Ugochi NwuluSenior Research Associate

Patient bedside monitoring at the Queen Elizabeth Hospital Birmingham

Birmingham and Black Country CLAHRC Theme 9: Improving Patient Safety –

Studying an evolving IT system

This theme evaluates the implementation of various clinical computing technologies in

University Hospital Birmingham NHS Foundation Trust that aim to improve safety and quality of care

Outline of presentation

Bedside monitoring: What, When, Who and Why

Interventions which improve patient outcomes: by improving patient bedside monitoring

What happens at UHB: an overview of PICS and the electronic observation form

Bedside monitoring in the future: advanced computerised solutions

Bedside monitoringWhat is monitored?

• TPR charts: temperature, pulse, respiratory rate, blood pressure & oxygen saturation most frequent measurements taken by health care professionals

• These VITAL SIGNS are important indicators of the body’s response to stressors and form part of a routine physical assessment

• Additionally – measures of consciousness (AVPU), urine output, pain scores are part of bedside monitoring

• Other aspects of bedside monitoring are often needed in different circumstances – after certain procedures

Bedside monitoringWhen to monitor?• On admission• According to ward/unit/specialty• Before and after a procedure/surgery• Before and after blood transfusions• As indicated with medications

NICE guidance recommends that all inpatients must havetheir vital signs recorded as a minimum every 12 hours but the

frequency should be increased when abnormal physiology is detected.

ALSO!Changes in patient's physical condition i.e. painPatient in distress or family reports a changeIntuition/clinical experience

Acutely ill patients in hospital: recognition of and response to acute illness of adults in hospital.CG50 National Institute for Health and Clinical Excellence 2007.

Bedside monitoring

Who monitors?• Observations are usually taken by nursing staff – both registered

and non registered.• Can often be delegated to more junior or less experienced

members of the team

Important that staff are aware of the significance of vital sign recording, and have the knowledge and skill to interpret them to ensure patient safety

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents. National Patient Safety Agency 2007

Bedside monitoring

Why is it important?

• Important to provide baseline set of vital signs to identify subsequent changes in a patient’s condition

• Critical events (cardiac arrests, deaths & unplanned ICU transfers) are often preceded by physiological deterioration (and often signs of physiological deterioration!)

Bedside monitoring can be perceived as basic and routine BUT plays a vital role to ensure safer patient care and early recognition of deterioration.

StaffEducation

Response

Call for help

Recognition

Monitoring

Reducing harm from deterioration

*adopted from the Chain of Prevention © Gary Smith

Record vital signs

Competence in recording/understanding physiological

observations

*adopted from the Chain of Prevention © Gary Smith

StaffEducation

Response

Call for help

Recognition

Monitoring

Response strategyCritical Care Outreach

Medical Emergency Teams

Escalation protocol

Communication tool

Interventions to improve patient outcomes

Interventions to improve patient outcomes

The Early Warning Score System

3 2 1 0 1 2 3

HR <30 30-39 40-49 50-99 100-109 110-129 ≥130

sBP 70-79 80-99 100-199 ≥200

O2 Sats <85 85-89 90-92 ≥93

RR <9 9-20 20-30 31-35 ≥36

TEMP <34 34 35 36-37 >38 ≥39

CNS A V P U

“Track and trigger” systems

•Used on paper-based and electronic observation charts

•Periodic observation of selected vital signs (the “tracking”) with pre-determined criteria (the “trigger”) for requesting the attendance of more experienced staff

*adopted from the Chain of Prevention © Gary Smith

StaffEducation

Response

Call for help

Recognition

Monitoring

An Early Warning Score

Interventions to improve patient outcomes (2)...

PICS is a rules based system for managing clinical investigations,

prescribing and drug administration

The use of PICS in the Trust

PICS is the Trust’s locally developed electronic

prescribing solution that is available on every

computer desktop in the Trust

PICS also has -

A change in prescribing -

From this to this

using this

A change in vital signs recordingFrom this To this

Using this

2007: Development of electronic form2009: Go-live in May. Pilot ward was Burns and Plastics2012: Now in majority of wards

Education Response

Call for help

Recognition

Monitoring

Electronic observation form

Alerts to doctors and nurses based on severity of SEWS

Emails to Critical Care Outreach

*adopted from the Chain of Prevention © Gary Smith

Ready access to electronic data capture

What next for bedside monitoring?Coming soon - a National Early Warning Score (NEWS)

Advanced computerised solutionsComing soonish - Wireless Vital Signs Monitor*

The monitor tracks a patient’s HR and RR by beaming Doppler radar technology into their chest.

It uses radio frequency electromagnetic waves reflected from the body's surface and only requires that the white device face the patient to work.

* Kaiser Permanente's Garfield Health Care Innovation Centre

Advanced computerised solutions (2)Coming when? Body Sensors and Smart Phones to Implantable Biodegradable Sensors*

Continuous vital signs monitoring: a wrist-worn device that measures HR/PR, 3- or 5-lead electrocardiography (ECG), SpO2, BP, RR and skin temperature through body sensors

*GE Wireless Communication (http://www.nanotechgalaxy.com)

ViSi Mobile® by Sotera Wireless

Research opportunities...

Thank you!

For further information about Theme 9 please contact:

Principal investigator: Dr Jamie Coleman, jamie.coleman@uhb.nhs.uk

Project manager: Miss Ugochi Nwulu, ugochi.nwulu@uhb.nhs.uk