Evaluation of the effects of implementing an electronic early warning score system: protocol for a stepped wedge study

Effect of Digital Early Warning Scores on Hospital Vital Sign Observation Protocol Adherence: Stepped-Wedge Evaluation

BACKGROUND

Early warning scores (EWS) are routinely used in hospitals to assess a patient's risk of deterioration. EWS are traditionally recorded on paper observation charts but are increasingly recorded digitally. In either case, evidence for the clinical effectiveness of such scores is mixed, and previous studies have not considered whether EWS leads to changes in how deteriorating patients are managed.

OBJECTIVE

This study aims to examine whether the introduction of a digital EWS system was associated with more frequent observation of patients with abnormal vital signs, a precursor to earlier clinical intervention.

METHODS

We conducted a 2-armed stepped-wedge study from February 2015 to December 2016, over 4 hospitals in 1 UK hospital trust. In the control arm, vital signs were recorded using paper observation charts. In the intervention arm, a digital EWS system was used. The primary outcome measure was time to next observation (TTNO), defined as the time between a patient's first elevated EWS (EWS ≥3) and subsequent observations set. Secondary outcomes were time to death in the hospital, length of stay, and time to unplanned intensive care unit admission. Differences between the 2 arms were analyzed using a mixed-effects Cox model. The usability of the system was assessed using the system usability score survey.

RESULTS

We included 12,802 admissions, 1084 in the paper (control) arm and 11,718 in the digital EWS (intervention) arm. The system usability score was 77.6, indicating good usability. The median TTNO in the control and intervention arms were 128 (IQR 73-218) minutes and 131 (IQR 73-223) minutes, respectively. The corresponding hazard ratio for TTNO was 0.99 (95% CI 0.91-1.07; P=.73).

CONCLUSIONS

We demonstrated strong clinical engagement with the system. We found no difference in any of the predefined patient outcomes, suggesting that the introduction of a highly usable electronic system can be achieved without impacting clinical care. Our findings contrast with previous claims that digital EWS systems are associated with improvement in clinical outcomes. Future research should investigate how digital EWS systems can be integrated with new clinical pathways adjusting staff behaviors to improve patient outcomes.

A Network Architecture and Routing Protocol for the MEDIcal WARNing System

The MEDIcal WARNing (MEDIWARN) system continuously and automatically monitors the vital parameters of pre-intensive care hospitalized patients and, thanks to an intelligent processing system, provides the medical teams with a better understanding of their patients’ clinical condition, thus enabling a prompt reaction to any change. Since the hospital units generally lack a wired infrastructure, a wireless network is required to collect sensor data in a server for processing purposes. This work presents the MEDIWARN communication system, addressing both the network architecture and a simple, lightweight and configurable routing protocol that fits the system requirements, such as the ability to offer path redundancy and mobility support without significantly increasing the network workload and latency. The novel protocol, called the MultiPath Routing Protocol for MEDIWARN (MP-RPM), was therefore designed as a solution to support low-latency reliable transmissions on a dynamic network while limiting the network overhead due to the control messages. The paper describes the MEDIWARN communication system and addresses the experimental performance evaluation of an implementation in a real use-case scenario. Moreover, the work discusses a simulative assessment of the MEDIWARN communication system performance obtained using different routing protocols. In particular, the timeliness and reliability results obtained by the MP-RPM routing protocol are compared with those obtained by two widely adopted routing protocols, i.e., the Ad-hoc On-demand Distance Vector (AODV) and the Destination-Sequenced Distance-Vector Routing (DSDV).

Stepped-Wedge Cluster Randomised Trial of Social Prescribing of Forest Therapy for Quality of Life and Biopsychosocial Wellbeing in Community-Living Australian Adults with Mental Illness: Protocol

Social Prescribing (SP) involves linking individuals with mental illness to local health and welfare services to improve quality of life (QoL) and biopsychosocial wellbeing. SP programs address psychosocial wellbeing by linking individuals to group activities. Forest Therapy (FT) is a group nature walk with prescribed activities that promote mindfulness, relaxation, and shared experience. Improvements in psychological and physical wellbeing have been demonstrated in FT, but psychosocial impacts have not been widely investigated. This study will implement an SP FT intervention and assess the impacts on QoL and biopsychosocial wellbeing. Participants will include 140 community-living adults with mental illness at Sydney/Gold Coast, Australia. A stepped-wedge cluster randomised design will be used; each participant will complete a 10-week control period followed by a 10-week FT intervention. Weekly 90-min FT sessions will be conducted in groups of 6–10 in local nature reserves. Validated tools will measure self-report QoL and biopsychosocial wellbeing pre- and post-control and intervention periods, and 5-week follow-up. Blood pressure and heart rate will be measured pre- and post-FT sessions. Hypothesised outcomes include improvements in QoL and biopsychosocial wellbeing. This study is the first to assess SP FT, and may provide evidence for a novel, scalable mental illness intervention.

Physician awareness and attitudes regarding early warning score systems in mainland China: a cross-sectional study

INTRODUCTION

The purpose of the study was to assess the application of the early warning score system (EWS-S) and gauge physician awareness, perceptions of necessity, and attitude regarding these tools based on previously experienced unnoticed clinical deterioration (CDET).

METHODS

A cross-sectional survey was carried out via an online questionnaire at a large 3,500-bed Class 3A general hospital in China. A total of 299 physicians of adult general wards were asked to answer a translated questionnaire that was localised from the original version. Demographic profiles were included as well as three other sections assessing awareness of CDET/EWS-S and gauging attitudes towards and perceptions of the necessity of EWS-S at our hospital.

RESULTS

There was a high level of physician awareness of the CDET problem. Most physicians knew about the existence of a systematic assessment tool for clinical application. Physicians with previous experience in reanimation, unplanned transfer to intensive care unit (UTICU) and/or death tended to consider EWS-S to be necessary in attentive and well-trained staff (p < 0.05). Physicians who had previous experience with UTICU were more likely to recommend implementing EWS-S in their wards compared with those without such experience (p < 0.05).

CONCLUSION

Most physicians have positive attitudes towards EWS-S. However, their awareness should be further heightened. Physicians who had previous experience with CDET/UTICU were more likely to employ EWS-S in their clinical practices. To better facilitate the implementation of EWS-S in Chinese hospitals, existing facilities, policy supports, standardised managements and the development of information systems should be strengthened.

ChroniSense National Early Warning Score Study (CHESS): a wearable wrist device to measure vital signs in hospitalised patients-protocol and study design

INTRODUCTION

The National Early Warning Score is used as standard clinical practice in the UK as a track and trigger system to monitor hospitalised patients. Currently, nurses are tasked to take routine vital signs measurements and manually record these on a clinical chart. Wearable devices could provide an easier, reliable, more convenient and cost-effective method of monitoring. Our aim is to evaluate the clinical validity of Polso (ChroniSense Medical, Yokneam Illit, Israel), a wrist-based device, to provide National Early Warning Scores.

METHODS AND ANALYSIS

We will compare Polso National Early Warning Score measurements to the currently used manual measurements in a UK Teaching District General Hospital. Patients aged 18 years or above who require recordings of observations of vital signs at least every 6 hours will be enrolled after consenting. The sample size for the study was calculated to be 300 participants based on the assumption that the final dataset will include four pairs of measurements per-patient and per-vital sign, resulting in a total of 1200 pairs of data points per vital sign. The primary outcome is the agreement on the individual parameter scores and values of the National Early Warning Score: (1) respiratory rate, (2) oxygen saturation, (3) body temperature, (4) systolic blood pressure and (5) heart rate. Secondary outcomes are the agreement on the aggregate National Early Warning Score. The incidence of adverse events will be recorded. The measurements by the device will not be used for the clinical decision-making in this study.

ETHICS AND DISSEMINATION

We obtained ethical approval, reference number 18/LO/0123 from London-Hampstead Research Ethics Committee, through the Integrated Research Application System, (reference number: 235 034. The study received no objection from the Medicine and Health Regulatory Authority, reference number: CI/20018/005 and has National Institute for Health Research portfolio adoption status CPMS number: 32 532.

TRIAL REGISTRATION NUMBER

NCT03448861; Pre-results.

Impact of Electronic Versus Paper Vital Sign Observations on Length of Stay in Trauma Patients: Stepped-Wedge, Cluster Randomized Controlled Trial

Background

Electronic recording of vital sign observations (e-Obs) has become increasingly prevalent in hospital care. The evidence of clinical impact for these systems is mixed.

Objective

The objective of our study was to assess the effect of e-Obs versus paper documentation (paper) on length of stay (time between trauma unit admission and “fit to discharge”) for trauma patients.

Methods

A single-center, randomized stepped-wedge study of e-Obs against paper was conducted in two 26-bed trauma wards at a medium-sized UK teaching hospital. Randomization of the phased intervention order to 12 study areas was computer generated. The primary outcome was length of stay.

Results

A total of 1232 patient episodes were randomized (paper: 628, e-Obs: 604). There were 37 deaths in hospital: 21 in the paper arm and 16 in the e-Obs arm. For discharged patients, the median length of stay was 5.4 (range: 0.2-79.0) days on the paper arm and 5.6 (range: 0.1-236.7) days on the e-Obs arm. Competing risks regression analysis for time to discharge showed no difference between the treatment arms (subhazard ratio: 1.05; 95% CI 0.82-1.35; P=.68). A greater proportion of patient episodes contained an Early Warning Score (EWS) ≥3 using the e-Obs system than using paper (subhazard ratio: 1.63; 95% CI 1.28-2.09; P<.001). However, there was no difference in the time to the subsequent observation, “escalation time” (hazard ratio 1.05; 95% CI 0.80-1.38; P=.70).

Conclusions

The phased introduction of an e-Obs documentation system was not associated with a change in length of stay. A greater proportion of patient episodes contained an EWS≥3 using the e-Obs system, but this was not associated with a change in “escalation time.”

Trial Registration

ISRCTN Registry ISRCTN91040762; http://www.isrctn.com/ISRCTN91040762 (Archived by WebCite at http://www.webcitation.org/72prakGTU)

Manual centile-based early warning scores derived from statistical distributions of observational vital-sign data

AIMS OF STUDY

To develop and validate a centile-based early warning score using manually-recorded data (mCEWS). To compare mCEWS performance with a centile-based early warning score derived from continuously-acquired data (from bedside monitors, cCEWS), and with other published early warning scores.

MATERIALS AND METHODS

We used an unsupervised approach to investigate the statistical properties of vital signs in an in-hospital patient population and construct an early-warning score from a "development" dataset. We evaluated scoring systems on a separate "validation" dataset. We assessed the ability of scores to discriminate patients at risk of cardiac arrest, unanticipated intensive care unit admission, or death, each within 24 h of a given vital-sign observation, using metrics including the area under the receiver-operating characteristic curve (AUC).

RESULTS

The development dataset contained 301,644 vital sign observations from 12,153 admissions (median age (IQR): 63 (49-73); 49.2% females) March 2014-September 2015. The validation dataset contained 1,459,422 vital-sign observations from 53,395 admissions (median age (IQR): 68 (48-81), 51.4% females) October 2015-May 2017. The AUC (95% CI) for the mCEWS was 0.868 (0.864-0.872), comparable with the National EWS, 0.867 (0.863-0.871), and other recently proposed scores. The AUC for cCEWS was 0.808 (95% CI, 0.804-0.812). The improvement in performance in comparison to the continuous CEWS was mainly explained by respiratory rate threshold differences.

CONCLUSIONS

Performance of an EWS is highly dependent on the database from which itis derived. Our unsupervised statistical approach provides a straightforward, reproducible method to enable the rapid development of candidate EWS systems.

Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa

Background

Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA.

Methods

We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009–2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score.

Results

Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27–49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)).

Conclusion

We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.