BackgroundThe recognition of patient deterioration depends largely on identifying abnormal vital signs, yet little is known about the daily pattern of vital signs measurement and charting.MethodsWe compared the pattern of vital signs and VitalPAC Early Warning Score (ViEWS) data collected from admissions to all adult inpatient areas (except high care areas, such as critical care units) of a NHS district general hospital from 1 May 2010 to 30 April 2011, to the hospital's clinical escalation protocol. Main outcome measures were hourly and daily patterns of vital signs and ViEWS value documentation; numbers of vital signs in the periods 08:00–11:59 and 20:00–23:59 with subsequent vital signs recorded in the following 6 h; and time to next observation (TTNO) for vital signs recorded in the periods 08:00–11:59 and 20:00–23:59.Results950 043 vital sign datasets were recorded. The daily pattern of observation documentation was not uniform; there were large morning and evening peaks, and lower night-time documentation. The pattern was identical on all days. 23.84% of vital sign datasets with ViEWS ≥ 9 were measured at night compared with 10.12–19.97% for other ViEWS values. 47.42% of patients with ViEWS=7–8 and 31.22% of those with ViEWS ≥ 9 in the period 20:00–23:59 did not have vital signs recorded in the following 6 h. TTNO decreased with increasing ViEWS value, but less than expected by the monitoring protocol.ConclusionsThere was only partial adherence to the vital signs monitoring protocol. Sicker patients appear more likely to have vital signs measured overnight, but even their observations were often not followed by timely repeat assessments. The observed pattern of monitoring may reflect the impact of competing clinical priorities.

Aims Despite initial promise, Workplace Based Assessments (WPBAs) have been criticised for failing to discriminate between trainees. With a largely summative component they have often been viewed as tick-box exercises of limited learning value1. Increasingly, reflection and good quality formative feedback are considered essential elements of medical learning2,3. We wanted paediatric trainees to be involved in designing new WPBAs that allow trainees to learn more from feedback and reflection, and remove the summative aspect of assessments. Methods Two areas for improvement were identified through discussion with trainees: safeguarding and written communication. Evidence of safeguarding experience and competence is becoming increasingly important, and yet was often challenging for trainees to bring to the summative Case Based Discussion (CBD) environment. The paper-based Sheffield Assessment Instrument for Letters (SAIL) was felt to be outdated and did not demonstrate adequate flexibility with the many forms of communication which trainees now use such as email for social care referrals. Two new tools were designed in conjunction with the RCPCH Assessment Methodology Working Group. Results The new assessment tools, Safeguarding CBD and Discussion of Correspondence (DOC) have subsequently been incorporated into the GMC-approved national assessment pilot. This new assessment style, referred to as ‘Supervised Learning Events’ (SLEs) allows trainees to select a learning opportunity from their own clinical practice and discuss this freely with a trainer, focussing on agreed learning objectives, and providing a forum for reflection unhampered by summative assessment. Conclusion These new tools will be evaluated and refined during the 2013–14 RCPCH Assessment National Pilot through focus groups and surveys. This was a fantastic opportunity for us as trainees to engage in a national policy development process. We hope that trainees will be involved in the evaluation of the new SLEs and to assist the RCPCH to continue its work to make SLEs a seamless part of training and professional development. References Macaulay C, Winyard P. Reflection: tick-box exercise or learning for all? British Medical Journal 2012:Nov 12. GMC. Good Medical Practice 2013. Goodyear HM, Bindal T, Wall D. How useful are structured electronic portfolio templates to encourage reflective practice? Medical Teacher 2013;35:71–73.