1. Ugochi Nwulu Senior Research Associate Patient bedside monitoring at the Queen Elizabeth Hospital Birmingham

2. Birmingham and Black Country CLAHRC Theme 9: Improving Patient Safety – Studying an evolving IT system This theme evaluates the implementation of various clinical computing technologies in University Hospital Birmingham NHS Foundation Trust that aim to improve safety and quality of care

3. Outline of presentation  Bedside monitoring: What, When, Who and Why  Interventions which improve patient outcomes: by improving patient bedside monitoring  What happens at UHB: an overview of PICS and the electronic observation form  Bedside monitoring in the future: advanced computerised solutions

4. Bedside monitoring What is monitored? TPR charts: temperature, pulse, respiratory rate, blood pressure & oxygen saturation most frequent measurements taken by health care professionals These VITAL SIGNS are important indicators of the body’s response to stressors and form part of a routine physical assessment Additionally – measures of consciousness (AVPU), urine output, pain scores are part of bedside monitoring Other aspects of bedside monitoring are often needed in different circumstances – after certain procedures

5. Bedside monitoring When to monitor? On admission According to ward/unit/specialty Before and after a procedure/surgery Before and after blood transfusions As indicated with medications NICE guidance recommends that all inpatients must have their vital signs recorded as a minimum every 12 hours but the frequency should be increased when abnormal physiology is detected. ALSO! Changes in patient's physical condition i.e. pain Patient in distress or family reports a change Intuition/clinical experience Acutely ill patients in hospital: recognition of and response to acute illness of adults in hospital.CG50 National Institute for Health and Clinical Excellence 2007.

6. Bedside monitoring Who monitors? Observations are usually taken by nursing staff – both registered and non registered. Can often be delegated to more junior or less experienced members of the team Important that staff are aware of the significance of vital sign recording, and have the knowledge and skill to interpret them to ensure patient safety Safer Care for the Acutely Ill Patient: Learning from Serious Incidents. National Patient Safety Agency 2007

7. Bedside monitoring Why is it important? Important to provide baseline set of vital signs to identify subsequent changes in a patient’s condition Critical events (cardiac arrests, deaths & unplanned ICU transfers) are often preceded by physiological deterioration (and often signs of physiological deterioration!) Bedside monitoring can be perceived as basic and routine BUT plays a vital role to ensure safer patient care and early recognition of deterioration.

8. Staff Education Response Call for help Recognition Monitoring Reducing harm from deterioration *adopted from the Chain of Prevention © Gary Smith Record vital signs Competence in recording/ understanding physiological observations

9. *adopted from the Chain of Prevention © Gary Smith Staff Education Response Call for help Recognition Monitoring Response strategy Critical Care Outreach Medical Emergency Teams Escalation protocol Communication tool Interventions to improve patient outcomes

10. The Early Warning Score System 3210123 HR<3030-3940-4950-99100-109110-129≥130 sBP70-7980-99100-199≥200 O 2 Sats<8585-8990-92≥93 RR<99-2020-3031-35≥36 TEMP<34343536-37>38≥39 CNSAVPU “Track and trigger” systems Used on paper-based and electronic observation charts Periodic observation of selected vital signs (the “tracking”) with pre-determined criteria (the “trigger”) for requesting the attendance of more experienced staff

11. *adopted from the Chain of Prevention © Gary Smith Staff Education Response Call for help Recognition Monitoring An Early Warning Score Interventions to improve patient outcomes (2)...

12. PICS is a rules based system for managing clinical investigations, prescribing and drug administration The use of PICS in the Trust PICS is the Trust’s locally developed electronic prescribing solution that is available on every computer desktop in the Trust

13. PICS also has - Paperless management of drug therapy/protocols Results reporting Automated lab requesting Real-time, event driven alerts Clinical procedures Discharge letters/summaries Order communications Electronic observation form Bed state, dependencies, estimated length of stay Clinical notes

14. A change in prescribing - From thisto this using this

15. A change in vital signs recording From thisTo this Using this 2007: Development of electronic form 2009: Go-live in May. Pilot ward was Burns and Plastics 2012: Now in majority of wards

16. Education Response Call for help Recognition Monitoring Electronic observation form Alerts to doctors and nurses based on severity of SEWS Emails to Critical Care Outreach *adopted from the Chain of Prevention © Gary Smith Ready access to electronic data capture

17. What next for bedside monitoring? Coming soon - a National Early Warning Score (NEWS)

18. Advanced computerised solutions Coming soonish - Wireless Vital Signs Monitor* The monitor tracks a patient’s HR and RR by beaming Doppler radar technology into their chest. It uses radio frequency electromagnetic waves reflected from the body's surface and only requires that the white device face the patient to work. * Kaiser Permanente's Garfield Health Care Innovation Centre

19. Advanced computerised solutions (2) Coming when? Body Sensors and Smart Phones to Implantable Biodegradable Sensors* Continuous vital signs monitoring: a wrist- worn device that measures HR/PR, 3- or 5- lead electrocardiography (ECG), SpO2, BP, RR and skin temperature through body sensors *GE Wireless Communication (http://www.nanotechgalaxy.com) ViSi Mobile ® by Sotera Wireless

20. Research opportunities...

21. Thank you! For further information about Theme 9 please contact: Principal investigator: Dr Jamie Coleman, jamie.coleman@uhb.nhs.ukjamie.coleman@uhb.nhs.uk Project manager: Miss Ugochi Nwulu, ugochi.nwulu@uhb.nhs.ukugochi.nwulu@uhb.nhs.uk