Improving vital sign documentation at triage: an emergency department quality improvement project

Assessing the Correct Documentation of Time and Physician Information on Medical Records in the Emergency Department of Queen's Hospital: An Audit and Re-audit

BACKGROUND

Medical records are confidential medical and legal documents describing a patient's contact with a healthcare facility. The quality of documentation has been found to be lower in settings of high patient volume and complex cases, such as the emergency department (ED). The variety and number of healthcare professionals involved in the care of the patient also negatively affect the quality of documentation. The aim of this paper is to present the results of an audit and re-audit conducted in the ED of Queen's Hospital, Romford, to assess ED record documentation against General Medical Council (GMC) and Royal College of Physicians (RCP) standards.

METHODS

For the audit, all records of patients who were discharged from the ED of Queen's Hospital in one day were reviewed and evaluated on whether they have a date, time, the full name of the physician, their GMC number, and signature documented, as per GMC and RCP official guidelines. No medical information or patient data were recorded. After the implementation of the change aiming to raise awareness of ED staff, a new sample was collected two months later, and the same parameters were assessed against the set standards.

RESULTS

Results of the audit showed a low percentage of documentation of all parameters, especially of GMC number and signature. After the presentation of the results and implementation of change, the results of the re-audit demonstrated significant raise in all percentages, with a relative improvement of 40% regarding the recording of GMC number and 65% regarding signature. However, the documentation of these two parameters remained low and below acceptable levels.

DISCUSSION

The re-audit results underline that the low compliance was significantly improved after the implementation of measures aiming to increase correct documentation awareness among ED staff. However, to maintain and even raise the level of current practice, additional systematic measures need to be put into action.

Contactless Vital Signs Acquisition Using Video Photoplethysmography, Motion Analysis and Passive Infrared Thermography Devices During Emergency Department Walk-In Triage in Pandemic Conditions

BACKGROUND

Contactless vital signs (VS) measurement with video photoplethysmography (vPPG), motion analysis (MA), and passive infrared thermometry (pIR) has shown promise.

OBJECTIVES

To compare conventional (contact-based) and experimental contactless VS measurement approaches for emergency department (ED) walk-in triage in pandemic conditions.

METHODS

Patients' heart rates (HR), respiratory rates (RR), and temperatures were measured with cardiorespiratory monitor and vPPG, manual count and MA, and contact thermometers and pIR, respectively.

RESULTS

There were 475 walk-in ED patients studied (95% of eligible). Subjects were 35.2 ± 20.8 years old (range 4 days‒95 years); 52% female, 0.2% transgender; had Fitzpatrick skin type of 2.3 ± 1.4 (range 1‒6), Emergency Severity Index of 3.0 ± 0.6 (range 2‒5), and contact temperature of 36.83°C (range 35.89-39.4°C) (98.3°F [96.6‒103°F]). Pediatric HR and RR data were excluded from analysis due to research challenges associated with pandemic workflow. For a 30-s, unprimed "Triage" window in 377 adult patients, vPPG-MA acquired 377 (100%) HR measurements featuring a mean difference with cardiorespiratory monitor HR of 5.9 ± 12.8 beats/min (R = 0.6833) and 252 (66.8%) RR measurements featuring a mean difference with manual RR of -0.4 ± 2.6 beats/min (R = 0.8128). Subjects' Emergency Severity Index components based on conventional VS and contactless VS matched for 83.8% (HR) and 89.3% (RR). Filtering out vPPG-MA measurements with low algorithmic confidence reduced VS acquired while improving correlation with conventional measurements. The mean difference between contact and pIR temperatures was 0.83 ± 0.67°C (range -1.16-3.5°C) (1.5 ± 1.2°F [range -2.1-6.3°F]); pIR fever detection improved with post hoc adjustment for mean bias.

CONCLUSION

Contactless VS acquisition demonstrated good agreement with contact methods during adult walk-in ED patient triage in pandemic conditions; clinical applications will need further study.

Sudanese emergency departments: a study to identify the barriers to a well-functioning triage

BACKGROUND

Triage system is a sorting system that categorizes patients on the basis of the severity of their condition and the availability of the resources in the emergency department. There has been little attention in the public literature to triage systems in Sudan. The aim of this study was to explore the triage system and identify the barriers in its application in hospitals in Sudan.

METHODS

A cross-sectional hospital based study was conducted at eight hospitals in Khartoum during December 2020. A multi-stage cluster sampling was applied. Data were obtained by interviewing emergency department staff using a structured questionnaire. The data were analyzed using statistical package for social sciences to find the association between various variables by chi-square test.

RESULTS

Most of the respondents stated that the triage system was deficient. Most of the participants of this study agreed that the role played by the administration in taking legislative decisions is crucial in improving the triage system. Among the factors found to be significant to a well-functioning triage system were, the need for substantial capital expenditure, p-value: 0.026, prudent legislative decisions, p-value: 0.026, adequate training of staff on means of performing efficient triaging, p-value: 0.007 and raising the awareness of the staff on the correct application of triage guidelines, p-value: 0.017.

CONCLUSION

Currently there is no formal triage system in the State of Khartoum and has yet to be established. Policy making by administrators will play an important role in its implementation. It is suggested that prompt executive orders on improving the current triage system in Khartoum, should be carried out sooner than later, as the ripple effects of a well-functioning triage will decrease the average length of stay, mortality and morbidity rates and will eventually increase the patient's satisfaction.

Manchester Triage System: assessment in an emergency hospital service

OBJECTIVES

to analyze demographic data, clinical profile and outcomes of patients in emergency services according to Manchester Triage System's priority level.

METHODS

a cross-sectional, analytical study, carried out with 3,624 medical records. For statistical analysis, the Chi-Square Test was used.

RESULTS

white individuals were more advanced in age. In the red and white categories, there was a higher percentage of men when compared to women (p=0.0018) and higher prevalence of personal history. Yellow priority patients had higher percentage of pain (p<0.0001). Those in red category had a higher frequency of altered vital signs, external causes, and death outcome. There was a higher percentage of exams performed and hospitalization in the orange category. Blue priority patients had a higher percentage of non-specific complaints and dismissal after risk stratification.

CONCLUSIONS

a higher percentage of altered vital signs, number of tests performed, hospitalization and death were evidenced in Manchester protocol's high priority categories.

Validation of Songklanagarind Pediatric Triage Model in the Emergency Department; a Cross-Sectional Study

Introduction:

An effective triage needs to consider many factors, such as good triage protocol, experienced triage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage (SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associated with triage appropriateness.

Methods:

This study was done in two phases. In the first phase, a team of emergency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT model by considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), Pediatric Canadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of the hospital as the core concept. In the second phase, a prospective observational study was conducted in the ED of Songklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to October 2019 to evaluate the accuracy of the developed triage model.

Results:

A total of 520 pediatric patients met the inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%, respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction of death, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triage were 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage were underlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75‒9.23), fever (OR = 0.60, 95%CI: 0.41‒0.88), dyspnea (OR: 6.38, 95%CI: 2.51‒16.22), diarrhea (OR = 0.26, 95%CI: 0.09‒0.73), oxygen saturation <95% (OR = 3.18, 95%CI: 1.09‒9.27), accessory muscle use during breathing (OR = 3.67, 95%CI: 1.09‒12.41), and wheezing or rhonchi (OR = 6.96, 95%CI: 3.14‒15.43).

Conclusion:

SPT showed good correlation of hospital admission rates and resource utilization with pediatric triage level of urgency. However, further efforts are needed to decrease the rates of over- and under-triage.

Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway

BACKGROUND

Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template.

METHODS

The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties.

RESULTS

All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method.

CONCLUSIONS

We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Man vs machine in emergency medicine - a study on the effects of manual and automatic vital sign documentation on data quality and perceived workload, using observational paired sample data and questionnaires

BACKGROUND

Emergency medicine is characterized by a high patient flow where timely decisions are essential. Clinical decision support systems have the potential to assist in such decisions but will be dependent on the data quality in electronic health records which often is inadequate. This study explores the effect of automated documentation of vital signs on data quality and workload.

METHODS

An observational study of 200 vital sign measurements was performed to evaluate the effects of manual vs automatic documentation on data quality. Data collection using questionnaires was performed to compare the workload on wards using manual or automatic documentation.

RESULTS

In the automated documentation time to documentation was reduced by 6.1 min (0.6 min vs 7.7 min, p <  0.05) and completeness increased (98% vs 95%, p <  0.05). Regarding workflow temporal demands were lower in the automatic documentation workflow compared to the manual group (50 vs 23, p <  0.05). The same was true for frustration level (64 vs 33, p <  0.05). The experienced reduction in temporal demands was in line with the anticipated, whereas the experienced reduction in frustration was lower than the anticipated (27 vs 54, p < 0.05).

DISCUSSION

The study shows that automatic documentation will improve the currency and the completeness of vital sign data in the Electronic Health Record while reducing workload regarding temporal demands and experienced frustration. The study also shows that these findings are in line with staff anticipations but indicates that the anticipations on the reduction of frustration may be exaggerated among the staff. The open-ended answers indicate that frustration focus will change from double documentation of vital signs to technical aspects of the automatic documentation system.

Strategies for improving physician documentation in the emergency department: a systematic review

BACKGROUND

Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown.

METHODS

We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation.

RESULTS

Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results.

CONCLUSIONS

Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

Acute Heart Failure in the Emergency Department: Respiratory Rate as a Risk Predictor

BACKGROUND/AIM

Several risk scores can stratify patients with acute heart failure (AHF) at the Emergency Department (ED). Registration of vital signs, such as blood pressure (BP), heart rate (HR) and respiratory rate (RR) upon admission is mandatory. Nevertheless, measurement of RR remains neglected worldwide.

PATIENTS AND METHODS

The predictive value of RR in classifying patients with AHF was investigated by processing several vital signs recorded in the ED.

RESULTS

HR and RR individually did not discriminate patients according to hospitalization length, Intensive Care Unit (ICU) admittance, mechanical respiratory support or death. The derivative indices, HR:RR and Respiratory Efficacy Index (REFI) (=RR×100/SatO₂), differentiated study patients regarding hospitalization length. Receiver operating characteristic curves predicting mortality and ICU admission for REFI and HR:RR revealed high accuracy, sensitivity and specificity for cut-off values of REFI >27 and HR:RR ≥4.

CONCLUSION

The RR and its derivative indices are easily accessible vital signs monitored at the ED which merit 'revitalization'.

The association between abnormal vital sign groups and undesirable patient outcomes

Introduction:

To determine the association between both abnormal individual vital signs and abnormal vital sign groups in the emergency department, and undesirable patient outcomes: hospital admission, medical emergency team calls and death.

Method:

We undertook a prospective cohort study in a tertiary referral emergency department (February–May 2015). Vital signs were collected prospectively in the emergency department and undesirable outcomes from the medical records. The primary outcomes were undesirable outcomes for individual vital signs (multivariate logistic regression) and vital sign groups (univariate analyses).

Results:

Data from 1438 patients were analysed. Admission was associated with tachycardia, tachypnoea, fever, ≥1 abnormal vital sign on admission to the emergency department, ≥1 abnormal vital sign at any time in the emergency department, a persistently abnormal vital sign, and vital signs consistent with both sepsis (tachycardia/hypotension/abnormal temperature) and pneumonia (tachypnoea/fever) (p < 0.05). Medical emergency team calls were associated with tachycardia, tachypnoea, ≥1 abnormal vital sign on admission (odds ratio: 2.3, 95% confidence interval: 1.4–3.8), ≥2 abnormal vital signs at any time (odds ratio: 2.4, 95% confidence interval: 1.2–4.7), and a persistently abnormal vital sign (odds ratio: 2.7, 95% confidence interval: 1.6–4.6). Death was associated with Glasgow Coma Score ≤13 (odds ratio: 6.3, 95% confidence interval: 2.5–16.0), ≥1 abnormal vital sign on admission (odds ratio: 2.6, 95% confidence interval: 1.2–5.6), ≥2 abnormal vital signs at any time (odds ratio: 6.4, 95% confidence interval: 1.4–29.5), a persistently abnormal vital sign (odds ratio: 4.3, 95% confidence interval: 2.0–9.0), and vital signs consistent with pneumonia (odds ratio: 5.3, 95% confidence interval: 1.9–14.8).

Conclusion:

Abnormal vital sign groups are generally superior to individual vital signs in predicting undesirable outcomes. They could inform best practice management, emergency department disposition, and communication with the patient and family.

Exploring Vital Sign Data Quality in Electronic Health Records with Focus on Emergency Care Warning Scores

BACKGROUND

Computerized clinical decision support and automation of warnings have been advocated to assist clinicians in detecting patients at risk of physiological instability. To provide reliable support such systems are dependent on high-quality vital sign data. Data quality depends on how, when and why the data is captured and/or documented.

OBJECTIVES

This study aims to describe the effects on data quality of vital signs by three different types of documentation practices in five Swedish emergency hospitals, and to assess data fitness for calculating warning and triage scores. The study also provides reference data on triage vital signs in Swedish emergency care.

METHODS

We extracted a dataset including vital signs, demographic and administrative data from emergency care visits (n=335027) at five Swedish emergency hospitals during 2013 using either completely paper-based, completely electronic or mixed documentation practices. Descriptive statistics were used to assess fitness for use in emergency care decision support systems aiming to calculate warning and triage scores, and data quality was described in three categories: currency, completeness and correctness. To estimate correctness, two further categories - plausibility and concordance - were used.

RESULTS

The study showed an acceptable correctness of the registered vital signs irrespectively of the type of documentation practice. Completeness was high in sites where registrations were routinely entered into the Electronic Health Record (EHR). The currency was only acceptable in sites with a completely electronic documentation practice.

CONCLUSION

Although vital signs that were recorded in completely electronic documentation practices showed plausible results regarding correctness, completeness and currency, the study concludes that vital signs documented in Swedish emergency care EHRs cannot generally be considered fit for use for calculation of triage and warning scores. Low completeness and currency were found if the documentation was not completely electronic.

Examining the utility of the Hamilton early warning scores (HEWS) at triage: Retrospective pilot study in a Canadian emergency department

OBJECTIVES

Early warning scores use vital signs to identify patients at risk of critical illness. The current study examines the Hamilton Early Warning Score (HEWS) at emergency department (ED) triage among patients who experienced a critical event during their hospitalization. HEWS was also evaluated as a predictor of sepsis.

METHODS

The study population included admissions to two hospitals over a 6-month period. Cases experienced a critical event defined by unplanned intensive care unit admission, cardiopulmonary resuscitation, or death. Controls were randomly selected from the database in a 2-to-1 ratio to match cases on the burden of comorbid illness. Receiver operating characteristic (ROC) curves were used to evaluate HEWS as a predictor of the likelihood of critical deterioration and sepsis.

RESULTS

The sample included 845 patients, of whom 270 experienced a critical event; 89 patients were excluded because of missing vitals. An ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting the likelihood of experiencing a critical event 0.62 (95% CI 0.58-0.66). HEWS had a fair discriminative ability for meeting criteria for sepsis 0.77 (95% CI 0.72-0.82) and good discriminative ability for predicting the occurrence of a critical event among septic patients 0.82 (95% CI 0.75-0.90).

CONCLUSION

This study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. However, HEWS may allow earlier identification of septic patients. Prospective studies are needed to further delineate the utility of the HEWS to identify septic patients in the ED.

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments

Background

Vital sign data are important for clinical decision making in emergency care. Clinical Decision Support Systems (CDSS) have been advocated to increase patient safety and quality of care. However, the efficiency of CDSS depends on the quality of the underlying vital sign data. Therefore, possible factors affecting vital sign data quality need to be understood.

This study aims to explore the factors affecting vital sign data quality in Swedish emergency departments and to determine in how far clinicians perceive vital sign data to be fit for use in clinical decision support systems. A further aim of the study is to provide recommendations on how to improve vital sign data quality in emergency departments.

Methods

Semi-structured interviews were conducted with sixteen physicians and nurses from nine hospitals and vital sign documentation templates were collected and analysed. Follow-up interviews and process observations were done at three of the hospitals to verify the results. Content analysis with constant comparison of the data was used to analyse and categorize the collected data.

Results

Factors related to care process and information technology were perceived to affect vital sign data quality. Despite electronic health records (EHRs) being available in all hospitals, these were not always used for vital sign documentation. Only four out of nine sites had a completely digitalized vital sign documentation flow and paper-based triage records were perceived to provide a better mobile workflow support than EHRs. Observed documentation practices resulted in low currency, completeness, and interoperability of the vital signs. To improve vital sign data quality, we propose to standardize the care process, improve the digital documentation support, provide workflow support, ensure interoperability and perform quality control.

Conclusions

Vital sign data quality in Swedish emergency departments is currently not fit for use by CDSS. To address both technical and organisational challenges, we propose five steps for vital sign data quality improvement to be implemented in emergency care settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0305-4) contains supplementary material, which is available to authorized users.

The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705,928 hospitalized patients in Germany from 2010-2012

BACKGROUND

Measurement of the respiratory rate is an important instrument for assessing the severity of acute disease. The respiratory rate is often not measured in routine practice because its clinical utility is inadequately appreciated. In Germany, documentation of the respiratory rate is obligatory when a patient with pneumonia is hospitalized. This fact has enabled us to study the prognostic significance of the respiratory rate in reference to a large medical database.

METHOD

We retrospectively analyzed data from the external quality-assurance program for community-acquired pneumonia for the years 2010-2012. All patients aged 18 years or older who were not mechanically ventilated on admission were included in the analysis. Logistic regression was used to determine the significance of the respiratory rate as a risk factor for in-hospital mortality.

RESULTS

705,928 patients were admitted to the hospital with community-acquired pneumonia (incidence: 3.5 cases per 1000 adults per year). The in-hospital mortality of these patients was 13.1% (92 227 persons). The plot of mortality as a function of respiratory rate on admission was U-shaped and slanted to the right, with the lowest mortality at a respiratory rate of 20/min on admission. If patients with a respiratory rate of 12-20/min are used as a baseline for comparison, patients with a respiratory rate of 27-33/min had an odds ratio (OR) of 1.72 for in-hospital death, and those with a respiratory rate above 33/min had an OR of 2.55. Further independent risk factors for in-hospital death were age, admission from a nursing home, hospital, or rehabilitation facility, chronic bedridden state, disorientation, systolic blood pressure, and pulse pressure.

CONCLUSION

Respiratory rate is an independent risk marker for in-hospital mortality in community-acquired pneumonia. It should be measured when patients are admitted to the hospital with pneumonia and other acute conditions.

A comparison of adherence to correctly documented triage level of critically ill patients between emergency department and the ambulance service nurses

Priority or triage has always occurred in emergency care. Today it is performed by both nurses in emergency departments (EDs) and ambulance services (ASs) to ensure patient safety. Recent studies have shown that nurses are unlikely to change their first impressions and patients suffering from blunt trauma are undertriaged. Our study aimed to compare and evaluate the adherence to correct triage level documentation, between nurses in the ED and the AS, according to current regulations. Of 592 analysed triage records from a university, a central and a district hospital, the adherence was 64% by ED nurses and 43% by AS nurses (p<0.001), but individual percentages ranged from 27% to 88%. Patient safety is jeopardised when nurses do not adhere to the triage system and do not correctly document the triage level. Internal feedback and control are two approaches to improve the patient outcome, indicating that organisational actions must be taken.