A multi-faceted approach to the physiologically unstable patient

Severity stratification of patients hospitalized on the Internal Medicine ward: work in progress

“…In some retrospective studies, cases were divided into classes of severity by calculating the MEWS score only after admitting the patient onto a hospital ward. 8,9 These papers, although extremely heterogeneous, confirm the report by Scotti and Pietrantronio that a high rate of patients admitted onto Internal Medicine wards have lower MEWS scores, mainly 0-1. The least that could be said, and this is by no means a holistic point of view, is that many of these patients could have been considered suitable for outside hospital care and in several cases this may have been inappropriate.…”

Resolving contentious hospital observation chart design decisions using a behavioural experimental approach

“…Clinicians have specifically questioned whether the novel ADDS chart design: (1) will remain beneficial to users highly experienced with alternative chart designs; (2) should present blood pressure and heart rate graphs as separate plots; (3) should use drawn-dot observations, an integrated colour track-and-trigger system, and grouped scoring-rows to support users; and (4) adopts a design layout that best facilitates users' calculation of summary scores. As with previous work Hammond et al, 2013;Kansal & Havill, 2012;Robb & Seddon, 2010), the study by compared charts that varied on more than one dimension. This means that, while Preece et al's results support the efficacy of the ADDS chart's overall design, they do not constitute evidence to support any of the specific design decisions employed.…”

“…Many factors can contribute to health professionals' failures to recognise and respond to a patient who deteriorates. These include: (a) a poor understanding of why vital signs are measured; (b) limited knowledge of the symptoms and signs that can signal deterioration; (c) failures in communication (including uncertainty in whether it is appropriate to seek assistance); (d) unclear roles and responsibilities; and (e) inadequate skills and expertise (Cioffi, Salter, Wilkes, VonuBoriceanu, & Scott, 2006;Robb & Seddon, 2010). However, another potential key contributor is often overlooked: the design of the observation chart itself.…”

“…Track-andtrigger systems combine the routine 'tracking' of vital sign observations with 'triggers' to prompt chart-users to act on deterioration according to pre-determined criteria . Charts that incorporate a track-and-trigger system can be subdivided by the type of alerting system: Hammond et al, 2013;Kansal & Havill, 2012;Robb & Seddon, 2010). However, these studies are limited in that they do not systematically compare design features between novel and existing charts.…”

“…This data can then be used to: (a) plan and implement appropriate interventions (e.g., medications); (b) evaluate a patient's response to interventions (e.g., before and after a surgical procedure); and, most importantly, (c) identify when a patient's general physical condition deteriorates (Koutoukidis, Stainton, & Hughson, 2012). It is important that health professionals have the means to accurately and efficiently identify clinical deterioration, as its prevalence within hospitals is widespread and increasing due to the changing characteristics of patients (e.g., ageing populations and an increased proportion of patients having complex medical issues) and healthcare systems (e.g., shorter hospital stays and increased bed occupancy) (ACSQHC, 2008;Bright et al, 2004;Johnstone, Rattray, & Myers, 2007;Robb & Seddon, 2010). Fortunately, observable derangements in vital signs often precede deterioration and therefore many serious adverse events are predictable (Buist et al, 2004;Goldhill, Worthington, Mulcahy, Tarling, & Sumner, 1999b;Jacques, Harrison, McLaws, & Kilborn, 2006;Kause et al, 2004).…”