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Relevance of the expression “obs stable”: a retrospective study Gregory Scott Academic clinical fellow Roshan Vijayan Core surgical trainee Pandora Male Medical student

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Obs stable

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Serious and important BMJ Seriousne ss Quite silly and not important Christmas BMJ Importanc e

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Should we seriously worry about what we write?

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What’s wrong with “obs stable”? 1.“Stable” might be interpreted as “normal” But A patient with persistent tachycardia has “stable” observations 2. “Obs stable” implies a lack of rigour

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What do we even mean by “stable”? Current obs within “normal” range? Variation in obs within “normal” limits (L) for a given time period (t)? t L

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Study Objective: To ascertain whether use of the term “obs stable” is so liberal as to render it meaningless. Design: Retrospective study Setting: Three London hospitals Methods –Searched notes for current admission of 46 randomly selected inpatients for “obs stable” entries –Reviewed the nursing observations recorded during the 24 hours preceding each entry –Calculated for these 24 hour periods: Frequency of any abnormalities Frequency of persistent abnormalities (occurring in every observation) Range (max.-min.) of observation values if at least two observations had been recorded

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Results: “obs stable” occurrences –1+ “obs stable” entry in 36 (78%) notes –178 “obs stable” entries total (3.9 per patient) –1 st “obs stable” entry on day 2 (median) –3.9 nursing observations charted in the 24 hours before each entry (SD 1.4)

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Results: abnormalities in the 24 hours preceding “obs stable” –1+ abnormality in 113 (71%) of 159 cases Tachypnoea (55%), hypotension (21%), tachycardia (13%), desaturation (16%) –1+ one persistent abnormality in 31 (19%) cases –Abnormality occurred in the observations immediately preceding an entry in 42% Definitions Hypotension = SBP 100/min Pyrexia = temperature >38C, Tachypnoea = RR≥20/min Oxygen desaturation = saturations <95%

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Results: all “stable” observations

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Results: 24 hourly range of “stable” observations

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Discussion: findings Doctors regularly used the expression “obs stable” “Obs stable” was often associated with a 24 hour period which included abnormal observations In two fifths of cases, an abnormality occurred in the observations immediately preceding an “obs stable” entry The range of observations over a 24 hour period that were designated “stable” occasionally exceeded normal values of diurnal variation

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Discussion: limitations Small sample No comparison with non-“stable” entries Arbitrary definition of abnormalities Arbitrary choice of 24 hour period Difficult to define “normal” diurnal variation

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Discussion: why do we write “obs stable”? Lack of time given to documentation Intended to be less committal Observation chart design The patient seems well

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Conclusions The meaning of “obs stable” is ambiguous and does not always indicate normality. What could we write instead? –Write the observations in full –Qualify “obs stable” by adding “for the last X hours” or –“Last abnormal observation was X [observation] at Y [time]” Perhaps obs stable has become ubiquitous precisely because it of its ambiguity.

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Thank you

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