure, respiratory rate, temperature and heart rate), echoing the findings of the recent cluster-randomised controlled trial of Medical Emergency Teams [2]. Smith and Oakley also observed the ‘rounding up or down’ of physiological values, the recording of EWS without documentation of associated raw data, and the incorrect calculation of the EWS, some of which was thought to be due to the design of the EWS weighting system. We believe that many of these problems can be minimised or solved by using computer systems to capture patients' raw physiology at the bedside and to calculate EWS automatically. It is known that the use of an EWS can drive improvements in the collection of data [3]. A system that routinely prompts staff to collect all routinely measured variables at the same visit would enhance this further. We are currently implementing a personal digital assistant (PDA) based system that collects all commonly recorded vital signs data and automatically calculates EWS [4]. This removes the need for healthcare staff to know the weightings for individual physiological parameters, thereby reducing the possibility of the ‘data manipulation’ alluded to by Smith and Oakley. All data is automatically stored electronically on the main server of the hospital using a wireless local area network (W-LAN), with raw physiology data, EWS, vital signs charts and oxygen therapy records being instantaneously available to any member of the hospital health care team via W-LAN or the hospital intranet. All vital signs charts are legible, accurate, up-to-date, timed and dated, with auditable tracking of data to the level of patient location and the person in-putting the data using electronic signatures. During the development of this system, we have demonstrated improved accuracy of EWS calculation (as errors can only be due only to the input of raw physiology), and a reduction in the time required by nurses to chart and calculate an EWS, compared with the traditional pen and paper method [5]. At the same time, we found further data (unpublished) that complement Smith and Oakley's assertion that EWS accuracy decreased with increasing patient illness. Our study [5] used five patient scenarios that were always given in the same order. Scenarios 1 and 2 were of equal patient severity of illness (to attempt to accommodate any learning effect) and were the least severe; scenarios 3, 4 and 5 were of progressively increasing patient severity of illness. We found that the time taken to complete the scenarios increased significantly with severity of illness (the complexity of the scenario) when the scenarios were completed using pen and paper. There was no such increase when the PDA was used to complete the scenarios. In this latter case, the participants were simply entering physiological data values in the PDA as opposed to having to derive the EWS score from the raw data when using pen and paper. Our findings, and those of Smith and Oakley, demonstrate the importance of accuracy in collecting and charting of vital signs, and of calculating EWS using ‘track and trigger’ systems. Inaccurate scoring can have important clinical consequences and implications for the validation of early warning scoring systems. We believe that the use of appropriate, clinically relevant information technology can improve these processes considerably. The PDA system referred to, VitalPACTM, is a collaborative development of The Learning Clinic Ltd and Portsmouth Hospitals NHS Trust.

Hospital-wide physiological surveillance–A new approach to the early identification and management of the sick patient

Hospitalised patients, who suffer cardiac arrest and require unanticipated intensive care unit (ICU) admission or die, often exhibit premonitory abnormalities in vital signs. Sometimes, the deterioration is well documented, though there is little discernable evidence of intervention. In other cases, monitoring and recording of vital signs is infrequent or incomplete. Healthcare providers have introduced "track and trigger" systems to allow early identification of patients with physiological abnormalities, and rapid response teams to facilitate rapid and appropriate management. However, even when "track and trigger" systems are used, the recording of vital signs, patient chart completion and team activation remain sub-optimal. We have developed a system for collecting routine vital signs data at the bedside using standard personal digital assistants (PDA). The PDAs act as "thin clients" linked by a wireless local area network (W-LAN) to the hospital's intranet system, where raw and derived data are integrated with other patient information, e.g., name, hospital number, laboratory results. It is possible for raw physiology data, early warning scores (EWS), vital signs charts and oxygen therapy records to be made instantaneously available to any member of the hospital healthcare team via the W-LAN or hospital intranet. Early and direct contact with members of the patient's primary clinical team or rapid response team can be made through an automated alerting system, triggered by the EWS data. The ability to capture physiological data at the bedside, and to make these available to anyone with appropriate access rights at any time and in any place, should provide previously unattainable, clinical and administrative benefits. Analysis of the raw physiological data and patient outcomes will also make it possible to validate existing and future "track and trigger" systems.

Long-term effect of introducing an early warning score on respiratory rate charting on general wards

The respiratory rate is an early indicator of disease, yet many clinicians underestimate its importance and hospitals report a poor level of respiratory rate recording. We studied the short- and long-term effects of introducing a new patient vital signs chart and the modified early warning score (MEWS), which incorporates respiratory rate on the prevalence of respiratory rate recording in six general wards of our hospital. Prior to the commencement of the study, the average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5 ± 13.5%. After the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to three wards, this rose to 68.9 ± 20.9%. When all six wards had been using both the new chart and the MEWS system for almost 1 year, the figure had reached 91.2 ± 5.6%. During the pre-introduction period, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%; p = 0.118). During the second two audit periods, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards ( p < 0.001). The study confirms the long-term beneficial effect of introducing the MEWS system on respiratory rate recording into the general wards of our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This may have an impact on the future incidence of potentially avoidable cardiac arrest, deaths and unanticipated intensive care unit admission.