Screening for Discomfort as the Fifth Vital Sign Using an Electronic Medical Recording System: A Feasibility Study

Abstract

Late referral to a specialized palliative care service hinders quality symptomatic management. The aim of this article is to describe the feasibility and clinical usefulness of screening for patient discomfort as the fifth vital sign using an electronic medical recording system to identify patients with undertreated physical symptoms. For the electronic medical recording system, all admitted patients received routine nurse assessment of discomfort (defined as any physical symptom) at every vital signs check using Item 2 of the Support Team Assessment Schedule Japanese version (STAS). All medically treated cancer patients admitted to seven oncology units were automatically screened at one-week intervals. Positive screening was defined as a STAS score of 2 or more at least two times during the previous week. For each patient identified by screening, a palliative care team reviewed the medical record and provided written recommendations when other treatments might improve the patient's physical symptoms. Of 629 patients screened, 87 (14%) initially met the positive screening criteria. Fifteen (17%) were false positive due to psychiatric symptoms without physical symptoms or due to misrecording. Of 72 cases with actual discomfort, 33 had already been referred to the palliative care team, 14 had received adequate palliative care as determined by the palliative care team, 14 had self-limiting transient discomfort, and one patient died before the screening day. In the remaining 10 cases (11% of symptomatic patients, 1.7% of all screened patients), the palliative care team recommended potentially useful interventions for symptom control; seven patients were referred to the palliative care team within one week. The time required for all screening processes was about 30 minutes per week. This experience demonstrates that screening for patient discomfort as the fifth vital sign using an electronic medical recording system can be successfully implemented and may be useful in facilitating early referral of distressing patients to the specialized palliative care service.

The relative meaning of absolute numbers: the case of pain intensity scores as decision support systems for pain management of patients with dementia

“…An additional advantage of this type of computerized system could be for specialized teams – such as pain specialists – to screen records of inpatients so that they could visit and review those patients with documented pain not otherwise referred to them (similarly to what has been proposed for the screening of discomfort of cancer patients by palliative care teams [ 35 ]). This is also an example of the ‘new uses’ generated by the introduction of electronic systems in place of paper-based ones and how their clinical utility extends to new aspects of patient care.…”

Do High Symptom Scores Trigger Clinical Actions? An Audit After Implementing Electronic Symptom Screening

“…To help standardize symptom assessment into routine clinical care, several large oncology settings have invested in electronic systems to capture patientreported symptom data. 1 Electronic symptom assessment has been shown to be feasible and efficient at helping to standardize screening, inform symptom management, and monitor adverse events and quality [1][2][3][4] ; however, it also represents a major investment in time and resources by the oncology system. Several randomized trials using electronic symptom reporting have suggested that routinely providing oncology providers with patient-reported symptom outcomes is beneficial, though the evidence is nuanced, with limitations to specific symptoms, particular tools or interventions, or nonsignificant results.…”

A systematic review of the use of the electronic health record for patient identification, communication, and clinical support in palliative care

“…Most common action taken by GP was to start an electronic anticipatory care plan. Morita et al, 22 Schizuoka, Japan Feasibility study of 629 male and female oncology patients screened for discomfort in a Japanese 700 bed cancer hospital Alert: CDS automatically screened pain scores; produce trigger for PC team Identified undertreated symptoms. Feasible to identify patients with considerable physical discomfort using EHR; no patient burden; minimal nursing burden.…”

“… 45 Other suggestions included adding additional diagnosis codes to the alert system to identify specific symptoms in patients who are not yet in need of PC, but can benefit from a change in treatment course or to alleviate discomfort. 19 , 22 …”