Intention Recognition With ProbLog

In many scenarios where robots or autonomous systems may be deployed, the capacity to infer and reason about the intentions of other agents can improve the performance or utility of the system. For example, a smart home or assisted living facility is better able to select assistive services to deploy if it understands the goals of the occupants in advance. In this article, we present a framework for reasoning about intentions using probabilistic logic programming. We employ ProbLog, a probabilistic extension to Prolog, to infer the most probable intention given observations of the actions of the agent and sensor readings of important aspects of the environment. We evaluated our model on a domain modeling a smart home. The model achieved 0.75 accuracy at full observability. The model was robust to reduced observability.

Midwives' views towards women using mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature

INTRODUCTION

There are many mobile telephone apps to help women self-monitor aspects of pregnancy and maternal health. This literature review aims to understand midwives’ perspectives on women self-monitoring their pregnancy using eHealth and mHealth, and establish gaps in research.

METHODS

MEDLINE, PubMed, Scopus, CINAHL and PsycINFO were systematically searched on midwifery, eHealth/mHealth and perspectives. Qualitative, quantitative and mixed-methods studies published in English were considered for inclusion in the review, without geographical limitations. Relevant articles were critically appraised and narrative synthesis was conducted.

RESULTS

Twelve relevant papers covering midwives’ perspectives of the use of eHealth and mHealth by pregnant women were obtained for inclusion in this review. Seven of these publications focused on midwives’ views of eHealth, and five on their perspectives of mHealth interventions. The studies included demonstrate that midwives generally hold ambivalent views towards the use of eHealth and mHealth technologies in antenatal care. Often, midwives acknowledged the potential benefits of such technologies, such as their ability to modernise antenatal care and to help women make more informed decisions about their pregnancy. However, midwives were quick to point out the risks and limitations of these, such as the accuracy of conveyed information, and negative impacts on the patient-professional relationship.

CONCLUSIONS

Post-COVID-19, where technology is continuously developing, there is a compelling need for studies that investigate the role of eHealth and mHealth in self-monitoring pregnancy, and the consequences this has for pregnant women, health professionals and organisations, as well as midwifery curricula.

Observational study of the relationship between nurse staffing levels and compliance with mandatory nutritional assessments in hospital

BACKGROUND

In the UK, it is recommended that hospital patients have their nutritional status assessed within 24 h of admission using the Malnutrition Universal Screening Tool (MUST). The present study aimed to examine the association between nurse staffing levels and missed nutritional status assessments.

METHODS

A single-centre, retrospective, observational study was employed using routinely collected MUST assessments from 32 general adult hospital wards over 2 years, matched to ward nurse staffing levels. We used mixed-effects logistic regression to control for ward characteristics and patient factors.

RESULTS

Of 43 451 instances where staffing levels could be linked to a patient for whom an assessment was due, 21.4% had no MUST score recorded within 24 h of admission. Missed assessments varied between wards (8-100%). There was no overall association between registered nurse staffing levels and missed assessments; although higher admissions per registered nurse were associated with more missed assessments [odds ratio (OR) = 1.09, P = 0.005]. Higher healthcare assistant staffing was associated with lower rates of missed assessments (OR = 0.80, P < 0.001). There was a significant interaction between registered nurses and healthcare assistants staffing levels (OR = 0.97, P = 0.011).

CONCLUSIONS

Despite a written hospital policy requiring a nutritional assessment within 24 h of admission, missed assessments were common. The observed results show that compliance with the policy for routine MUST assessments within 24 h of hospital admission is sensitive to staffing levels and workload. This has implications for planning nurse staffing.

Escalation triggers and expected responses in obstetric early warning systems used in UK consultant-led maternity units

Background

The use of obstetric early warning systems (OEWS) are recommended as an adjunct to reduce maternal morbidity and mortality. The aim of this review was to document the variation in OEWS trigger thresholds and the quality of information included within accompanying escalation protocols.

Methods

A review of OEWS charts and escalation policies across consultant-led maternity units in the UK (n = 147) was conducted. OEWS charts were analysed for variation in the values of physiological parameters triggering different levels of clinical escalation. Relevant data within the escalation protocols were also searched for: urgency of clinical response; seniority of responder; frequency of on-going clinical monitoring; and clinical setting recommended for on-going care.

Results

The values of physiological parameters triggering specific clinical responses varied significantly between OEWS. Only 99 OEWS charts (67.3%) had an escalation protocol as part of the chart. For 29 charts (19.7%), the only escalation information included was generic, for example to “contact a doctor if triggers”. Only 76 (51.7%) charts detailed the required seniority of responder, 37 (25.2%) the frequency for on-going clinical monitoring, eight (5.4%) the urgency of clinical response and two (1.4%) the recommended clinical setting for on-going care.

Conclusion

The observed variations in the trigger thresholds used in OEWS charts and the quality of information included within the accompanying escalation protocols is likely to lead to suboptimal detection and response to clinical deterioration during pregnancy and the post-partum period. The development of a national OEWS and escalation protocol would help to standardise care across obstetric units.

Impact of the coronavirus pandemic on the patterns of vital signs recording and staff compliance with expected monitoring schedules on general wards

Introduction

Coronavirus disease 2019 (COVID-19) placed increased burdens on National Health Service hospitals and necessitated significant adjustments to their structures and processes. This research investigated if and how these changes affected the patterns of vital sign recording and staff compliance with expected monitoring schedules on general wards.

Methods

We compared the pattern of vital signs and early warning score (EWS) data collected from admissions to a single hospital during the initial phase of the COVID-19 pandemic with those in three control periods from 2018, 2019 and 2020. Main outcome measures were weekly and monthly hospital admissions; daily and hourly patterns of recorded vital signs and EWS values; time to next observation and; proportions of ‘on time’, ‘late’ and ‘missed’ vital signs observations sets.

Results

There were large falls in admissions at the beginning of the COVID-19 era. Admissions were older, more unwell on admission and throughout their stay, more often required supplementary oxygen, spent longer in hospital and had a higher in-hospital mortality compared to one or more of the control periods. More daily observation sets were performed during the COVID-19 era than in the control periods. However, there was no clear evidence that COVID-19 affected the pattern of vital signs collection across the 24-h period or the week.

Conclusions

The increased burdens of the COVID-19 pandemic, and the alterations in healthcare structures and processes necessary to respond to it, did not adversely affect the hospitals’ ability to monitor patients under its care and to comply with expected monitoring schedules.

The performance of the National Early Warning Score and National Early Warning Score 2 in hospitalised patients infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

INTRODUCTION

Since the introduction of the UK's National Early Warning Score (NEWS) and its modification, NEWS2, coronavirus disease 2019 (COVID-19), has caused a worldwide pandemic. NEWS and NEWS2 have good predictive abilities in patients with other infections and sepsis, however there is little evidence of their performance in COVID-19.

METHODS

Using receiver-operating characteristics analyses, we used the area under the receiver operating characteristic (AUROC) curve to evaluate the performance of NEWS or NEWS2 to discriminate the combined outcome of either death or intensive care unit (ICU) admission within 24 h of a vital sign set in five cohorts (COVID-19 POSITIVE, n = 405; COVID-19 NOT DETECTED, n = 1716; COVID-19 NOT TESTED, n = 2686; CONTROL 2018, n = 6273; CONTROL 2019, n = 6523).

RESULTS

The AUROC values for NEWS or NEWS2 for the combined outcome were: COVID-19 POSITIVE, 0.882 (0.868-0.895); COVID-19 NOT DETECTED, 0.875 (0.861-0.89); COVID-19 NOT TESTED, 0.876 (0.85-0.902); CONTROL 2018, 0.894 (0.884-0.904); CONTROL 2019, 0.842 (0.829-0.855).

CONCLUSIONS

The finding that NEWS or NEWS2 performance was good and similar in all five cohorts (range = 0.842-0.894) suggests that amendments to NEWS or NEWS2, such as the addition of new covariates or the need to change the weighting of existing parameters, are unnecessary when evaluating patients with COVID-19. Our results support the national and international recommendations for the use of NEWS or NEWS2 for the assessment of acute-illness severity in patients with COVID-19.

The impact of the Tracey judgment on the rates and outcomes of in-hospital cardiac arrests in UK hospitals participating in the National Cardiac Arrest Audit

AIMS

The aim was to determine if the 17 June 2014 Tracey judgment regarding 'do not attempt cardiopulmonary resuscitation' decisions led to increases in the rate of in-hospital cardiac arrests resulting in a resuscitation attempt (IHCA) and/or proportion of resuscitation attempts deemed futile.

METHOD

Using UK National Cardiac Arrest Audit data, the IHCA rate and proportion of resuscitation attempts deemed futile were compared for two periods (pre-judgment (01 July 2012 - 16 June 2014, inclusive) and post-judgment (01 July 2014 - 30 June 2016, inclusive)) using interrupted time series analyses.

RESULTS

A total of 43,109 IHCAs (115 hospitals) were analysed. There were fewer IHCAs post- than pre-judgment (21,324 vs 21,785, respectively). The IHCA rate was declining over time before the judgment but there was an abrupt and statistically significant increase in the period immediately following the judgment (p<0.001). This was not sustained post-judgment. The proportion of resuscitation attempts deemed futile was smaller post-judgment than pre-judgment (8.2% vs 14.9%, respectively). The rate of attempts deemed futile decreased post-judgment (p<0.001).

CONCLUSION

The IHCA rate increased immediately after the Tracey judgment while the proportion of resuscitation attempts deemed futile decreased. The precise mechanisms for these changes are unclear.

What is the nursing time and workload involved in taking and recording patients' vital signs? A systematic review

AIMS AND OBJECTIVES

To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores.

BACKGROUND

While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown.

DESIGN

Systematic review.

METHODS

A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist.

RESULTS

Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed.

CONCLUSIONS

Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible.

RELEVANCE TO CLINICAL PRACTICE

There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown.

Impact of using data from electronic protocols in nursing performance management: A qualitative interview study

Aim

To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol.

Background

Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses’ practice in hospital wards.

Method

Seventeen acute hospital nursing staff participated in semi‐structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device.

Results

Before electronic EWS data was used to monitor compliance, staff combined protocol‐led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration.

Conclusions

Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety.

Implications for nursing management

Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.

The association between nurse staffing levels and the timeliness of vital signs monitoring: a retrospective observational study in the UK

OBJECTIVES

Omissions and delays in delivering nursing care are widely reported consequences of staffing shortages, with potentially serious impacts on patients. However, studies so far have relied almost exclusively on nurse self-reporting. Monitoring vital signs is a key part of nursing work and electronic recording provides an opportunity to objectively measure delays in care. This study aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and adherence to a vital signs monitoring protocol.

DESIGN

Retrospective observational study.

SETTING

32 medical and surgical wards in an acute general hospital in England.

PARTICIPANTS

538 238 nursing shifts taken over 30 982 ward days.

PRIMARY AND SECONDARY OUTCOME MEASURES

Vital signs observations were scheduled according to a protocol based on the National Early Warning Score (NEWS). The primary outcome was the daily rate of missed vital signs (overdue by ≥67% of the expected time to next observation). The secondary outcome was the daily rate of late vital signs observations (overdue by ≥33%). We undertook subgroup analysis by stratifying observations into low, medium and high acuity using NEWS.

RESULTS

Late and missed observations were frequent, particularly in high acuity patients (median=44%). Higher levels of RN staffing, measured in hours per patient per day (HPPD), were associated with a lower rate of missed observations in all (IRR 0.983, 95% CI 0.979 to 0.987) and high acuity patients (0.982, 95% CI 0.972 to 0.992). However, levels of NA staffing were only associated with the daily rate (0.954, CI 0.949 to 0.958) of all missed observations.

CONCLUSIONS

Adherence to vital signs monitoring protocols is sensitive to levels of nurse and NA staffing, although high acuity observations appeared unaffected by levels of NAs. We demonstrate that objectively measured omissions in care are related to nurse staffing levels, although the absolute effects are small.

STUDY REGISTRATION

The data and analyses presented here were part of the larger Missed Care study (ISRCTN registration: 17930973).

The response to patient deterioration in the UK National Health Service - A survey of acute hospital policies

BACKGROUND

The assessment of acute-illness severity in adult non-pregnant patients in the United Kingdom is based on early warning score (EWS) values that determine the urgency and nature of the response to patient deterioration. This study aimed to describe, and identify variations in, the expected clinical response outlined in 'deteriorating patient' policies/guidelines in acute NHS hospitals.

METHODS

A copy of the local 'deteriorating patient' policy/guideline was requested from 152 hospitals. Each was analysed against pre-determined areas of interest, e.g., minimum expected vital sign observations frequency, expected response and expected staff response times.

RESULTS

In the 55 responding hospitals (36.2%), the documented structure and process of the response to deterioration varied considerably. All hospitals used a 12-hourly minimum vital signs measurement frequency. Thereafter, for a low-risk patient, the minimum frequency varied from '6-12 hourly' to 'hourly'. Frequencies were higher for higher risk categories. Expected escalation responses were highly individualised between hospitals. Other than repeat observations, only nine (16.4%) documents described specific clinical actions for ward staff to consider/perform whilst awaiting responding personnel. Maximum permitted response times for medium-risk and high-risk patients varied widely, even when based on the same EWS. Only 33/55 documents (60%) gave clear instructions regarding who to contact 'out of hours'.

CONCLUSIONS

The 'deteriorating patient' policies of the hospitals studied varied in their contents and often omitted precise instructions for staff. We recommend that individual hospitals review these documents, and that research and/or consensus are used to develop a national algorithm regarding the response to patient deterioration.

Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study

Objective

To determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.

Design

This is a retrospective longitudinal observational study using routinely collected data. We used multilevel/hierarchical mixed-effects regression models to explore the association between patient outcomes and daily variation in RN and nursing assistant staffing, measured as hours per patient per day relative to ward mean. Analyses were controlled for ward and patient risk.

Participants

138 133 adult patients spending >1 days on general wards between 1 April 2012 and 31 March 2015.

Outcomes

In-hospital deaths.

Results

Hospital mortality was 4.1%. The hazard of death was increased by 3% for every day a patient experienced RN staffing below ward mean (adjusted HR (aHR) 1.03, 95% CI 1.01 to 1.05). Relative to ward mean, each additional hour of RN care available over the first 5 days of a patient’s stay was associated with 3% reduction in the hazard of death (aHR 0.97, 95% CI 0.94 to 1.0). Days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05, 95% CI 1.01 1.09). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality.

Conclusion

Lower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing and do not give support to policies that encourage the use of nursing assistants to compensate for shortages of RNs.

National Early Warning Score Accurately Discriminates the Risk of Serious Adverse Events in Patients With Liver Disease

BACKGROUND & AIMS

The National Early Warning Score (NEWS) is used to identify deteriorating adult hospital inpatients. However, it includes physiological parameters frequently altered in patients with cirrhosis. We aimed to assess the performance of the NEWS in acute and chronic liver diseases.

METHODS

We collected vital signs, recorded in real time, from completed consecutive admissions of patients 16 years or older to a large acute-care hospital in Southern England, from January 1, 2010, through October 31, 2014. Using International Classification of Diseases, 10th revision, codes, we categorized patients as having primary liver disease, secondary liver disease, or none. For patients with liver disease, 2 analysis groups were developed: the first was based on clinical group (such as acute or chronic, alcohol-induced, or associated with portal hypertension), and the second was based on a summary of liver-related, hospital-level mortality indicator diagnoses. For each, we compared the abilities of the NEWS and 34 other early warning scores to discriminate 24-hour mortality, cardiac arrest, or unanticipated admission to the intensive care unit using the area under the receiver operating characteristic (AUROC) curve and early warning score efficiency curve analyses.

RESULTS

The NEWS identified patients with primary, nonprimary, and no diagnoses of liver disease with AUROC values of 0.873 (95% CI, 0.860-0.886), 0.898 (95% CI, 0.891-0.905), and 0.879 (95% CI, 0.877-0.881), respectively. High AUROC values were also obtained for all clinical subgroups; the NEWS identified patients with alcohol-related liver disease with an AUROC value of 0.927 (95% CI, 0.912-0.941). The NEWS identified patients with liver diseases with higher AUROC values than other early warning scoring systems.

CONCLUSIONS

The NEWS accurately discriminates patients at risk of death, admission to the intensive care unit, or cardiac arrest within a 24-hour period for a range of liver-related diagnoses. Its widespread use provides a ready-made, easy-to-use option for identifying patients with liver disease who require early assessment and intervention, without the need to modify parameters, weightings, or escalation criteria.

A comparison of the ability of the National Early Warning Score and the National Early Warning Score 2 to identify patients at risk of in-hospital mortality: A multi-centre database study

Aims

To compare the ability of the National Early Warning Score (NEWS) and the National Early Warning Score 2 (NEWS2) to identify patients at risk of in-hospital mortality and other adverse outcomes.

Methods

We undertook a multi-centre retrospective observational study at five acute hospitals from two UK NHS Trusts. Data were obtained from completed adult admissions who were not fit enough to be discharged alive on the day of admission. Diagnostic coding and oxygen prescriptions were used to identify patients with type II respiratory failure (T2RF). The primary outcome was in-hospital mortality within 24 h of a vital signs observation. Secondary outcomes included unanticipated intensive care unit admission or cardiac arrest within 24 h of a vital signs observation. Discrimination was assessed using the c-statistic.

Results

Among 251,266 adult admissions, 48,898 were identified to be at risk of T2RF by diagnostic coding. In this group, NEWS2 showed statistically significant lower discrimination (c-statistic, 95% CI) for identifying in-hospital mortality within 24 h (0.860, 0.857–0.864) than NEWS (0.881, 0.878-0.884). For 1394 admissions with documented T2RF, discrimination was similar for both systems: NEWS2 (0.841, 0.827-0.855), NEWS (0.862, 0.848–0.875). For all secondary endpoints, NEWS2 showed no improvements in discrimination.

Conclusions

NEWS2 modifications to NEWS do not improve discrimination of adverse outcomes in patients with documented T2RF and decrease discrimination in patients at risk of T2RF. Further evaluation of the relationship between SpO₂ values, oxygen therapy and risk should be investigated further before wide-scale adoption of NEWS2.

Relationships between healthcare staff characteristics and the conduct of vital signs observations at night: Results of a survey and factor analysis

AIM

To explore the association of healthcare staff with factors relevant to completing observations at night.

DESIGN

Online survey conducted with registered nurses, midwives, healthcare support staff and student nurses who had worked at least one night shift in a National Health Service hospital in England.

METHODS

Exploratory factor analysis and mixed effects regression model adjusting for role, number of night shifts worked, experience and shift patterns.

RESULTS

Survey items were summarized into four factors: (a) workload and resources; (b) prioritization; (c) safety culture; (d) responsibility and control. Staff experience and role were associated with conducting surveillance tasks. Nurses with greater experience associated workload and resources with capacity to complete work at night. Responses of student nurses and midwives showed higher propensity to follow the protocol for conducting observations. Respondents working night shifts either exclusively or occasionally perceived that professional knowledge rather than protocol guided care tasks during night shifts.

Predicting in-hospital mortality and unanticipated admissions to the intensive care unit using routinely collected blood tests and vital signs: Development and validation of a multivariable model

Aim

The National Early Warning System (NEWS) is based on vital signs; the Laboratory Decision Tree Early Warning Score (LDT-EWS) on laboratory test results. We aimed to develop and validate a new EWS (the LDTEWS:NEWS risk index) by combining the two and evaluating the discrimination of the primary outcome of unanticipated intensive care unit (ICU) admission or in-hospital mortality, within 24 h.

Methods

We studied emergency medical admissions, aged 16 years or over, admitted to Oxford University Hospitals (OUH) and Portsmouth Hospitals (PH). Each admission had vital signs and laboratory tests measured within their hospital stay. We combined LDT-EWS and NEWS values using a linear time-decay weighting function imposed on the most recent blood tests. The LDTEWS:NEWS risk index was developed using data from 5 years of admissions to PH, and validated on a year of data from both PH and OUH. We tested the risk index’s ability to discriminate the primary outcome using the c-statistic.

Results

The development cohort contained 97,933 admissions (median age = 73 years) of which 4723 (4.8%) resulted inhospital death and 1078 (1.1%) in unanticipated ICU admission. We validated the risk index using data from PH (n = 21,028) and OUH (n = 16,383). The risk index showed a higher discrimination in the validation sets (c-statistic value (95% CI)) (PH, 0.901 (0.898–0.905); OUH, 0.916 (0.911–0.921)), than NEWS alone (PH, 0.877 (0.873–0.882); OUH, 0.898 (0.893–0.904)).

Conclusions

The LDTEWS:NEWS risk index increases the ability to identify patients at risk of deterioration, compared to NEWS alone.

The association between nurse staffing and omissions in nursing care: A systematic review

AIMS

To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.

BACKGROUND

Research has established associations between nurse staffing levels and adverse patient outcomes including in-hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy.

DESIGN

Systematic review.

DATA SOURCES

We searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles.

REVIEW METHODS

Two reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.

RESULTS

Eighteen studies gave subjective reports of missed care. Seventy-five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care.

CONCLUSIONS

Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

A fundamental conflict of care: Nurses' accounts of balancing patients' sleep with taking vital sign observations at night

Aims and objectives

To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night.

Background

Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why.

Design

A qualitative interpretative design informed this study.

Methods

Seventeen semi‐structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used.

Results

At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night‐time frequency of these observations was determined by clinical judgement, ward‐level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under‐monitored, while patients nearing the end of life could be over‐monitored.

Conclusion

In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long‐term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions.

Relevance to clinical practice

Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under‐monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.

What impact does nursing care left undone have on patient outcomes? Review of the literature

Aims and objectives

Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes.

Background

A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear.

Design

Systematic review.

Methods

We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses’ aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review.

Results

Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged.

Conclusions

The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self‐reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required.

Relevance to clinical practice

Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses’ reports of missed care and consider routine monitoring as a quality and safety indicator.

Heap leach cyanide irrigation and risk to wildlife: Ramifications for the international cyanide management code

Exposed cyanide-bearing solutions associated with gold and silver recovery processes in the mining industry pose a risk to wildlife that interact with these solutions. This has been documented with cyanide-bearing tailings storage facilities, however risks associated with heap leach facilities are poorly documented, monitored and audited. Gold and silver leaching heap leach facilities use cyanide, pH-stabilised, at concentrations deemed toxic to wildlife. Their design and management are known to result in exposed cyanide-bearing solutions that are accessible to and present a risk to wildlife. Monitoring of the presence of exposed solutions, wildlife interaction, interpretation of risks and associated wildlife deaths are poorly documented. This paper provides a list of critical monitoring criteria and attempts to predict wildlife guilds most at risk. Understanding the significance of risks to wildlife from exposed cyanide solutions is complex, involving seasonality, relative position of ponding, temporal nature of ponding, solution palatability, environmental conditions, in situ wildlife species inventory and provision of alternative drinking sources for wildlife. Although a number of heap leach operations are certified as complaint with the International Cyanide Management Code (Cyanide Code), these criteria are not considered by auditors nor has systematic monitoring regime data been published. Without systematic monitoring and further knowledge, wildlife deaths on heap leach facilities are likely to remain largely unrecorded. This has ramifications for those operations certified as compliance with the Cyanide Code.

Vital signs and other observations used to detect deterioration in pregnant women: an analysis of vital sign charts in consultant-led UK maternity units

BACKGROUND

Obstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care.

METHODS

One-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers.

RESULTS

There was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of 'normal' vital sign ranges were found, the most common being: heart rate=50-99beats/min; respiratory rate=11-20breaths/min; blood pressure, systolic=100-149mmHg, diastolic ≤89mmHg; SpO₂=95-100%; temperature=36.0-37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency.

CONCLUSION

The wide range of 'normal' vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding 'normal' vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Early warning scores: unravelling detection and escalation

PURPOSE

The purpose of this paper is to increase understanding of how patient deterioration is detected and how clinical care escalates when early warning score (EWS) systems are used.

DESIGN/METHODOLOGY/APPROACH

The authors critically review a recent National Early Warning Score paper published in IJHCQA using personal experience and EWS-related publications, and debate the difference between detection and escalation.

FINDINGS

Incorrect EWS choice or poorly understood EWS escalation may result in unnecessary workloads forward and responding staff.

PRACTICAL IMPLICATIONS

EWS system implementers may need to revisit their guidance materials; medical and nurse educators may need to expand the curriculum to improve EWS system understanding and use.

ORIGINALITY/VALUE

The paper raises the EWS debate and alerts EWS users that scrutiny is required.

Comparison of the National Early Warning Score in non-elective medical and surgical patients

BACKGROUND

The National Early Warning Score (NEWS) is used to identify deteriorating patients in hospital. NEWS is a better discriminator of outcomes than other early warning scores in acute medical admissions, but it has not been evaluated in a surgical population. The study aims were to evaluate the ability of NEWS to discriminate cardiac arrest, death and unanticipated ICU admission in patients admitted to surgical specialties, and to compare the performance of NEWS in admissions to medical and surgical specialties.

METHODS

Hospitalwide data over 31 months, from adult inpatients who stayed at least one night or died on the day of admission, were analysed. The data were categorized as elective or non-elective surgical or medical admissions. The ability of NEWS to discriminate the outcomes above in these different groups was assessed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

There were too few outcomes to permit meaningful comparison of elective admissions, so the analysis was constrained to comparison of non-elective admissions. NEWS performed equally well, or better, for surgical as for medical patients. For death within 24 h the AUROC for surgical admissions was 0·914 (95 per cent c.i. 0·907 to 0·922), compared with 0·902 (0·898 to 0·905) for medical admissions. For the combined outcome of any of death, cardiac arrest or unanticipated ICU admission, the AUROC was 0·874 (0·868 to 0·880) for surgical admissions and 0·874 (0·871 to 0·877) for medical admissions.

CONCLUSION

NEWS discriminated deterioration in non-elective surgical patients at least as well as in non-elective medical patients.

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study

BACKGROUND

Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events.

OBJECTIVE

To describe IHCA demographics during three day/time periods-weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)-and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care.

METHODS

We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals.

RESULTS

Risk-adjusted outcomes (OR (95% CI)) were worse (p<0.001) for both weekend daytime (ROSC>20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses.

CONCLUSIONS

IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at night and weekends, rather than patient case mix, appear to be responsible.

Reducing the number and impact of outbreaks of nosocomial viral gastroenteritis: time-series analysis of a multidimensional quality improvement initiative

BACKGROUND

Nosocomial norovirus infections and their control measures disrupt patient care, increase staff workload and raise healthcare costs.

OBJECTIVE

To determine the impact on outbreaks of nosocomial viral gastroenteritis, staff and patients affected, and bed closures of a multidimensional quality improvement (QI) initiative focused on education; improved patient surveillance; early automated recognition and notification of infection of index patients; and proactive care and control measures.

METHODS

In a pragmatic, retrospective, observational study, we compared numbers of suspected/confirmed norovirus outbreaks at Portsmouth Hospitals National Health Service Trust (PHT) with regional and national data, before and after a multidimensional QI initiative. We also compared mean daily bed closures due to norovirus-like symptoms. At PHT only we recorded patient and staff numbers with norovirus-like symptoms, and days of disruption due to outbreaks.

RESULTS

Annual outbreak numbers fell between 2009-2010 and 2010-2014 by 91% at PHT compared with 15% and 28% for Wessex and England, respectively. After April 2010, recorded outbreaks were 8 (PHT), 383 (Wessex) and 5063 (England). For the winter periods from 2010/2011 to 2013/2014, total bed closures due to norovirus were 38 (PHT; mean 0.5 per week), 3565 (Wessex hospitals; mean 48.8 per hospital per week) and 2730 (England; mean 37.4 per hospital per week). At PHT, patients affected by norovirus-like symptoms fell by 92%, affected staff by 81% and days of disruption by 88%.

CONCLUSIONS

A multiyear QI programme, including use of real-time electronic identification of patients with norovirus-like symptoms, and an early robust response to suspected infection, resulted in virtual elimination of outbreaks. The ability to identify index cases of infection early facilitates prompt action to prevent ongoing transmission and appears to be a crucial intervention.

'Errors' and omissions in paper-based early warning scores: the association with changes in vital signs--a database analysis

OBJECTIVES

To understand factors associated with errors using an established paper-based early warning score (EWS) system. We investigated the types of error, where they are most likely to occur, and whether 'errors' can predict subsequent changes in patient vital signs.

METHODS

Retrospective analysis of prospectively collected early warning system database from a single large UK teaching hospital.

RESULTS

16,795 observation sets, from 200 postsurgical patients, were collected. Incomplete observation sets were more likely to contain observations which should have led to an alert than complete observation sets (15.1% vs 7.6%, p<0.001), but less likely to have an alerting score correctly calculated (38.8% vs 30.0%, p<0.001). Mis-scoring was much more common when leaving a sequence of three or more consecutive observation sets with aggregate scores of 0 (55.3%) than within the sequence (3.0%, p<0.001). Observation sets that 'incorrectly' alerted were more frequently followed by a correctly alerting observation set than error-free non-alerting observation sets (14.7% vs 4.2%, p<0.001). Observation sets that 'incorrectly' did not alert were more frequently followed by an observation set that did not alert than error-free alerting observation sets (73.2% vs 45.8%, p<0.001).

CONCLUSIONS

Missed alerts are particularly common in incomplete observation sets and when a patient first becomes unstable. Observation sets that 'incorrectly' alert or 'incorrectly' do not alert are highly predictive of the next observation set, suggesting that clinical staff detect both deterioration and improvement in advance of the EWS system by using information not currently encoded within it. Work is urgently needed to understand how best to capture this information.

Are observation selection methods important when comparing early warning score performance?

INTRODUCTION

Sicker patients generally have more vital sign assessments, particularly immediately before an adverse outcome, and especially if the vital sign monitoring schedule is driven by an early warning score (EWS) value. This lack of independence could influence the measured discriminatory performance of an EWS.

METHODS

We used a population of 1564,143 consecutive vital signs observation sets collected as a routine part of patients' care. We compared 35 published EWSs for their discrimination of the risk of death within 24h of an observation set using (1) all observations in our dataset, (2) one observation per patient care episode, chosen at random and (3) one observation per patient care episode, chosen as the closest to a randomly selected point in time in each episode. We compared the area under the ROC curve (AUROC) as a measure of discrimination for each of the 35 EWSs under each observation selection method and looked for changes in their rank order.

RESULTS

There were no significant changes in rank order of the EWSs based on AUROC between the different observation selection methods, except for one EWS that included age among its components. Whichever method of observation selection was used, the National Early Warning Score (NEWS) showed the highest discrimination of risk of death within 24h. AUROCs were higher when only one observation set was used per episode of care (significantly higher for many EWSs, including NEWS).

CONCLUSIONS

Vital sign measurements can be treated as if they are independent - multiple observations can be used from each episode of care--when comparing the performance and ranking of EWSs, provided no EWS includes age.

Procedure for measuring simultaneously the solar and visible properties of glazing with complex internal or external structures

Accurate solar and visual transmittances of materials in which surfaces or internal structures are complex are often not easily amenable to standard procedures with laboratory-based spectrophotometers and integrating spheres. Localized "hot spots" of intensity are common in such materials, so data on small samples is unreliable. A novel device and simple protocols have been developed and undergone validation testing. Simultaneous solar and visible transmittance and reflectance data have been acquired for skylight components and multilayer polycarbonate roof panels. The pyranometer and lux sensor setups also directly yield "light coolness" in lumens/watt. Sample areas must be large, and, although mainly in sheet form, some testing has been done on curved panels. The instrument, its operation, and the simple calculations used are described. Results on a subset of diffuse and partially diffuse materials with no hot spots have been cross checked using 150 mm integrating spheres with a spectrophotometer and the Air Mass 1.5 spectrum. Indications are that results are as good or better than with such spheres for transmittance, but reflectance techniques need refinement for some sample types.

Development and validation of risk models to predict outcomes following in-hospital cardiac arrest attended by a hospital-based resuscitation team

AIM

The National Cardiac Arrest Audit (NCAA) is the UK national clinical audit for in-hospital cardiac arrest. To make fair comparisons among health care providers, clinical indicators require case mix adjustment using a validated risk model. The aim of this study was to develop and validate risk models to predict outcomes following in-hospital cardiac arrest attended by a hospital-based resuscitation team in UK hospitals.

METHODS

Risk models for two outcomes-return of spontaneous circulation (ROSC) for greater than 20min and survival to hospital discharge-were developed and validated using data for in-hospital cardiac arrests between April 2011 and March 2013. For each outcome, a full model was fitted and then simplified by testing for non-linearity, combining categories and stepwise reduction. Finally, interactions between predictors were considered. Models were assessed for discrimination, calibration and accuracy.

RESULTS

22,479 in-hospital cardiac arrests in 143 hospitals were included (14,688 development, 7791 validation). The final risk model for ROSC>20min included: age (non-linear), sex, prior length of stay in hospital, reason for attendance, location of arrest, presenting rhythm, and interactions between presenting rhythm and location of arrest. The model for hospital survival included the same predictors, excluding sex. Both models had acceptable performance across the range of measures, although discrimination for hospital mortality exceeded that for ROSC>20min (c index 0.81 versus 0.72).

CONCLUSIONS

Validated risk models for ROSC>20min and hospital survival following in-hospital cardiac arrest have been developed. These models will strengthen comparative reporting in NCAA and support local quality improvement.

A national survey of obstetric early warning systems in the United Kingdom: five years on

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Decision-tree early warning score (DTEWS) validates the design of the National Early Warning Score (NEWS)

AIM OF STUDY

To compare the performance of a human-generated, trial and error-optimised early warning score (EWS), i.e., National Early Warning Score (NEWS), with one generated entirely algorithmically using Decision Tree (DT) analysis.

MATERIALS AND METHODS

We used DT analysis to construct a decision-tree EWS (DTEWS) from a database of 198,755 vital signs observation sets collected from 35,585 consecutive, completed acute medical admissions. We evaluated the ability of DTEWS to discriminate patients at risk of cardiac arrest, unanticipated intensive care unit admission or death, each within 24h of a given vital signs observation. We compared the performance of DTEWS and NEWS using the area under the receiver-operating characteristic (AUROC) curve.

RESULTS

The structures of DTEWS and NEWS were very similar. The AUROC (95% CI) for DTEWS for cardiac arrest, unanticipated ICU admission, death, and any of the outcomes, all within 24h, were 0.708 (0.669-0.747), 0.862 (0.852-0.872), 0.899 (0.892-0.907), and 0.877 (0.870-0.883), respectively. Values for NEWS were 0.722 (0.685-0.759) [cardiac arrest], 0.857 (0.847-0.868) [unanticipated ICU admission}, 0.894 (0.887-0.902) [death], and 0.873 (0.866-0.879) [any outcome].

CONCLUSIONS

The decision-tree technique independently validates the composition and weightings of NEWS. The DT approach quickly provided an almost identical EWS to NEWS, although one that admittedly would benefit from fine-tuning using clinical knowledge. We believe that DT analysis could be used to quickly develop candidate models for disease-specific EWSs, which may be required in future.

Pain: a quality of care issue during patients' admission to hospital

AIM

To determine the extent of clinically significant pain suffered by hospitalized patients during their stay and at discharge.

BACKGROUND

The management of pain in hospitals continues to be problematic, despite long-standing awareness of the problem and improvements, e.g. acute pain teams and patient-controlled analgesia, epidural analgesia. Poorly managed pain, especially acute pain, often leads to adverse physical and psychological outcomes including persistent pain and disability. A systems approach may improve the management of pain in hospitals.

DESIGN

A descriptive cross-sectional exploratory design.

METHOD

A large electronic pain score database of vital signs and pain scores was interrogated between 1st January 2010 and 31st December 2010 to establish the proportion of hospital inpatient stays with clinically significant pain during the hospital stay and at discharge.

FINDINGS

A total of 810,774 pain scores were analysed, representing 38,451 patient stays. Clinically significant pain was present in 38·4% of patient stays. Across surgical categories, 54·0% of emergency admissions experienced clinically significant pain, compared with 48·0% of elective admissions. Medical areas had a summary figure of 26·5%. For 30% patients, clinically significant pain was followed by a consecutive clinically significant pain score. Only 0·2% of pain assessments were made independently of vital signs.

CONCLUSION

Reducing the risk of long-term persistent pain should be seen as integral to improving patient safety and can be achieved by harnessing organizational pain management processes with quality improvement initiatives. The assessment of pain alongside vital signs should be reviewed. Setting quality targets for pain are essential for improving the patient's experience.