Observation charts with overlapping blood pressure and heart rate graphs do not yield the performance advantage that health professionals assume: an experimental study
Abstract:These findings suggest that overlapping graphs do not yield the performance advantage that many health professionals assume, either for novices or experienced nurses, even when the Seagull Sign is used.
“…Focus groups were scheduled during shift overlap, staff development sessions and education forums to enable as many staff as possible to attend. An interview schedule guided discussion with items based on a review of the literature and from evaluations of early chart versions22 24 29 33 34 (see box 1). Trigger questions for semistructured focus groups
BackgroundOptimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger ‘Observation and Response Charts’ were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards.MethodsAcross eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2–6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach.FindingsIn this exploration of initial user experiences, key emergent themes were: tensions between vital sign ‘ranges versus precision’ to support decision making; using a standardised ‘generalist chart in a range of specialist practice’ areas; issues of ‘clinical credibility’, ‘professional autonomy’ and ‘influences of doctors’ when communicating abnormal signs; and ‘permission and autonomy’ when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of ‘increased activity/uncertain benefit’ was uncovered.ConclusionsFindings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design characteristics will be possible when these broader cultural issues are addressed.
“…Focus groups were scheduled during shift overlap, staff development sessions and education forums to enable as many staff as possible to attend. An interview schedule guided discussion with items based on a review of the literature and from evaluations of early chart versions22 24 29 33 34 (see box 1). Trigger questions for semistructured focus groups
BackgroundOptimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger ‘Observation and Response Charts’ were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards.MethodsAcross eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2–6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach.FindingsIn this exploration of initial user experiences, key emergent themes were: tensions between vital sign ‘ranges versus precision’ to support decision making; using a standardised ‘generalist chart in a range of specialist practice’ areas; issues of ‘clinical credibility’, ‘professional autonomy’ and ‘influences of doctors’ when communicating abnormal signs; and ‘permission and autonomy’ when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of ‘increased activity/uncertain benefit’ was uncovered.ConclusionsFindings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design characteristics will be possible when these broader cultural issues are addressed.
“…Vital signs data are generally recorded on paper charts placed at the end of the patients’ beds or in their rooms. These processes are subject to potential error and/or failure, such as inadequate monitoring frequency,1–3 5 10–12 incomplete data,1 10 13 inaccurate calculations of early warning score (EWS),14–17 and poor legibility and interpretability of charts,18 19 all of which have been implicated in the failure to recognise, or respond to, patient deterioration 1–3 5…”
BackgroundAvoidable hospital mortality is often attributable to inadequate patient vital signs monitoring, and failure to recognise or respond to clinical deterioration. The processes involved with vital sign collection and charting; their integration, interpretation and analysis; and the delivery of decision support regarding subsequent clinical care are subject to potential error and/or failure.ObjectiveTo determine whether introducing an electronic physiological surveillance system (EPSS), specifically designed to improve the collection and clinical use of vital signs data, reduced hospital mortality.MethodsA pragmatic, retrospective, observational study of seasonally adjusted in-hospital mortality rates in three main hospital specialties was undertaken before, during and after the sequential deployment and ongoing use of a hospital-wide EPSS in two large unconnected acute general hospitals in England. The EPSS, which uses wireless handheld computing devices, replaced a paper-based vital sign charting and clinical escalation system.ResultsDuring EPSS implementation, crude mortality fell from a baseline of 7.75% (2168/27 959) to 6.42% (1904/29 676) in one hospital (estimated 397 fewer deaths), and from 7.57% (1648/21 771) to 6.15% (1614/26 241) at the second (estimated 372 fewer deaths). At both hospitals, multiyear statistical process control analyses revealed abrupt and sustained mortality reductions, coincident with the deployment and increasing use of the system. The cumulative total of excess deaths reduced in all specialties with increasing use of the system across the hospital.ConclusionsThe use of technology specifically designed to improve the accuracy, reliability and availability of patients’ vital signs and early warning scores, and thereby the recognition of and response to patient deterioration, is associated with reduced mortality in this study.
“…A more recent experimental study has demonstrated that abnormal blood pressure and heart rate observations can be detected more quickly and accurately when these two vital signs are plotted separately, especially on charts with an integrated colour‐based early‐warning scoring‐system (Christofidis et al . ). However, no empirical study to date has directly assessed the effects of other individual observation chart design features on the detection of patient deterioration.…”
Section: Introductionmentioning
confidence: 97%
“…In Christofidis et al . 's () experiment, overlapping blood pressure, and heart rate plots actually impeded recognition of abnormal vital signs by experienced nurses and novice chart‐users alike, slowing them down and increasing their error rates. It has been suggested that performance‐preference dissociations like this arise due to the inordinate influence of extraneous factors, such as familiarity and aestheics, on people's judgements and preferences (Andre & Wickens ).…”
Our findings suggest that several individual design features can affect novice chart-users' ability to detect patient deterioration. More broadly, the study further demonstrates the need to evaluate chart designs empirically.
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