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Considine J, Casey P, Omonaiye O, van Gulik N, Allen J, Currey J. Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review. J Clin Nurs 2024; 33:2544-2561. [PMID: 38454551 DOI: 10.1111/jocn.17099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/11/2023] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Penelope Casey
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Olumuyiwa Omonaiye
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Nantanit van Gulik
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Joshua Allen
- Department of Nursing, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Judy Currey
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
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Avey S, Chatterjee M, Manyakov NV, Cooper P, Sabins N, Mosca K, Mori S, Baribaud F, Morris M, Lehar J, Deiteren A, Cossu M, Smets S, Huizer T, Lamousé‐Smith E, Campbell K, Pandis I. Using a wearable patch to develop a digital monitoring biomarker of inflammation in response to LPS challenge. Clin Transl Sci 2024; 17:e13734. [PMID: 38380580 PMCID: PMC10880037 DOI: 10.1111/cts.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/13/2024] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Remote inflammation monitoring with digital health technologies (DHTs) would provide valuable information for both clinical research and care. Controlled perturbations of the immune system may reveal physiological signatures which could be used to develop a digital biomarker of inflammatory state. In this study, molecular and physiological profiling was performed following an in vivo lipopolysaccharide (LPS) challenge to develop a digital biomarker of inflammation. Ten healthy volunteers received an intravenous LPS challenge and were monitored for 24 h using the VitalConnect VitalPatch (VitalPatch). VitalPatch measurements included heart rate (HR), heart rate variability (HRV), respiratory rate (RR), and skin temperature (TEMP). Conventional episodic inpatient vital signs and serum proteins were measured pre- and post-LPS challenge. The VitalPatch provided vital signs that were comparable to conventional methods for assessing HR, RR, and TEMP. A pronounced increase was observed in HR, RR, and TEMP as well as a decrease in HRV 1-4 h post-LPS challenge. The ordering of participants by magnitude of inflammatory cytokine response 2 h post-LPS challenge was consistent with ordering of participants by change from baseline in vital signs when measured by VitalPatch (r = 0.73) but not when measured by conventional methods (r = -0.04). A machine learning model trained on VitalPatch data predicted change from baseline in inflammatory protein response (R2 = 0.67). DHTs, such as VitalPatch, can improve upon existing episodic measurements of vital signs by enabling continuous sensing and have the potential for future use as tools to remotely monitor inflammation.
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Affiliation(s)
- Stefan Avey
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | | | | | - Philip Cooper
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Nina Sabins
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Kenneth Mosca
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Simone Mori
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Frédéric Baribaud
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Mark Morris
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Joseph Lehar
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | | | - Marta Cossu
- Janssen Pharmaceutical Research and DevelopmentLeidenThe Netherlands
| | - Sophie Smets
- Janssen Pharmaceutical Research and DevelopmentMerksemBelgium
| | - Tanja Huizer
- Janssen Pharmaceutical Research and DevelopmentLeidenThe Netherlands
| | - Esi Lamousé‐Smith
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
| | - Kim Campbell
- Janssen Pharmaceutical Research and DevelopmentSpring HousePennsylvaniaUSA
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Khan SR, Wang X, Jiang T, Ju W, Radacsi N, Kadir MA, Rabbani KSE, Cunningham S, Mitra S. Multi-Modal Portable Respiratory Rate Monitoring Device for Childhood Pneumonia Detection. MICROMACHINES 2023; 14:708. [PMID: 37420941 DOI: 10.3390/mi14040708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/26/2023] [Accepted: 03/21/2023] [Indexed: 07/09/2023]
Abstract
Accurate assessment of Respiratory Rate (RR) is the most important mechanism in detecting pneumonia in low-resource settings. Pneumonia is a disease with one of the highest mortality rates among young children under five. However, the diagnosis of pneumonia for infants remains challenging, especially in low- and middle-income countries (LMIC). In such situations, RR is most often measured manually with visual inspection. Accurate RR measurement requires the child to remain calm without any stress for a few minutes. The difficulty in achieving this with a sick child in a clinical environment can result in errors and misdiagnosis, even more so when the child is crying and non-cooperating around unfamiliar adults. Therefore, we propose an automated novel RR monitoring device built with textile glove and dry electrodes which can make use of the relaxed posture when the child is resting on the carer's lap. This portable system is non-invasive and made with affordable instrumentation integrated on customized textile glove. The glove has multi-modal automated RR detection mechanism that simultaneously uses bio-impedance and accelerometer data. This novel textile glove with dry electrodes can easily be worn by a parent/carer and is washable. The real-time display on a mobile app shows the raw data and the RR value, allowing a healthcare professional to monitor the results from afar. The prototype device has been tested on 10 volunteers with age variation of 3 years to 33 years, including male and female. The maximum variation of measured RR with the proposed system is ±2 compared to the traditional manual counting method. It does not create any discomfort for either the child or the carer and can be used up to 60 to 70 sessions/day before recharging.
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Affiliation(s)
- Sadeque Reza Khan
- School of Engineering and Physical Sciences, Institute of Sensors, Signals and Systems, Heriot-Watt University, Edinburgh EH14 4AS, UK
| | - Xiaohan Wang
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Tiantao Jiang
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Wei Ju
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Norbert Radacsi
- School of Engineering, Institute for Materials and Processes, The University of Edinburgh, Robert Stevenson Road, Edinburgh EH9 3FB, UK
| | - Muhammad Abdul Kadir
- Department of Biomedical Physics and Technology, University of Dhaka, Dhaka 1000, Bangladesh
| | | | - Steve Cunningham
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Srinjoy Mitra
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
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The quality of vital signs measurements and value preferences in electronic medical records varies by hospital, specialty, and patient demographics. Sci Rep 2023; 13:3858. [PMID: 36890179 PMCID: PMC9995491 DOI: 10.1038/s41598-023-30691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
We aimed to assess the frequency of value preferences in recording of vital signs in electronic healthcare records (EHRs) and associated patient and hospital factors. We used EHR data from Oxford University Hospitals, UK, between 01-January-2016 and 30-June-2019 and a maximum likelihood estimator to determine the prevalence of value preferences in measurements of systolic and diastolic blood pressure (SBP/DBP), heart rate (HR) (readings ending in zero), respiratory rate (multiples of 2 or 4), and temperature (readings of 36.0 °C). We used multivariable logistic regression to investigate associations between value preferences and patient age, sex, ethnicity, deprivation, comorbidities, calendar time, hour of day, days into admission, hospital, day of week and speciality. In 4,375,654 records from 135,173 patients, there was an excess of temperature readings of 36.0 °C above that expected from the underlying distribution that affected 11.3% (95% CI 10.6-12.1%) of measurements, i.e. these observations were likely inappropriately recorded as 36.0 °C instead of the true value. SBP, DBP and HR were rounded to the nearest 10 in 2.2% (1.4-2.8%) and 2.0% (1.3-5.1%) and 2.4% (1.7-3.1%) of measurements. RR was also more commonly recorded as multiples of 2. BP digit preference and an excess of temperature recordings of 36.0 °C were more common in older and male patients, as length of stay increased, following a previous normal set of vital signs and typically more common in medical vs. surgical specialities. Differences were seen between hospitals, however, digit preference reduced over calendar time. Vital signs may not always be accurately documented, and this may vary by patient groups and hospital settings. Allowances and adjustments may be needed in delivering care to patients and in observational analyses and predictive tools using these factors as outcomes or exposures.
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5
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Holland M, Kellett J. The United Kingdom's National Early Warning Score: should everyone use it? A narrative review. Intern Emerg Med 2023; 18:573-583. [PMID: 36602553 PMCID: PMC9813902 DOI: 10.1007/s11739-022-03189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/24/2022] [Indexed: 01/06/2023]
Abstract
This review critiques the benefits and drawbacks of the United Kingdom's National Early Warning Score (NEWS). Potential developments for the future are considered, as well as the role for NEWS in an emergency department (ED). The ability of NEWS to predict death within 24 h has been well validated in multiple clinical settings. It provides a common language for the assessment of clinical severity and can be used to trigger clinical interventions. However, it should not be used as the only metric for risk stratification as its ability to predict mortality beyond 24 h is not reliable and greatly influenced by other factors. The main drawbacks of NEWS are that measuring it requires trained professionals, it is time consuming and prone to calculation error. NEWS is recommended for use in acute UK hospitals, where it is linked to an escalation policy that reflects postgraduate experience; patients with lower NEWS are first assessed by a junior clinician and those with higher scores by more senior staff. This policy was based on expert opinion that did not consider workload implications. Nevertheless, its implementation has been shown to improve the efficient recording of vital signs. How and who should respond to different NEWS levels is uncertain and may vary according to the clinical setting and resources available. In the ED, simple triage scores which are quicker and easier to use may be more appropriate determinants of acuity. However, any alternative to NEWS should be easier and cheaper to use and provide evidence of outcome improvement.
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Affiliation(s)
- Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, A676 Deane Road, Bolton, BL3 5AB UK
| | - John Kellett
- Department of Emergency Medicine, University Hospital, Odense, Denmark
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6
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Rosli SN, Soh KL, Ong SL, Halain AA, Abdul Raman R, Soh KG. Physical assessment skills practised by critical care nurses: A cross-sectional study. Nurs Crit Care 2023; 28:109-119. [PMID: 35023244 DOI: 10.1111/nicc.12748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Physical assessment skills are essential to clinical decision-making in nursing as they help nurses to identify and respond to patients' deterioration. Nurses develop confidence and can detect any out-of-range parameters in diagnosing and treating patients. Prior studies surveyed 120 skills but did not explicitly assess critical care. AIM To determine the range of physical assessment skills practised by critical care nurses and their adoption factors. STUDY DESIGN This study uses a cross-sectional survey design. A self-administered questionnaire evaluating 40 physical assessment skills was conducted with 133 staff nurses (response rate: 96.4%) in three critical care units at a Malaysian government hospital between November 2019 and January 2020. RESULTS Most nurses applied 32 (80%) skills during every working shift, involving the vital signs and all body systems except the gastrointestinal system. Five skills (12.5%) were occasionally applied, while three skills (7.5%) were rarely applied or not part of most nurses' clinical practice. About 20% of the nurses did not routinely check the respiration rate. Medical and surgical intensive care unit nurses (U = 1129, p < .001) and nurses who had served over 10 years (H (2) = 9.60, p = .008) used more physical assessment skills than others. Nurses felt that continuing nursing education, participating in relevant courses and implementing standardised forms to record physical assessments would improve the application of such skills. CONCLUSION Clinical practice in these critical care settings challenges the assertion that physical assessment is vital to critical care nursing roles. Concerns highlighted by the nurses should be addressed by nursing management so that the application of physical assessment skills can be enhanced, especially in critical care settings. RELEVANCE TO CLINICAL PRACTICE The findings indicated that physical assessment skills in critical care need to be improved. Education and training should emphasise these skills.
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Affiliation(s)
- Syeril Nadia Rosli
- Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Kim Lam Soh
- Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Swee Leong Ong
- School of Nursing Science, Faculty of Medicine, Universiti Sultan Zainal Abidin Malaysia, Terengganu, Malaysia
| | - Azura Abdul Halain
- Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Rosna Abdul Raman
- Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Kim Geok Soh
- Department of Sport Studies, Faculty of Educational Studies, University Putra Malaysia, Seri Kembangan, Malaysia
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7
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Palmer JH, James S, Wadsworth D, Gordon CJ, Craft J. How registered nurses are measuring respiratory rates in adult acute care health settings: An integrative review. J Clin Nurs 2022. [PMID: 36097417 DOI: 10.1111/jocn.16522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/06/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES This integrative review aimed to draw conclusions from evidence on how registered nurses are measuring respiratory rates for acute care patients. BACKGROUND Despite the growing research supporting respiratory rate as an early indicator for clinical deterioration, respiratory rate has consistently been the least frequently measured and accurately documented vital sign. DESIGN An integrative review. METHODS A systematic literature search was conducted in June 2022 in four databases: CINAHL, PubMed, Medline and Scopus. Quality appraisal was undertaken using the Joanna Briggs Institute's Checklist. PRISMA guidelines were followed to ensure explicit reporting and reported in the PRISMA checklist. RESULTS Overall, 9915 records were identified, and 19 met the inclusion criteria. Of these 19 articles, seven themes emerged: estimation and digit preference, lack of understanding and knowledge, not valuing the clinical significance of respiratory rate, oxygen saturation substitute, interobserver agreement, subjective concern and count duration. A high prevalence of bias, estimation and incorrect technique was evident. A total of 15 articles reported specifically on how registered nurses are measuring respiratory rates on general medical and surgical wards. CONCLUSIONS Despite its importance, this integrative review has determined that respiratory rates are not being assessed correctly by nursing staff in the acute care environment. Evidence of using estimation, value bias or quick count and multiply techniques are emerging themes which urgently require further research. No patient or public contribution.
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Affiliation(s)
- Jennifer H Palmer
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia.,Critical Care and Support Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia
| | - Daniel Wadsworth
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia.,Sunshine Coast Health Institute, Birtinya, Queensland, Australia
| | - Christopher J Gordon
- Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,CIRUS Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Judy Craft
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia
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Bettencourt AP, Schondelmeyer AC, Bonafide CP. Continuous Pulse Oximetry Monitoring in Bronchiolitis Patients Not Receiving Oxygen-Reply. JAMA 2020; 324:1350-1351. [PMID: 33021664 PMCID: PMC7754544 DOI: 10.1001/jama.2020.12743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amanda P Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Characteristics of Rapid Response Calls in the United States: An Analysis of the First 402,023 Adult Cases From the Get With the Guidelines Resuscitation-Medical Emergency Team Registry. Crit Care Med 2020; 47:1283-1289. [PMID: 31343475 DOI: 10.1097/ccm.0000000000003912] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation-Medical Emergency Team cohort between 2005 and 2015. DESIGN Retrospective multicenter cohort study. SETTING Three hundred sixty U.S. hospitals. PATIENTS Consecutive adult patients experiencing rapid response team activation. INTERVENTIONS Rapid response team activation. MEASUREMENTS AND MAIN RESULTS The cohort included 402,023 rapid response team activations from 347,401 unique healthcare encounters. Respiratory triggers (38.0%) and cardiac triggers (37.4%) were most common. The most frequent interventions-pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%)-were noninvasive. Fluids were the most common medication ordered (19.3%), but new antibiotic orders were rare (1.2%). More than 10% of rapid response teams resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations. CONCLUSIONS Although patients requiring rapid response team activation have high inpatient mortality, most rapid response team activations involve relatively few interventions, which may limit these teams' ability to improve patient outcomes.
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10
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Towards development of alert thresholds for clinical deterioration using continuous predictive analytics monitoring. J Clin Monit Comput 2019; 34:797-804. [PMID: 31327101 DOI: 10.1007/s10877-019-00361-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
Patients who deteriorate while on the acute care ward and are emergently transferred to the Intensive Care Unit (ICU) experience high rates of mortality. To date, risk scores for clinical deterioration applied to the acute care wards rely on static or intermittent inputs of vital sign and assessment parameters. We propose the use of continuous predictive analytics monitoring, or data that relies on real-time physiologic monitoring data captured from ECG, documented vital signs, laboratory results, and other clinical assessments to predict clinical deterioration. A necessary step in translation to practice is understanding how an alert threshold would perform if applied to a continuous predictive analytic that was trained to detect clinical deterioration. The purpose of this study was to evaluate the positive predictive value of 'risk spikes', or large abrupt increases in the output of a statistical model of risk predicting clinical deterioration. We studied 8111 consecutive patient admissions to a cardiovascular medicine and surgery ward with continuous ECG data. We first trained a multivariable logistic regression model for emergent ICU transfer in a test set and tested the characteristics of the model in a validation set of 4059 patient admissions. Then, in a nested analysis we identified large, abrupt spikes in risk (increase by three units over the prior 6 h; a unit is the fold-increase in risk of ICU transfer in the next 24 h) and reviewed hospital records of 91 patients for clinical events such as emergent ICU transfer. We compared results to 59 control patients at times when they were matched for baseline risk including the National Warning Score (NEWS). There was a 3.4-fold higher event rate for patients with risk spikes (positive predictive value 24% compared to 7%, p = 0.006). If we were to use risk spikes as an alert, they would fire about once per day on a 73-bed acute care ward. Risk spikes that were primarily driven by respiratory changes (ECG-derived respiration (EDR) or charted respiratory rate) had highest PPV (30-35%) while risk spikes driven by heart rate had the lowest (7%). Alert thresholds derived from continuous predictive analytics monitoring are able to be operationalized as a degree of change from the person's own baseline rather than arbitrary threshold cut-points, which can likely better account for the individual's own inherent acuity levels. Point of care clinicians in the acute care ward settings need tailored alert strategies that promote a balance in recognition of clinical deterioration and assessment of the utility of the alert approach.
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11
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Li T, Divatia S, McKittrick J, Moss J, Hijnen NM, Becker LB. A pilot study of respiratory rate derived from a wearable biosensor compared with capnography in emergency department patients. Open Access Emerg Med 2019; 11:103-108. [PMID: 31123424 PMCID: PMC6511238 DOI: 10.2147/oaem.s198842] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/21/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: Respiratory rate is assessed less frequently than other vital signs, and documented respiratory rates are often erroneous. This pilot study compared respiratory rates derived from a wearable biosensor to those derived from capnography. Methods: Emergency department patients with respiratory complaints were enrolled and had capnography via nasal cannula and a wireless, wearable biosensor from Philips applied for approximately one hour. Respiratory rates were obtained from both of these methods. We determined the difference between median respiratory rates obtained from the biosensor and capnography and the proportion of biosensor-derived respiratory rates that were within three breaths/minute of the capnography-derived respiratory rates for each patient. A Spearman correlation coefficient was calculated to assess the strength of the correlation between mean respiratory rates derived from both methods. Plots of minute-by-minute respiratory rates, per patient, for each monitoring method were shown to two physicians. The physicians identified time periods in which the respiratory rates appeared invalid. The proportion of time with invalid respiratory rates for each patient, for each method, was calculated and averaged. Results: We analyzed data for 17 patients. Median biosensor-derived respiratory rate was 20 breaths/minute (range: 7-40 breaths/minute) and median capnography-derived respiratory rate was 25 breaths/minute (range: 0-58 breaths/minute). Overall, 72.8% of biosensor-derived respiratory rates were within three breaths per minute of the capnography-derived respiratory rates. Overall mean difference was 3.5 breaths/minute (±5.2 breaths/minute). Respiratory rates appeared invalid 0.7% of the time for the biosensor and 5.0% of the time for capnography. Conclusion: Our pilot study suggests that the Philips wearable biosensor can continuously obtain respiratory rates that are comparable to capnography-derived respiratory rates among emergency department patients with respiratory complaints.
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Affiliation(s)
- Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, USA
| | - Shreya Divatia
- Department of Connected Sensing, Philips North America Corporation, Cambridge, MA 02171, USA
| | - Justine McKittrick
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jeena Moss
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Nicole M Hijnen
- Department of Connected Sensing, Philips North America Corporation, Cambridge, MA 02171, USA
| | - Lance B Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, USA
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12
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Schondelmeyer AC, Jenkins AM, Allison B, Timmons KM, Loechtenfeldt AM, Pope-Smyth ST, Vaughn LM. Factors Influencing Use of Continuous Physiologic Monitors for Hospitalized Pediatric Patients. Hosp Pediatr 2019; 9:423-428. [PMID: 31043435 DOI: 10.1542/hpeds.2019-0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Continuous physiologic monitors (CPMs) generate frequent alarms and are used for up to 50% of children who are hospitalized outside of the ICU. Our objective was to assess factors that influence the decision to use CPMs. METHODS In this qualitative study, we used group-level assessment, a structured method designed to engage diverse stakeholder groups. We recruited clinicians and other staff who work on a 48-bed hospital medicine unit at a freestanding children's hospital. We developed a list of open-ended prompts used to address CPM use on inpatient units. Demographic data were collected from each participant. We conducted 6 sessions to permit maximum participation among all groups, and themes from all sessions were merged and distilled. RESULTS Participants (n = 78) included nurses (37%), attending physicians (17%), pediatric residents (32%), and unit staff (eg, unit coordinator; 14%). Participants identified several themes. First, there are patient factors (eg, complexity and instability) for which CPMs are useful. Second, participants perceived that alarms have negative effects on families (eg, anxiety and sleep deprivation). Third, CPMs are often used as surrogates for clinical assessments. Fourth, CPM alarms cause anxiety and fatigue for frontline staff. Fifth, the decision to use CPMs should be, but is not often, a team decision. Sixth, and finally, there are issues related to the monitor system's setup that reduces its utility. CONCLUSIONS Hospital medicine staff identified patient-, staff-, and system-level factors relevant to CPM use for children who were hospitalized. These data will inform the development of system-level interventions to improve CPM use and address high alarm rates.
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Affiliation(s)
- Amanda C Schondelmeyer
- Divisions of Hospital Medicine and .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley M Jenkins
- Divisions of Hospital Medicine and.,Department of Internal Medicine, University of Cincinnati Hospital, Cincinnati, Ohio
| | | | | | | | - Sally T Pope-Smyth
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lisa M Vaughn
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and.,Emergency Medicine
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Loughlin PC, Sebat F, Kellett JG. Respiratory Rate: The Forgotten Vital Sign-Make It Count! Jt Comm J Qual Patient Saf 2018; 44:494-499. [PMID: 30071969 DOI: 10.1016/j.jcjq.2018.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/04/2018] [Indexed: 01/29/2023]
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Lyons PG, Edelson DP, Churpek MM. Rapid response systems. Resuscitation 2018; 128:191-197. [PMID: 29777740 DOI: 10.1016/j.resuscitation.2018.05.013] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/20/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems. AIMS We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation. DATA SOURCES Articles written in English and published in PubMed. RESULTS Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement. CONCLUSIONS Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.
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Affiliation(s)
- Patrick G Lyons
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Dana P Edelson
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Matthew M Churpek
- Department of Medicine, University of Chicago, Chicago, IL, United States.
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