Electronic alerts a step closer

December 2015 Vol 15 (6)

Paperless capture of vital signs is another step closer at Canterbury District Health Board with the rollout of electronic patient observations software and an early warning score (EWS) system now underway in the first ward. Nursing Review reports


Sue WoodEarlier detection of a patient’s deteriorating vital signs is the driver behind replacing bedside paper charts with an electronic app.

This shift to electronic recording of patient observations, or vital signs, is now underway in Christchurch Hospital. Project leader Sue Wood says the first nurse was issued a mini-iPad loaded with the software on 7 November in a neurosurgical ward and the Patientrack software will be rolled out ward by ward over the coming year.

For the time being, nurses will be recording the standard physiological observations (‘obs’) both electronically and on paper as they become accustomed to using Patientrack. The app’s early warning score (EWS) trigger that electronically alerts clinicians when a patient’s vital signs are deteriorating is about a year away from activation.

Wood is quality and patient safety director at Canterbury District Health Board and leader of the project, which began after the board flagged that one area for improvement was the care of the deteriorating patient. The former director of nursing at MidCentral District Health Board and current member of the National IT Board has championed TrendCare acuity software to highlight the workload demands placed on nursing and says this latest project will also contribute data to help nurses measure the patient workload.


Improving responses

But the key driver for the project, in which Canterbury DHB is partnering with Waitemata DHB, is to improve responses to the deteriorating patient. International data shows common setbacks include variable recording of patient obs and similarly variable responses when vitals signs begin to deteriorate.

All DHBs now have EWS systems and many have specialist outreach teams that are triggered by these systems to respond to deteriorating patients. Waitemata’s outreach teams see around 2,000 patients a year and Canterbury’s teams around 1,000 patients a year.

Wood says that if a deteriorating patient is identified earlier, clinicians may be able to stop or reverse the deterioration. Even for those patients who may not live longer as a result, the earlier their deterioration is identified the greater the likelihood of a better care experience for both them and their families.


Gaps in paper-based information

Wood addressed October’s National Nursing Informatics Conference on the Patientrack project and how it hopes moving from paper to electronic recording of observations and to automatic EWS calculations will make a difference to patient care. She says problems with the current paper chart system include gaps in information due to delayed or missing obs.

“Maybe the nurse made a call that doing obs at the set time wasn’t appropriate [patient asleep] or the patient wasn’t there or the nurse was called away or busy with another patient – but there’s no evidence so you don’t know.” 

Nurses and doctors often waste time looking for the bedside chart and once found it might not contain all that they need anyway, as sometimes “people are holding pieces of information in their head that doesn’t necessarily get to the chart”.

Also escalations of care aren’t always triggered, despite charts revealing that the recorded patient observations tick all the boxes on the EWS trigger list. “People make clinical judgements based on what they see and may or may not call in help as a result.”

Worryingly, research also shows that 50 to 80 per cent of the time EWS scores are incorrect – often because the numbers aren’t added up correctly.

Wood believes that electronic observations capture can overcome some of these issues. Rather than having to hunt for a paper chart, the nurse can pull out their own mini-tablet from their pocket and collect and record the data at the bedside.


Consistency and continuity

She says it provides consistency and continuity in how the data is recorded (no handwriting issues) and automatically calculates an early warning score. Patientrack has a simple interface and can be installed on a tablet, smartphone, laptop on wheels or a device tethered to the bedside.

Obs data, like oxygen saturation and blood pressure, can be ‘beamed’ directly in from machines to a mobile device. However, Wood says the UK experience has shown there are risks so the preference is to key in the data by hand. Along with the typical observations of vital signs, Canterbury will also be electronically recording other relevant observations like fluid balances, weight, pain or nausea.

How often obs should be recorded i.e. hourly, four-hourly, or six-hourly, can be configured for each patient and the smartphone or tablet in the nurse’s pocket will prompt them when obs are due. The software will also record whether the obs for each patient are done early or late (and includes the option of recording why some or all obs were not done at the designated time). The updated observations can be seen immediately by the patient’s clinical team on any computer screen or mobile device linked to the hospital’s IT system.

Wood says this real-time data means the shift leader can see whether obs are being done in a timely fashion and can use it as a workload management tool to monitor whether an individual nurse or ward is overloaded.

Patientrack also does real-time analysis of the deterioration risk, calculates an EWS score, and has the ability to automatically alert the relevant clinicians.


Reduction in avoidable mortality

In the UK, electronic early warning systems have been shown to reduce avoidable mortality caused by late detection or notification of deterioration, as well as reduce cardiac arrests. Wood says the data provided by Patientrack will also allow Canterbury and partner Waitemata to be able to audit the effect of different observation protocols and the impact of the electronic alert system on avoidable mortality. Canterbury is also developing an electronic nursing assessment system – for use with the interRAI tool – to assess the risk of  falls and pressure injuries alongside Patientrack.

But first, Canterbury is slowly rolling out the new technology ward by ward to accustom nurses and doctors to the electronic obs system and give them time to fine-tune the electronic trigger alert levels. These must be set at just the right level of sensitivity to ensure more deteriorating patients are detected and helped in time than has been possible with the soon-to-be old-fashioned bedside chart.

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