The Impact of an Electronic Patient Bedside Observation and Handover System on Clinical Practice: Mixed-Methods Evaluation

Motif discovery in hospital ward vital signs observation networks

Vital signs observations are regular measurements used by healthcare staff to track a patient's overall health status on hospital wards. We look at the potential in re-purposing aggregated and anonymised hospital data sources surrounding vital signs recording to provide new insights into how care is managed and delivered on wards. In this paper, we conduct a retrospective longitudinal observational study of 770,720 individual vital signs recordings across 20 hospital wards in South Wales (UK) and present a network modelling framework to explore and extract behavioural patterns via analysis of the resulting network structures at a global and local level. Self-loop edges, dyad, triad, and tetrad subgraphs were extracted and evaluated against a null model to determine individual statistical significance, and then combined into ward-level feature vectors to provide the means for determining notable behaviours across wards. Modelling data as a static network, by aggregating all vital sign observation data points, resulted in high uniformity but with the loss of important information which was better captured when modelling the static-temporal network, highlighting time's crucial role as a network element. Wards mostly followed expected patterns, with chains or stand-alone supplementary observations by clinical staff. However, observation sequences that deviate from this are revealed in five identified motif subgraphs and 6 anti-motif subgraphs. External ward characteristics also showed minimal impact on the relative abundance of subgraphs, indicating a 'superfamily' phenomena that has been similarly seen in complex networks in other domains. Overall, the results show that network modelling effectively captured and exposed behaviours within vital signs observation data, and demonstrated uniformity across hospital wards in managing this practice.

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.

The Effect of Clinical Decision Support Systems on Patients, Nurses, and Work Environment in ICUs: A Systematic Review

This study aimed to examine the impact of clinical decision support systems on patient outcomes, working environment outcomes, and decision-making processes in nursing. The authors conducted a systematic literature review to obtain evidence on studies about clinical decision support systems and the practices of ICU nurses. For this purpose, the authors searched 10 electronic databases, including PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE, Science Direct, Tr-Dizin, Harman, and DergiPark. Search terms included "clinical decision support systems," "decision making," "intensive care," "nurse/nursing," "patient outcome," and "working environment" to identify relevant studies published during the period from the year 2007 to October 2022. Our search yielded 619 articles, of which 39 met the inclusion criteria. A higher percentage of studies compared with others were descriptive (20%), conducted through a qualitative (18%), and carried out in the United States (41%). According to the results of the narrative analysis, the authors identified three main themes: "patient care outcomes," "work environment outcomes," and the "decision-making process in nursing." Clinical decision support systems, which target practices of ICU nurses and patient care outcomes, have positive effects on outcomes and show promise in improving the quality of care; however, available studies are limited.

Information displays for automated surveillance algorithms of in-hospital patient deterioration: a scoping review

OBJECTIVE

Surveillance algorithms that predict patient decompensation are increasingly integrated with clinical workflows to help identify patients at risk of in-hospital deterioration. This scoping review aimed to identify the design features of the information displays, the types of algorithm that drive the display, and the effect of these displays on process and patient outcomes.

MATERIALS AND METHODS

The scoping review followed Arksey and O'Malley's framework. Five databases were searched with dates between January 1, 2009 and January 26, 2022. Inclusion criteria were: participants-clinicians in inpatient settings; concepts-intervention as deterioration information displays that leveraged automated AI algorithms; comparison as usual care or alternative displays; outcomes as clinical, workflow process, and usability outcomes; and context as simulated or real-world in-hospital settings in any country. Screening, full-text review, and data extraction were reviewed independently by 2 researchers in each step. Display categories were identified inductively through consensus.

RESULTS

Of 14 575 articles, 64 were included in the review, describing 61 unique displays. Forty-one displays were designed for specific deteriorations (eg, sepsis), 24 provided simple alerts (ie, text-based prompts without relevant patient data), 48 leveraged well-accepted score-based algorithms, and 47 included nurses as the target users. Only 1 out of the 10 randomized controlled trials reported a significant effect on the primary outcome.

CONCLUSIONS

Despite significant advancements in surveillance algorithms, most information displays continue to leverage well-understood, well-accepted score-based algorithms. Users' trust, algorithmic transparency, and workflow integration are significant hurdles to adopting new algorithms into effective decision support tools.

An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse-patient interactions and communication

AIM

To explore how nurses' use of electronic health records impacts on the quality of nurse-patient interactions and communication.

DESIGN

An integrative review.

DATA SOURCES

MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022.

REVIEW METHODS

Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach.

RESULTS

One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face-to-face communication, promotes task-orientated and formulaic communication and impacts on types of communication patterns.

CONCLUSION

Research examining nurse-patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse-patient communications, reflecting a task-driven approach, were predominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient.

IMPACT

The move to electronic health records has taken place largely without consideration of the impact that this might have on nurse-patient interaction and communication. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse-patient interactions and communication.

PATIENT OR PUBLIC CONTRIBUTION

Studies examined within this review included patient participants that informed the analysis and interpretation of data.

Digital NEWS? How to amplify the benefits of NEWS in a digital healthcare system

With the transition of documentation systems, the National Early Warning Score (NEWS) is moving into a digital environment as a part of electronic health records. This paper aims to explore the opportunities and challenges of the digital environment for delivery of NEWS and the impact on safety of deteriorating patients. We make five recommendations to maximise the impact of a change to digital systems for patients, clinicians and healthcare organisations.

Health professionals' initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

Background

Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability.

Methods

A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts.

Results

Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits.

Conclusions

Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03411-1.

Electronic Records With Tablets at the Point of Care in an Internal Medicine Unit: Before-After Time Motion Study

BACKGROUND

There are many benefits of nursing professionals being able to consult electronic health records (EHRs) at the point of care. It promotes quality and patient security, communication, continuity of care, and time dedicated to records.

OBJECTIVE

The aim of this study was to evaluate whether making EHRs available at the point of care with tablets reduces nurses' time spent on records compared with the current system. The analysis included sociodemographic and qualitative variables, time spent per patient, and work shift. This time difference can be used for direct patient care.

METHODS

A before-after time motion study was carried out in the internal medicine unit. There was a total of 130 observations of 2 hours to 3 hours in duration of complete patient records that were carried out at the beginning of the nurses' work shifts. We calculated the time dedicated to measuring vital signs, patient evaluation, and EHR recording. The main variable was time spent per patient.

RESULTS

The average time spent per patient (total time/patients admitted) was lower with the tablet group (mean 4.22, SD 0.14 minutes) than with the control group (mean 4.66, SD 0.12 minutes); there were statistically significant differences (W=3.20, P=.001) and a low effect (d=.44) between groups. The tablet group saved an average of 0.44 (SD 0.13) minutes per patient. Similar results were obtained for the afternoon shift, which saved an average of 0.60 (SD 0.15) minutes per patient (t₃₄=3.82, P=.01) and high effect (d=.77). However, although there was a mean difference of 0.26 (SD 0.22) minutes per patient for the night shift, this was not statistically significant (t₂₉=1.16, P=.25). The "nonparticipating" average age was higher (49.57, SD 2.92 years) compared with the "afternoon shift participants" and "night shift participants" (P=.007). "Nonparticipants" of the night shift had a worse perception of the project.

CONCLUSIONS

This investigation determined that, with EHRs at the point of care, the time spent for registration by the nursing staff decreases, because of reduced movements and avoiding data transcription. It eliminates unnecessary work that does not add value, and therefore, care is improved. So, we think EHRs at the point of care should be the future or natural method for nursing to undertake. However, variables that could have a negative effect include age, night shift, and nurses' perceptions. Therefore, it is proposed that training in the different work platforms and the participation of nurses are fundamental axes that any institution should consider before their implementation.

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (the DETECT study): A qualitative interview study

BACKGROUND

Failure to recognize and respond to clinical deterioration in a timely and effective manner is an urgent safety concern, driving the need for early identification systems to be embedded in the care of children in hospital. Pediatric early warning systems (PEWS) or PEW scores alert health professionals (HPs) to signs of deterioration, trigger a review and escalate care as needed. PEW scoring allows HPs to record a child's vital signs and other key data including parent concern.

AIM

This study aimed to explore the experiences and perceptions of parents about the acceptability of a newly implemented electronic surveillance system (the DETECT surveillance system), and factors that influenced acceptability and their awareness around signs of clinical deterioration and raising concern.

METHODS

Descriptive, qualitative semi-structured telephone interviews were undertaken with parents of children who had experienced a critical deterioration event (CDE) (n = 19) and parents of those who had not experienced a CDE (non-CDE parents) (n = 17). Data were collected between February 2020 and February 2021.

RESULTS

Qualitative data were analyzed using generic thematic analysis. Analysis revealed an overarching theme of trust as a key factor that underpinned all aspects of children's vital signs being recorded and monitored. The main themes reflect three domains of parents' trust: trust in themselves, trust in the HPs, and trust in the technology.

CONCLUSION

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (The DETECT system) were positive; they found it acceptable and welcomed the use of new technology to support the care of their child.