Patient bedside monitoring at the Queen
Elizabeth Hospital Birmingham
Ugochi Nwulu
Senior Research Associate
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
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
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
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
ALSO!
Changes in patient's physical
condition i.e. pain
Patient in distress or family
reports a change
Intuition/clinical experience
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.
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.
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
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.
Reducing harm from deterioration
Record vital signs
Staff
Education
Recognition
Monitoring
Competence in recording/
understanding physiological
observations
*adopted from the Chain of Prevention © Gary Smith
Call for help
Response
Interventions to improve patient outcomes
Response strategy
Critical Care Outreach
Medical Emergency
Teams
Staff
Education
Recognition
Monitoring
Call for help
Escalation
protocol
*adopted from the Chain of Prevention © Gary Smith
Response
Communication
tool
Interventions to improve patient outcomes
“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
The Early Warning Score System
HR
3
2
1
0
1
2
3
<30
30-39
40-49
50-99
100-109
110-129
≥130
70-79
80-99
100-199
85-89
90-92
≥93
sBP
O2 Sats
<85
RR
<9
TEMP
<34
CNS
34
35
≥200
9-20
20-30
31-35
36-37
>38
≥39
A
V
P
≥36
U
Interventions to improve patient outcomes (2)...
An Early Warning Score
Staff
Education
Recognition
Monitoring
Call for help
*adopted from the Chain of Prevention © Gary Smith
Response
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
PICS is a rules based system for
managing clinical investigations,
prescribing and drug
administration
PICS also has Paperless management
of drug therapy/protocols
Discharge
letters/summaries
Results reporting
Order communications
Automated lab
requesting
Electronic observation
form
Real-time, event driven
alerts
Bed state, dependencies,
estimated length of stay
Clinical procedures
Clinical notes
A change in prescribing -
From this
to this
using this
A change in vital signs recording
From this
To 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
Electronic observation form
Education
Recognition
Monitoring
Alerts to doctors
and nurses based
on severity of SEWS
*adopted from the Chain of Prevention © Gary Smith
Response
Ready
access to
electronic
data
capture
Call for help
Emails to
Critical
Care
Outreach
What next for bedside monitoring?
Coming soon - a National Early Warning Score (NEWS)
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
Advanced computerised solutions (2)
Coming when? Body Sensors and Smart Phones to Implantable Biodegradable
Sensors*
ViSi Mobile® by Sotera Wireless
*GE Wireless Communication (http://www.nanotechgalaxy.com)
Continuous vital signs
monitoring: a wristworn device that
measures HR/PR, 3- or 5lead electrocardiography
(ECG), SpO2, BP, RR and
skin temperature
through body sensors
Research opportunities...
Thank you!
For further information about Theme 9 please contact:
Principal investigator: Dr Jamie Coleman, jamie.coleman@uhb.nhs.uk
Project manager: Miss Ugochi Nwulu, ugochi.nwulu@uhb.nhs.uk