1. 1 VitalPAC: a means of hospital-wide physiological surveillance? SPSRN Burn June 2009 Nicola Mackintosh

2. 2 Outline  Context & project overview  The nature of the problem, ‘failure to rescue’ and the proposed safety solution – VitalPAC  What could be the problem with the solution?  Examining the potential for unintended consequences

3. 3 Research Context  Context: Innovations Programme / NIHR King’s PSSQ Research Centre  Project: two year study examining the management of complications in medicine and maternity in four wards of two foundation trusts  Methods: ethnography (observations, interviews, documentary review, analysis of routine data)  Focus:  How is deterioration socially framed, negotiated and managed?  How have safety strategies such as VitalPAC been adopted and what is their impact?  What contextual features facilitate ‘mindful’ application of these tools?

4. 4 Background Policy Context  Widespread evidence of ‘failure to rescue’ i.e. failure not only to recognise warning signs, but to interpret and institute timely, appropriate clinical management once deterioration is identified (NCEPOD 2005, NPSA 2007, O’Neill 2008).  Up to 50% of ward based patients received substandard care prior to ICU admission; up to 41% of ICU admissions were potentially avoidable (McQuillan 1998)  Deterioration in a patient’s condition identified by WHO as a key topic (Joint Commission 2008)

5. 5 Latent Failures & Error Producing Conditions (NPSA 2007) Work/environment factors e.g. lack of guidelines, lack of training Team factors e.g. hierarchies Individual (staff) factors e.g. inadequate handover Task factors e.g. observations rated as low priority Patient factors e.g. signs of deterioration not always visually obvious Failure to detect, interpret and respond to the deteriorating patient

6. 6 Safety Solutions  Early recognition e.g. Early Warning Scores (EWS), intelligent assessment tools such as ‘VitalPAC’  Graded response strategy for those at risk  Access to personnel with core critical care competencies and diagnostic skills e.g. Medical Emergency Team, Critical Care Outreach Service  Education and training / core competencies in monitoring, measuring, interpreting and responding e.g. Immediate Life Support Training

7. 7 Early Warning Scores  EWS operate by allotting points to vital sign measurements on basis of physiological derangement from a ‘predetermined range’  When score reaches an arbitrarily predefined threshold it triggers ‘call for help’  To date the extent to which the existing tools are valid or reliable predictors of deterioration is unknown (McGaughey et al 2007)

8. 8 VitalPAC – the rationale  VitalPAC (intelligent assessment tool) – may facilitate appropriate graded medical response based on the severity of the condition of the patient. Alerts preset and linked to a central surveillance system; designing out variability in practitioners’ responses to the information

9. 9 VitalPAC – the process

10. 10 VitalPAC – potential for reduction of risks?  Task  Accurate and legible recording of data  Individualised practice  Correct ascription of weighted value according to physiological derangement; arithmetic addition of weighted values to form EWS  Team  Remote access to aid medical prioritisation when medical team ‘offsite’  License to overcome professional hierarchies  Point of reference for junior staff

11. 11 VitalPAC – opportunity for performance feedback?

12. 12 VitalPAC – evidence of impact?  Key questions – does VP trigger remedial actions at the right time? Does it reduce rates of ‘failure to rescue’? Does it reduce avoidable adverse events or death?  Little empirical research to date  Absence of data examining impact of VP on patient outcome  EWS error rate of 28.6% compared to 9.5% with VP (Prytherch 2006)  Even with track and trigger systems recording of vital signs, patient chart completion and RRT activation remains sub-optimal (Hillman et al 2005)

13. 13 Potential Problems With The Solution?  ‘Technological determinism’ (Webster 2007) underpins rationale for the tool  Ignores technology’s capability as ‘one actor among many in changing configurations of social and technical elements’ (Law and Hassard 1999)  Considers redundancy as a problem to be solved rather than recognising duplication of effort in recording data as source of reliability (Tjora and Scambler 2008)

14. 14 Boundaries Of Risk  Tool focuses on individual behaviour; system design failures are marginalised.  Inadequate staffing levels, inappropriate skill mix, high workload known to impact on levels of surveillance, sensitivity to warning signs and capacity to respond to an emergency (Carr-Hill et al 2003)  Inbuilt algorithm designed to influence nurses’ behaviour – may have little impact on regulation of medical response  Disjuncture regarding chain of command - observations performed by care assistant; initiation of appropriate escalation strategy by qualified staff

15. 15 Claiming Authority And Jurisdiction Over A Contested Field  Potential for technology to serve as tool to demonstrate power, professional skills and decision making  VitalPAC could provide opportunity for boundary work; may enable nurses to gain authority and ‘symbolic capital’ – improving social position (Gieryn 1999, Bourdieu 1998)

16. 16 Potential Unintended Consequences (1)  System failure – information inaccessible  Impact of remote access on interprofessional collaboration – removal of ‘key material structuring device’ and the face to face communication that often happens around the ward round (Greenhalgh 2008)  Apprenticeship – difficult for novices to develop key assessment skills  Impact on work practices: increase in workload due to loss of ‘batching’ of observations, difficulties accessing computers during busy times e.g. ward rounds

17. 17 Potential Unintended Consequences (2)  Overdue observations? Normalisation of deviance – departures from safety system that get recast as acceptable risk and become the norm (Vaughan 1996)  Devaluation of tacit knowledge and merit of subjective data in defining patients at risk  Necessity for pragmatism, application of contingent standards when staff decide to over-ride the system e.g. around end of life care and chronic illness - increasing the margin for error  Colonisation - staff controlled by the very ICT installed to facilitate working routines; ‘symbolic violence’ (Habermas 1987, Bourdieu 1977)  Routinisation  Construction of hierarchy of importance of vital signs according to attribution of weighted value

18. 18 ‘Medical Gaze’  Technology of power - ‘e-panopticon’ (Foucault 1976)  ‘The patient is rendered as a universalised datum, disconnected from both any tangible, corporeal body and the sentient human being, becoming an image that can be moved through computer networks anywhere around the world. Understanding such a patient does not require human touch’ (Samson 1999)

19. 19 The Tool As A means Of Surveillance  Software warns if erroneous values are entered  The system flags up when partial data consistently entered or ‘unlikely observations’ entered or the same data regularly recorded  Aggregated data can provide an overview of the health status of the hospital patient population  Opportunities for performance monitoring / score cards  Medico-legal and clinical negligence implications

20. 20 Operationalising New Modes of Surveillance  Interpretation of numerical data becomes the mode of framing generalisable knowledge about social phenomena (May 2006)  Performance management can become an organisational ritual, ‘a dramaturgical performance’ (Power 1997)  Opportunities for blame of particular professional groups

21. 21 Summary  Codifying and standardising ‘the indeterminancy of expert systems and knowledge will have limited effect in practice’ (Webster 2007)  Important to capture how the tool ‘mediates’ practice and influences pragmatic decision making