The impact of introducing medical emergency team system on the documentations of vital signs

Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review

AIM(S)

To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients.

DESIGN

Scoping review of international, peer-reviewed research studies.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023.

REPORTING METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

RESULTS

Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies).

CONCLUSION

Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Action protocol of medical staff for airway obstruction after anterior cervical spine surgery: A systematic review of case reports

BACKGROUND

Postoperative airway obstruction after anterior cervical spine surgery (ACSS) can be a fatal complication. Occasionally, it rapidly progresses to complete obstruction. There are no established standardized protocols on how medical staff should assess for signs and symptoms, seek help, or facilitate airway management after ACSS to prevent unfavorable events. This study aimed to primarily describe a systematic approach by assessing the signs and treatment outcomes of airway compromise in patients who underwent ACSS. Further, it recommended an action protocol after extubation for medical staff according to patients' symptoms to prevent unfavorable outcomes.

METHODS

An extensive literature search was performed on PubMed, Web of Science, and the Cochrane Library to identify case reports, case series, and cohort studies restricted to English and published between January 1990 and March 2023. We included cases that described the signs, symptoms, and treatment of airway obstruction after ACSS. Meanwhile, cases involving complications of other known causes, cases of trauma or occipital-cervical fixation, or those using bone morphogenetic protein were excluded.

RESULTS

Twenty cases from 17 studies were obtained, and their study quality was acceptable. Four patients died, and two presented with hypoxic ischemic encephalopathy. Further, five of six patients had fatal complications that initially developed within 7 h after surgery. Then, 9 (69%) of 13 patients with evidence of hematoma (69%) showed initial symptoms within 12 h after surgery. Finally, 9 of 11 patients with early-stage symptoms had favorable outcomes, and patients who developed late-stage symptoms commonly had unfavorable outcomes.

CONCLUSION

The early identification of signs and symptoms and immediate treatment are important, particularly within 12 h postoperatively. We suggest a novel action protocol for medical staff according to symptom urgency, which includes the measurement of neck circumference using a string for evaluating neck swelling.

Vital sign assessment and nursing interventions in medical and surgical patients with rapid response system triggers

AIM(S)

To explore vital sign assessment (both complete and incomplete sets of vital signs), and escalation of care per policy and nursing interventions in response to clinical deterioration.

DESIGN

This cohort study is a secondary analysis of data from the Prioritising Responses of Nurses To deteriorating patient Observations cluster randomised controlled trial of a facilitation intervention on nurses' vital sign measurement and escalation of care for deteriorating patients.

METHODS

The study was conducted in 36 wards at four metropolitan hospitals in Victoria, Australia. Medical records of all included patients from the study wards during three randomly selected 24-h periods within the same week were audited at three time points: pre-intervention (June 2016), and at 6 (December 2016) and 12 months (June 1017) post-intervention. Descriptive statistics were used to summarise the study data, and relationships between variables were examined using chi-square test.

RESULTS

A total of 10,383 audits were conducted. At least one vital sign measurement was documented every 8 h in 91.6% of audits, and a complete set of vital signs was documented every 8 h in 83.1% of audits. There were pre-Medical Emergency Team, Medical Emergency Team or Cardiac Arrest Team triggers in 25.8% of audits. When triggers were present, a rapid response system call occurred in 26.8% of audits. There were 1350 documented nursing interventions in audits with pre-Medical Emergency Team (n = 2403) or Medical Emergency Team triggers (n = 273). One or more nursing interventions were documented in 29.5% of audits with pre-Medical Emergency Team triggers and 63.7% of audits with Medical Emergency Team triggers.

CONCLUSION

When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE

Medical and surgical ward nurses in acute care wards frequently engage in vital sign assessment. Interventions by medical and nurgical nurses may occur prior to, or in parallel with calling the rapid response system. Nursing interventions are a key but under-recognised element of the organisational response to deteriorating patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses engage in a range of nursing interventions to manage deteriorating patients, (aside from rapid response system activation) that are not well understood, nor well described in the literature to date.

IMPACT

This study addresses the gap in the literature regarding nurses' management of deteriorating patients within their scope of practice (aside from RRS activation) in real world settings. When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration. The results of this research are relevant to nurses working on medical and surgical wards.

REPORTING METHOD

The trial was reported according to the Consolidated Standards of Reporting Trials extension for Cluster Trials recommendations, and this paper is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Assessments of perioperative respiratory pattern with non-contact vital sign monitor in children undergoing minor surgery: a prospective observational study

PURPOSE

Nurses routinely assess respiration of hospitalized children; however, respiratory rate measurements are technically difficult due to rapid and small chest wall movements. The aim of this study is to reveal the respiratory status of small children undergoing minor surgery with load cells placed under the bed legs, and to test the hypothesis that respiratory rate (primary variable) is slower immediately after arrival to the ward and recovers in 2 h.

METHODS

Continuous recordings of the load cell signals were performed and stable respiratory waves within the 10 discriminative perioperative timepoints were used for respiratory rate measurements. Apnea frequencies were calculated at pre and postoperative nights and 2 h immediately after returning to the ward after surgery.

RESULTS

Continuous recordings of the load cell signals were successfully performed in 18 children (13 to 119 months). Respiratory waves were appraisable for more than 70% of nighttime period and 40% of immediate postoperative period. There were no statistically significant differences of respiratory rate in any timepoint comparisons (p = 0.448), thereby not supporting the study hypothesis. Respiratory rates changed more than 5 breaths per minute postoperatively in 5 out of 18 children (28%) while doses of fentanyl alone did not explain the changes. Apnea frequencies significantly decreased 2 h immediately after returning to the ward and during the operative night compared to the preoperative night.

CONCLUSION

Respiratory signal extracted from load cell sensors under the bed legs successfully revealed various postoperative respiratory pattern change in small children undergoing minor surgery.

CLINICAL TRAIL REGISTRATION

UMIN (University Hospital Information Network) Clinical Registry: UMIN000045579 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052039 ).

The Accuracy of Wrist-Worn Photoplethysmogram-Measured Heart and Respiratory Rates in Abdominal Surgery Patients: Observational Prospective Clinical Validation Study

BACKGROUND

Postoperative deterioration is often preceded by abnormal vital parameters. Therefore, vital parameters of postoperative patients are routinely measured by nursing staff. Wrist-worn sensors could potentially provide an alternative tool for the measurement of vital parameters in low-acuity settings. These devices would allow more frequent or even continuous measurements of vital parameters without relying on time-consuming manual measurements, provided their accuracy in this clinical population is established.

OBJECTIVE

This study aimed to assess the accuracy of heart rate (HR) and respiratory rate (RR) measures obtained via a wearable photoplethysmography (PPG) wristband in a cohort of postoperative patients.

METHODS

The accuracy of the wrist-worn PPG sensor was assessed in 62 post-abdominal surgery patients (mean age 55, SD 15 years; median BMI 34, IQR 25-40 kg/m²). The wearable obtained HR and RR measurements were compared to those of the reference monitor in the postanesthesia or intensive care unit. Bland-Altman and Clarke error grid analyses were performed to determine agreement and clinical accuracy.

RESULTS

Data were collected for a median of 1.2 hours per patient. With a coverage of 94% for HR and 34% for RR, the device was able to provide accurate measurements for the large majority of the measurements as 98% and 93% of the measurements were within 5 bpm or 3 rpm of the reference signal. Additionally, 100% of the HR and 98% of the RR measurements were clinically acceptable on Clarke error grid analysis.

CONCLUSIONS

The wrist-worn PPG device is able to provide measurements of HR and RR that can be seen as sufficiently accurate for clinical applications. Considering the coverage, the device was able to continuously monitor HR and report RR when measurements of sufficient quality were obtained.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03923127; https://www.clinicaltrials.gov/ct2/show/NCT03923127.

Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study

AIMS OF THE STUDY

To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation.

METHODS

Monocentric retrospective observational study of prospectively collected data on all MET calls between 1^st of January 2012 until 31^st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation.

RESULTS

A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO₂) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%.

CONCLUSION

While most common reasons for MET calls over the years were staff concern and low SpO₂, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.

Exploration of a rapid response team model of care: A descriptive dual methods study

BACKGROUND

Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration.

OBJECTIVE

To explore the characteristics of a collaborative rapid response team model.

DESIGN

Dual methodology was used for this descriptive study.

SETTING

The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia).

PARTICIPANTS

Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards.

METHODS

A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically.

RESULTS

The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation.

CONCLUSIONS

Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Outcomes of Vital Sign Monitoring of an Acute Surgical Cohort With Wearable Sensors and Digital Alerting Systems: A Pragmatically Designed Cohort Study and Propensity-Matched Analysis

Background: The implementation and efficacy of wearable sensors and alerting systems in acute secondary care have been poorly described.

Objectives: to pragmatically test one such system and its influence on clinical outcomes in an acute surgical cohort.

Methods: In this pragmatically designed, pre-post implementation trial, participants admitted to the acute surgical unit at our institution were recruited. In the pre-implementation phase (September 2017 to May 2019), the SensiumVitals™ monitoring system, which continuously measures temperature, heart, and respiratory rates, was used for monitoring alongside usual care (intermittent monitoring in accordance with the National Early Warning Score 2 [NEWS 2] protocol) without alerts being generated. In the post-implementation phase (May 2019 to March 2020), alerts were generated when pre-established thresholds for vital parameters were breached, requiring acknowledgement from healthcare staff on provided mobile devices. Hospital length of stay, intensive care use, and 28-days mortality were measured. Balanced cohorts were created with 1:1 ‘optimal’ propensity score logistic regression models.

Results: The 1:1 matching method matched the post-implementation group (n = 141) with the same number of subjects from the pre-implementation group (n = 141). The median age of the entire cohort was 52 (range: 18–95) years and the median duration of wearing the sensor was 1.3 (interquartile range: 0.7–2.0) days. The median alert acknowledgement time was 111 (range: 1–2,146) minutes. There were no significant differences in critical care admission (planned or unplanned), hospital length of stay, or mortality.

Conclusion: This study offered insight into the implementation of digital health technologies within our institution. Further work is required for optimisation of digital workflows, particularly given their more favourable acceptability in the post pandemic era. Clinical trials registration information: ClinicalTrials.gov Identifier: NCT04638738.

Evaluation of a Novel Contactless Electrical Impedance Device for Measuring Respiratory and Heart Rates: A Pilot Study

Although the respiratory rate is an important vital sign, it is rarely recorded in hospitals given the lack of convenient measurement devices. Posh Wellness Laboratory Inc. (Tokyo, Japan) developed a novel contactless card-type respiratory/heart rate monitoring device that measures electrical impedance variations on the human chest. This study was aimed to test and validate the accuracy of the proposed device compared with conventional medical monitors. To evaluate the card-type monitoring device, we compared the measurements from the device with those from the mechanical ventilators and electrocardiogram monitors. Patients who were hospitalized in the Emergency Department of Shimane University Hospital from April 5 to 30, 2021 were included in this study. A card-type sensor was attached to five patients who agreed to participate in this study. Four of the five patients were receiving mechanical ventilation. The respiratory rate error provided by the card-type sensor remained within 15% compared with the measurements of the conventional medical monitor. In contrast, the heart rate counts were largely different from the measurements. Thus, the proposed device can successfully measure the respiratory rate, whereas heart rate measurements require further improvement. Our small, lightweight, radiation-free, and contactless monitoring device can conveniently measure the respiratory rate of patients. With the improvement of measuring the heart rate, we would like to assess a larger number and a wider range of patients.

Accuracy of vital parameters measured by a wearable patch following major abdominal cancer surgery

INTRODUCTION

Recent advances in wearable technology allow for the development of wirelessly connected sensors to continuously measure vital parameters in the general ward or even at home. The present study assesses the accuracy of a wearable patch (Healthdot) for continuous monitoring of heartrate (HR) and respiration rate (RR).

MATERIALS AND METHODS

The Healthdot measures HR and RR by means of chest accelerometry. The study population consisted of patients following major abdominal oncological surgery. The analysis focused on the agreement between HR and RR measured by the Healthdot and the gold standard patient monitor in the intensive and post-anesthesia care unit.

RESULTS

For HR, a total of 112 h of measurements was collected in 26 patients. For RR, a total of 102 h of measurements was collected in 21 patients. On second to second analysis, 97% of the HR and 87% of the RR measurements were within 5 bpm and 3 rpm of the reference monitor. Assessment of 5-min averaged data resulted in 96% of the HR and 95% of the RR measurements within 5 bpm and 3 rpm of the reference monitor. A Clarke error grid analysis showed that 100% of the HR and 99.4% of the 5-min averaged data was clinically acceptable.

CONCLUSION

The Healthdot accurately measured HR and RR in a cohort of patients recovering from major abdominal surgery, provided that good quality data was obtained. These results push the Healthdot forward as a clinically acceptable tool in low acuity settings for unobtrusive, automatic, wireless and continuous monitoring.

Effect of National Early Warning Scoring System Implementation on Cardiopulmonary Arrest, Unplanned ICU Admission, Emergency Surgery, and Acute Kidney Injury in an Emergency Hospital, Egypt

Purpose

To evaluate the effect of national early warning scoring system (NEWS) implementation in identifying patients at risk of clinical deterioration at an emergency hospital.

Background

Early warning score has been developed to facilitate early detection of deterioration by categorizing a patients’ severity of illness and prompting nursing staff to request a medical review at specific trigger points.

Patients and Methods

A prospective, control/intervention groups’, quasi-experimental design was utilized. A sample of 364 adult patients were admitted to the inpatient unit at an emergency hospital for six months. The patients were divided into a study group (174 patients) and a control group (190 patients). All study patients were followed up to either death or hospital discharge before and after implementing a new observation chart. The patients’ outcomes were compared and analyzed between both groups.

Results

In the intervention period, compared to the control period, a significant reduction was seen in the number of cardiopulmonary arrest (4.7% vs 1.1%, p = 0.046), unplanned ICU admission (5.3% vs 1.7%, p = 0.049), emergency surgery (6.3% vs 0%, p = 0.001), acute kidney injury (6.8% vs 1.1%, p = 0.006). As well, there was a significant increase in the number of patients receiving medical reviews following clinical deterioration in terms of escalation plan (3.2% vs 26.4%, p = <0.001).

Conclusion

The implementation of NEWS was associated with a significant improvement in patients’ outcomes in hospital wards, increases in the frequency of vital signs measurements, and an increase in the number of medical reviews following clinical instability.

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Improper monitoring and deviations from physiologic treatment goals in patients with brain injury in the early phases of emergency care

Severe traumatic brain injury (TBI), out-of-hospital cardiac arrest (OHCA) and intracerebral- and subarachnoid hemorrhage (ICH/SAH) are conditions associated with high mortality and morbidity. The aim of this study was to investigate the feasibility of obtaining continuous physiologic data and to identify possible harmful physiological deviations in these patients, in the early phases of emergency care. Patients with ICH/SAH, OHCA and severe TBI treated by the Physician-staffed Emergency Medical Service (P-EMS) between September and December 2016 were included. Physiological data were obtained from site of injury/illness, during transport, in the emergency department (ED) and until 3 h after admittance to the intensive care unit. Physiological deviations were based on predefined target values within each 5-min interval. 13 patients were included in the study, of which 38% survived. All patients experienced one or more episodes of hypoxia, 38% experienced episodes of hypercapnia and 46% experienced episodes of hypotension. The mean proportion of time without any monitoring in the pre-hospital phase was 29%, 47% and 56% for SpO2, end-tidal CO2 and systolic blood pressure, respectively. For the ED these proportions were 57%, 71% and 56%, respectively. Continuous physiological data was not possible to obtain in this study of critically ill and injured patients with brain injury. The patients had frequent deviations in blood pressure, SpO2 and end tidal CO2-levels, and measurements were frequently missing. There is a potential for improved monitoring as a tool for quality improvement in pre-hospital critical care.

Quels sont le fonctionnement, les caractéristiques, les effets et les modalités d’implantation des équipes d’intervention rapide ? Une revue de la littérature

Introduction&#160;: Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context&#160;: Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective&#160;: To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design&#160;: Literature review.Method&#160;: Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords&#160;: &#8220;health care team&#8221; and &#8220;rapid response team&#8221;.Results&#160;: 121 articles were included. The collected data were divided into five categories&#160;: 1) composition and operation of RRTs, 2) benefits and limitations of RRTs, 3) perceptions of RRTs by health care teams, organizations, and patients, 4) implementation strategies, and 5) facilitators and barriers to implementation.Discussion&#160;: Although there are many articles related to RRTs, it appears that&#160;: 1) few studies analyze the difference in outcomes in hospitalized patients related to the composition of RRTs, 2) few studies describe how RRTs should work, 3) more studies are needed on the impacts of RRTs on hospitalized patients, 4) organizations&#8217; and patients&#8217; perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion&#160;: The results show that there is a lack of studies on the difference in outcomes in hospitalized patients related to the composition of RRTs, on how RRTs should work, on the impacts of RRTs on hospitalized patients, on organizations&#8217; and patients&#8217; perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.

Quantitative systematic review: Sources of inaccuracy in manually measured adult respiratory rate data

AIMS

To identify the potential sources of inaccuracy in manually measured adult respiratory rate (RR) data and quantify their effects.

DESIGN

Quantitative systematic review with meta-analyses where appropriate.

DATA SOURCES

Medline, CINAHL, and Cochrane Library (from database inception to 31 July 2019).

REVIEW METHODS

Studies presenting data on individual sources of inaccuracy in the manual measurement of adult RR were analysed, assessed for quality, and grouped according to the source of inaccuracy investigated. Quantitative data were extracted and synthesized and meta-analyses performed where appropriate.

RESULTS

Included studies (N = 49) identified five sources of inaccuracy. The awareness effect creates an artefactual reduction in actual RR, and observation methods involving shorter counts cause systematic underscoring. Individual RR measurements can differ substantially in either direction between observations due to inter- or intra-observer variability. Value bias, where particular RRs are over-represented (suggesting estimation), is a widespread problem. Recording omission is also widespread, with higher average rates in inpatient versus triage/admission contexts.

CONCLUSION

This review demonstrates that manually measured RR data are subject to several potential sources of inaccuracy.

IMPACT

RR is an important indicator of clinical deterioration and commonly included in track-and-trigger systems. However, the usefulness of RR data depends on the accuracy of the observations and documentation, which are subject to five potential sources of inaccuracy identified in this review. A single measurement may be affected by several factors. Hence, clinicians should interpret recorded RR data cautiously unless systems are in place to ensure its accuracy. For nurses, this includes counting rather than estimating RRs, employing 60-s counts whenever possible, ensuring patients are unaware that their RR is being measured, and documenting the resulting value. For any given site, interventions to improve measurement should take into account the local organizational and cultural context, available resources, and the specific measurement issues that need to be addressed.

Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department

INTRODUCTION

Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department.

METHOD

A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed.

RESULTS

Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved.

DISCUSSION

Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.

Remote Patient Monitoring in Adults Receiving Transfusion or Infusion for Hematological Disorders Using the VitalPatch and accelerateIQ Monitoring System: Quantitative Feasibility Study

Background

Frequent vital sign monitoring during and after transfusion of blood products and certain chemotherapies or immunotherapies is critical for detecting infusion reactions and treatment management in patients. Currently, patients return home with instructions to contact the clinic if they feel unwell. Continuous monitoring of vital signs for hematological patients treated with immunotherapy or chemotherapy or receiving blood transfusions using wearable electronic biosensors during and post treatment may improve the safety of these treatments and make remote data collection in an outpatient care setting possible.

Objective

This study aimed to evaluate patient experiences with the VitalPatch wearable sensor (VitalConnect) and to evaluate the usability of data generated by the physIQ accelerateIQ monitoring system for the investigator and nurse.

Methods

A total of 12 patients with hematological disorders receiving red blood cell transfusions, an intravenous (IV) proteasome inhibitor, or an IV immunotherapy agent were included in the study and wore the VitalPatch for 12 days. Patients completed questionnaires focusing on wearability and nurses completed questionnaires focusing on the usability of the VitalPatch.

Results

A total of 12 patients were enrolled over 9 months, with 4 receiving red blood cell transfusions, 4 receiving IV proteasome inhibitors, and 4 receiving IV immunotherapy. These patients were treated for diseases such as multiple myeloma, myelodysplastic syndrome, and non-Hodgkin lymphoma. Of these patients, 83% (10/12) were aged 60 years and older. A total of 4 patients (4/12, 33%) withdrew from the study (3 because of skin irritation and 1 because of patch connection issues). Patients wore biosensor patches at baseline and for 1-week post administration. Patient-reported outcomes (PROs) were collected at baseline, day 1, day 5, and day 8. No difference in the PRO was observed when nurses or patients applied the patch. PRO data indicated minimal impact on the patient’s life. Ease of use, influence on sleep, impact on follow-up of health, or discomfort with continuous monitoring did not change between baseline and day 8. Changes in PRO were observed on day 5, where a 20% (2/10) increase in skin irritation was reported. Withdrawals because of skin irritation were reported in all cases when wearing the second patch. Nurses reported the placement of the VitalPatch to be easy and felt measurements to be reliable.

Conclusions

Generally, the VitalPatch was well tolerated and shown to be an attractive device because of its wearability and low impact on daily activities in patients, therefore making it suitable for implementation in future studies.

Improving Respiratory Rate Accuracy in the Hospital: A Quality Improvement Initiative

Respiratory rate (RR) is a predictor of adverse outcomes. However, RRs are inaccurately measured in the hospital. We conducted a quality improvement (QI) initiative using plan-do-study-act methodology on one inpatient unit of a safety-net hospital to improve RR accuracy. We added time-keeping devices to vital sign carts and retrained patient-care assistants on a newly modified workflow that included concomitant RR measurement during automated blood pressure measurement. The median RR was 18 (interquartile range [IQR] 18-20) preintervention versus 14 (IQR 15-20) postintervention. RR accuracy, defined as ±2 breaths of gold-standard measurements, increased from 36% preintervention to 58% postintervention (P < .01). The median time for vital signs decreased from 2:36 minutes (IQR, 2:04-3:20) to 1:55 minutes (IQR, 1:40-2:22; P < .01). The intervention was associated with a 7.8% reduced incidence of tachypnea-specific systemic inflammatory response syndrome (SIRS = 2 points with RR > 20; 95% CI, -13.5% to -2.2%). Our interdisciplinary, low-cost, low-tech QI initiative improved the accuracy and efficiency of RR measurement.

Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review

Introduction

The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes.

Methods

A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach.

Results

Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality.

Conclusions

A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.

Pulse oximetry and the enduring neglect of respiratory rate assessment: a commentary on patient surveillance

Clinical surveillance provides essential data on changes in a patient's condition. The common method for performing this surveillance is the assessment of vital signs. Despite the importance of these signs, research has found that vital signs are not rigorously assessed in clinical practice. Respiratory rate, arguably the most important vital sign, is the most neglected. Poor understanding might contribute to nurses incorrectly valuing oxygen saturation more than respiratory rate. Nurses need to understand the importance of respiratory rate assessment as a vital sign and the benefits and limitations of pulse oximetry as a clinical tool. By better understanding pulse oximetry and respiratory rate assessment, nurses might be more inclined to conduct rigorous vital signs' assessment. Research is needed to understand why many nurses do not appreciate the importance of vital signs' monitoring.

Insight into hospital ward nurses' concerns about patient health and the corresponding Medical Emergency Team nurse response

AIM

This study aims to understand the concerns of nurses when making MET calls which did not fulfil the vital sign criteria, and the MET nurses subsequent responses to these calls.

METHODS

This was a retrospective report-based study. Research material included nursing reports and MET forms related to MET calls made due to nurses' concern. Inductive content analysis was used to identify observations, which were then quantified based on the research material.

FINDINGS

From a total of 546 MET calls, 39 visits (7%) were due to nurses' concern. In these 39 visits, the vital sign criteria did not reach the alert threshold, but nurses made the call due to subjective worry. In 13% of visits, the alert concern was inadequate contact with the doctor. MET nurses responded to the alert by providing clinical and indirect nursing; more specifically, they performed examinations and nursing interventions and collaborated with other professionals.

CONCLUSION

A nurse's worry is influenced by subjective changes in the patient's condition or an inadequate doctor's response rather than objective physiological measurements. A MET nurse's ability to assess patient condition, respond to nurses' calls, and acknowledge justified alerts help MET nurses support concerned nurses and encourage them to contact the MET if necessary.

Wireless vitals-Proof of concept for wireless patient monitoring in an emergency department setting

Vital sign assessment is a common task in emergency medicine, but resources for continuous monitoring are restricted, data is often recorded manually, and entangled wires cause frustration. Therefore, we designed a small, wireless photoplethysmographic device capable of continuously assessing pulse, respiratory frequency and oxygen saturation on the sternum and tested the performance and feasibility in an emergency department setting. Fifty (56.3 ± 20.2 years), consenting emergency patients (29 male) were recruited. Heart rate, respiratory rate and oxygen saturation were recorded simultaneously using the device and standard monitoring equipment. Data was compared using Bland-Altman plotting (heart rate, respiratory rate) and mean difference (oxygen saturation). The bias for heart- and respiratory rate was 0.4 (limits of agreements -11.3, 12.2 and -6.1, 7.0). Mean difference for oxygen saturation was -0.21 ± 2.35%. This may be the first wireless device to use photoplethysmography on the sternum for vital sign assessment. We noted good agreement with standard monitors, but lack of standardization in data processing between monitoring systems may limit the generalizability of these findings. Although further improvements are needed, the feasibility of this approach provides proof of concept for a new paradigm of large scale, wireless patient monitoring.

Wearable sensors to improve detection of patient deterioration

INTRODUCTION

Monitoring a patient's vital signs forms a basic component of care, enabling the identification of deteriorating patients and increasing the likelihood of improving patient outcomes. Several paper-based track and trigger warning scores have been developed to allow clinical evaluation of a patient and guidance on escalation protocols and frequency of monitoring. However, evidence suggests that patient deterioration on hospital wards is still missed, and that patients are still falling through the safety net. Wearable sensor technology is currently undergoing huge growth, and the development of new light-weight wireless wearable sensors has enabled multiple vital signs monitoring of ward patients continuously and in real time.

AREAS COVERED

In this paper, we aim to closely examine the benefits of wearable monitoring applications that measure multiple vital signs; in the context of improving healthcare and delivery. A review of the literature was performed.

EXPERT COMMENTARY

Findings suggest that several sensor designs are available with the potential to improve patient safety for both hospital patients and those at home. Larger clinical trials are required to ensure both diagnostic accuracy and usability.

Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study

Background

Unchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.

Objective

To determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.

Design

A mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).

Setting

English hospitals participating in the NCAA audit.

Participants

NHS staff (approximately 300) and patients (13 million).

Interventions

Education, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.

Main outcome measures

IHCA rates, survival and hospital-wide mortality.

Data sources

NCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.

Methods

A literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).

Results

Across NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.

Limitations

The organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.

Conclusions

Standardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.

Future work

To assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Acoustic respiration rate and pulse oximetry-derived respiration rate: a clinical comparison study

Respiration rate (RR) is a critical vital sign that provides early detection of respiratory compromise. The acoustic technique of measuring continuous respiration rate (RR_a) interprets the large airway sound envelope to calculate respiratory rate while pulse oximetry-derived respiratory rate (RR_oxi) interprets modulations of the photoplethsymograph in response to hemodynamic changes during the respiratory cycle. The aim of this study was to compare the performance of these technologies to each other and to a capnography-based reference device. Subjects were asked to decrease their RR from 14 to 4 breaths per minute (BPM) and then increase RR from 14 to 24 BPM. The effects of physiological noise, ambient noise, and head movement and shallow breathing on device performance were also evaluated. The test devices were: (1) RR_a, Radical-7 (Masimo Corporation), (2) RR_oxi, Nellcor™ Bedside Respiratory Patient Monitoring System (Medtronic), and (3) reference device, Capnostream20p™ (Medtronic). All devices were configured with their default settings. Twenty-nine healthy adult subjects were included in the study. During abrupt changes in breathing, overall RR_oxi was accurate for longer periods of time than RR_a; specifically, RR_oxi was more accurate during low and normal RR, but not during high RR. RR_oxi also displayed a value for significantly longer time periods than RR_a when the subjects produced physiological sounds and moved their heads, but not during shallow breathing or ambient noise. RR_oxi may be more accurate than RR_a during development of bradypnea. Also, RR_oxi may display a more reliable RR value during routine patient activities.

Frequency of vital sign measurement among intubated patients in the general ward and nurses' attitudes toward vital sign measurement

Purpose

The lack of recognition of respiratory distress may result in emergency tracheal intubation in the general ward. However, few studies have examined the differences in the frequency of vital sign measurement between patients with and without emergency tracheal intubation in the general ward. Thus, this study aimed to investigate the differences in the frequency of vital sign measurements between patients with and without emergency tracheal intubation.

Patients and methods

This is a single-center, retrospective, observational study of unplanned intensive care unit (ICU) admissions from the general wards between December 2015 and February 2017. This study included patients with emergency medical intubations in the general ward who were then transferred to the ICU. Vital signs measured within 24 hours prior to ICU admission were compared between patients who did and did not require emergency tracheal intubation in the general ward. A survey was also conducted to explore the nurses' attitudes toward vital sign measurements.

Results

Compared with other vital signs, the respiratory rate was significantly less frequently measured. Moreover, the frequency of respiratory rate measurement was lower in the 38 patients who were intubated than in the 102 patients who were not intubated in the general ward (P=0.07). The survey revealed that 54% of the participating nurses considered assessment of the respiratory rate as the most troublesome nursing task and ~15% of nurses did not routinely measure respiratory rates.

Conclusion

Respiratory rate was less frequently assessed in deteriorating patients in the general ward, possibly because it was considered a troublesome task.

Evaluating the validity and reliability of the V-scale instrument (Turkish version) used to determine nurses' attitudes towards vital sign monitoring

AIM

The aim of this study was to determine the validity and reliability of the Turkish version of the V-scale, which measures nurses' attitudes towards vital signs monitoring in the detection of clinical deterioration.

METHODS

This validity and reliability study was conducted at a tertiary hospital in Ankara, Turkey, in 2016. A total of 169 ward nurses participated in the study. Exploratory factor analysis, Cronbach's alpha coefficient, and the intraclass correlation coefficient were used to determine the validity and reliability of the scale.

RESULTS

A 5-factor, 16-item scale explained 60.823% of the total variance according to the validity analysis. Our version matched the original scale in terms of the number of items and factor structure. Cronbach's alpha coefficient of the Turkish version of the V-scale was 0.764. The test-retest reliability results were 0.855 for the overall intraclass correlation coefficient, and the t-test result was P > 0.05.

CONCLUSION

The V-scale is a reliable and valid instrument to measure Turkish nurses' attitudes towards vital signs monitoring in the detection of clinical deterioration.

Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

OBJECTIVES

This study aimed to evaluate whether use of a discharge criteria tool for nursing assessment of patients in Post Anaesthesia Care Unit (PACU) would enhance nurses' recognition and response to patients at-risk of deterioration and improve patient outcomes.

METHODS

A prospective non-randomised pre-post intervention study was conducted in three hospitals in Australia. Participants were adults undergoing elective surgery before (n=723) and after (n=694) implementation of the Post-Anaesthetic Care Tool (PACT).

RESULTS

Nursing response to patients at-risk of deterioration was higher using PACT, with more medical consultations initiated by PACU nurses (19% vs 30%, P<0.001) and more patients with Medical Emergency Team activation criteria modified by an anaesthetist while in PACU (6.5% vs 13.8%, P<0.001). There were higher rates of analgesia administration (37.3% vs 54.2%, P=0.001), nursing assessment of pain and documentation of ongoing analgesia prior to discharge (55% vs 85%, P<0.001). More adverse events were recorded in PACU after introduction of the PACT (8.3% vs 16.7%, P<0.001). The rate of adverse events after discharge from PACU remained constant (16.5%), but the rate of cardiac events (5.1% vs 2.6%, P=0.021) and clinical deterioration (8.7% vs 4.3%, P=0.001) following PACU discharge significantly decreased, using the PACT. Despite the increased number of patients with adverse events in phase 2, healthcare costs did not increase significantly. Length of stay in PACU and length of hospital admission for those patients who had an adverse event in PACU were significantly reduced after implementation of the PACT.

CONCLUSION

This study found that using a structured discharge criteria tool, the PACT, enhanced nurses' recognition and response to patients who experienced clinical deterioration, reduced length of stay for patients who experienced an adverse event in PACU and was cost-effective.

Risk for Cardiorespiratory Instability Following Transfer to a Monitored Step-Down Unit

BACKGROUND

Hospitalized patients who develop at least one instance of cardiorespiratory instability (CRI) have poorer outcomes. We sought to describe the admission characteristics, drivers, and time to onset of initial CRI events in monitored step-down unit (SDU) patients.

METHODS

Admission characteristics and continuous monitoring data (frequency 1/20 Hz) were recorded in 307 subjects. Vital sign deviations beyond local instability trigger threshold criteria, with a tolerance of 40 s and cumulative duration of 4 of 5 min, were classified as CRI events. The CRI driver was defined as the first vital sign to cross a threshold and meet persistence criteria. Time to onset of initial CRI was the number of days from SDU admission to initial CRI, and duration was length of the initial CRI epoch.

RESULTS

Subjects transferred to the SDU from units with higher monitoring capability were more likely to develop CRI (CRI n = 133 [44%] vs no CRI n = 174 [31%] P = .042). Time to onset varied according to the CRI driver. Subjects with at least one CRI event had a longer hospital stay (CRI 11.3 ± 10.2 d vs no CRI 7.8 ± 9.2 d, P < .001) and SDU stay (CRI 6.1 ± 4.9 d vs no CRI 3.5 ± 2.9 d, P < .001). First events were more often due to S_pO2 , whereas breathing frequency was the most common driver of all CRI.

CONCLUSIONS

Initial CRI most commonly occurred due to S_pO2 and was associated with prolonged SDU and hospital stay. Findings suggest the need for clinicians to more closely monitor SDU patients transferred from an ICU and parameters (S_pO2 , breathing frequency) that more commonly precede CRI events.

An analysis of messages sent between nurses and physicians in deteriorating internal medicine patients to help identify issues in failures to rescue

OBJECTIVE

To evaluate in patients who deteriorate and require transfer to the intensive care unit (ICU), how many have a critical text message communicating deterioration and what is the quality of this message? Is message quality, message response or the timeliness of rapid response team (RRT) activation related to death?

METHODS

We conducted a retrospective chart review of all ICU transfers from General Internal Medicine (GIM) wards from January 2012 until August 2014. All critical messages (CM) in the 48h prior to ICU transfer were analyzed for RRT calling criteria, time to RRT activation, message quality, presence of vitals, and the quality and timeliness of physician response.

RESULTS

Of the 236 patients in the study, 93 (39%) had a CM in the 48h prior to ICU transfer. Within this subset, 76 patients did not have prior RRT activation and the median times from CM to RRT activation and CM to ICU transfer were 8.9 [IQR 2.9, 20.7] and 15.6 [IQR 9.0, 28.7] hours, respectively. Only 45% of messages contained 2 or more vitals and only 3% of messages contained Situation, Background, Assessment, and Recommendations (SBAR). Physician response was timely (3 [IQR 2, 17] min) but response quality was poor; nearly one quarter of responses only acknowledged receipt. Among message characteristics, only the number of SBAR elements was correlated with in-hospital survival (p=0.047).

CONCLUSION

Communication between nurses and physicians about critically ill patients could be improved. There appear to be significant gaps in the quality of messages, their responses, and delays in RRT activation.

Postoperative glucocorticoid enhances recovery after endovascular aortic repair for chronic type B aortic dissection: a single-center experience

Background

Thoracic endovascular aortic repair (TEVAR) has been chosen as a less invasive alternative for type B aortic dissections (TBADs). However, the therapeutic effect of TEVAR has been challenged by postoperative adverse events, which were induced by inflammatory response. Glucocorticoids have been widely used because of the powerful and effective anti-inflammatory properties. Nevertheless, the prognostic effect of glucocorticoids after TBAD patients underwent TEVAR remains unclear. The objective of this study was to assess the potential effect of postoperative glucocorticoids on the prognosis of TEVAR for TBADs.

Methods

A total of 92 chronic TBADs patients underwent TEVAR with epidural anesthesia between June 2012 and June 2014 was retrospectively reviewed. The patients were stratified into dexamethasone (DXM) and non-dexamethasone group (N-DXM). The indications for TEVAR were as following: malperfusion (n = 28); contained or impending rupture (n = 17); persistent intractable chest/back pain (n = 32); refractory hypertension (n = 15).

Results

No 30-day mortality and incision infection occurred in each group. The postoperative pain score on the second day was significantly higher in N-DXM group (3.60 ± 0.21 versus 4.83 ± 0.32, P = 0.001). The differences of white blood cell, body temperature and heart rate were pronounced in both groups judged by the peak values (13.01 ± 0.58 × 10⁹/L versus 10.04 ± 0.61 × 10⁹/L, 37.67 ± 0.08 °C versus 37.92 ± 0.09 °C and 89.06 ± 1.21 bpm versus 95.95 ± 1.70 bpm, P = 0.002, 0.04 and 0.001, respectively). The white blood cells in DXM group significantly increased on the second and third postoperative day (P = 0.009 and 0.023), while the body temperature and heart rate showed an apparent decline on the second (P = 0.001 and 0.028), third (P = 0.007 and 0.005) and fourth postoperative days (P = 0.024 and 0.018). However, the changes of false lumen volumes and the endoleak incidence at 3-month follow-up were comparable in the two groups. No significant difference of post-implantation syndrome was observed either.

Conclusions

Although postoperative prophylactic glucocorticoids administration was unable to influence mortality, incision infection or the change of false lumen volumes, it enabled to enhance the recovery of vital signs and alleviate the postoperative pain. A prospective, randomized controlled trial has been registered (NCT02523300), which will be warranted before prophylactic administration of glucocorticoids after TEVAR procedure could be recommended in the clinical work.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0234-2) contains supplementary material, which is available to authorized users.

A noncontact RF-based respiratory sensor: results of a clinical trial

BACKGROUND

Respiratory rate (RR) is a critical vital signs monitored in health care setting. Current monitors suffer from sensor-contact failure, inaccurate data, and limited patient mobility. There is a critical need for an accurate and reliable and noncontact system to monitor RR. We developed a contact-free radio frequency (RF)-based system that measures movement using WiFi signal diffraction, which is converted into interpretable data using a Fourier transform. Here, we investigate the system's ability to measure fine movements associated with human respiration.

MATERIALS AND METHODS

Testing was conducted on subjects using visual cue, fixed-tempo instruction to breath at standard RRs. Blinded instruction-based RRs were compared to RF-acquired data to determine measurement accuracy. The RF-based technology was studied on postoperative ventilator-dependent patients. Blinded ventilator capnographic RR data were collected for each patient and compared to RF-acquired data to determine measurement accuracy.

RESULTS

Respiratory rate data collected from 10 subjects breathing at a fixed RR (14, 16, 18, or 20) demonstrated 95.5% measurement accuracy between the patient's actual rate and that measured by our RF technology. Ten patients were enrolled into the clinical trial. Blinded ventilator capnographic RR data were compared to RF-based acquired data. The RF-based data showed 88.8% measurement accuracy with ventilator capnography.

CONCLUSIONS

Initial clinical pilot trials with our contact-free RF-based monitoring system demonstrate a high degree of RR measurement accuracy when compared to capnographic data. Based on these results, we believe RF-based systems present a promising noninvasive, inexpensive, and accurate tool for continuous RR monitoring.

Association of Opioids and Sedatives with Increased Risk of In-Hospital Cardiopulmonary Arrest from an Administrative Database

Background

While opioid use confers a known risk for respiratory depression, the incremental risk of in-hospital cardiopulmonary arrest, respiratory arrest, or cardiopulmonary resuscitation (CPRA) has not been studied. Our aim was to investigate the prevalence, outcomes, and risk profile of in-hospital CPRA for patients receiving opioids and medications with central nervous system sedating side effects (sedatives).

Methods

A retrospective analysis of adult inpatient discharges from 2008–2012 reported in the Premier Database. Patients were grouped into four mutually exclusive categories: (1) opioids and sedatives, (2) opioids only, (3) sedatives only, and (4) neither opioids nor sedatives.

Results

Among 21,276,691 inpatient discharges, 53% received opioids with or without sedatives. A total of 96,554 patients suffered CPRA (0.92 per 1000 hospital bed-days). Patients who received opioids and sedatives had an adjusted odds ratio for CPRA of 3.47 (95% CI: 3.40–3.54; p<0.0001) compared with patients not receiving opioids or sedatives. Opioids alone and sedatives alone were associated with a 1.81-fold and a 1.82-fold (p<0.0001 for both) increase in the odds of CPRA, respectively. In opioid patients, locations of CPRA were intensive care (54%), general care floor (25%), and stepdown units (15%). Only 42% of patients survived CPRA and only 22% were discharged home. Opioid patients with CPRA had mean increased hospital lengths of stay of 7.57 days and mean increased total hospital costs of $27,569.

Conclusions

Opioids and sedatives are independent and additive risk factors for in-hospital CPRA. The impact of opioid sparing analgesia, reduced sedative use, and better monitoring on CPRA incidence deserves further study.

Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.

There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.

The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.

For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

VITAL SIGNS MEASUREMENT: AN INDICATOR OF SAFE CARE DELIVERED TO ELDERLY PATIENTS

ABSTRACT The study's aim was to analyze the importance assigned by the nursing staff to the recording of vital signs of elderly inpatients, as well as perceived barriers and benefits. Data were collected through interviews held with 13 nurses and the reports were analyzed using content analysis, considering the health belief model proposed by Rosenstock. The categories that emerged from the analysis indicate barriers that interfere in the proper monitoring of vital signs, namely: workload, lack of availability and accessibility of basic equipment such as thermometers, stethoscopes and sphygmomanometers, which compromises the nursing assessment and leads to a greater susceptibility to incidents. Although the facility does not provide conditions to measure vital signs properly, the nursing staff attempts to do what is feasible given their current knowledge and context to achieve the best outcome possible in view of the resources available.

Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses

OBJECTIVE

To develop and determine the psychometrics properties of an instrument (V-scale) and to explore nurses' attitudes towards vital signs monitoring in the detection of clinical deterioration in general wards.

DESIGN

Scale development with psychometric testing and a descriptive quantitative survey.

SETTING

Tertiary acute care hospital.

PARTICIPANTS

A total of 614 general ward nurses.

FINDINGS

Principal component analysis revealed a 16-item instrument in a five-factor solution (key indicators, knowledge, communication, workload and technology) that explained 56.27% of the variance. The internal consistency was sufficient with Cronbach's alpha of 0.71 and strong item subscale correlations (0.56-0.89). The test-retest reliability was adequate with an Intraclass Correlation Coefficient (ICC) of 0.85. Many nurses (56.9%) erroneously perceived blood pressure changes as the first indicator of deterioration, and 46% agreed that an altered respiratory rate was the least important indicator. Most nurses (59.8%) also reported relying on oxygen saturation to evaluate respiratory dysfunction, and 27.4% indicated that they make quick estimates of the respiratory rate. Current practices for vital signs monitoring were considered to be time consuming (21.0%) and overwhelming (35.3%). Nurses' attitudes were most significantly influenced by whether they had a degree qualification followed by whether they worked in a general ward with a specialty and had >5 years of experience.

CONCLUSIONS

This exploratory study provides evidence for the psychometric properties of the V-scale. It reveals a need for continuous professional development to improve ward nurses' attitudes towards vital signs monitoring. Vital signs monitoring needs to be prioritized in workload planning.