Dynamic Electronic Tracking and Escalation to reduce Critical care Transfers (DETECT): the protocol for a stepped wedge mixed method study to explore the clinical effectiveness, clinical utility and cost-effectiveness of an electronic physiological surveillance system for use in children.

BACKGROUND: Active monitoring of hospitalised adults, using handheld electronic physiological surveillance systems, is associated with reduced in-patient mortality in the UK. Potential also exists to improve the recognition and response to deterioration in hospitalised children. However, the clinical effectiveness, the clinical utility, and the cost-effectiveness of this technology to reduce paediatric critical deterioration, have not been evaluated in an NHS environment. METHOD: This is a non-randomised stepped-wedge prospective mixed methods study. Participants will be in-patients under the age of 18 years, at a tertiary children's hospital. Day-case, neonatal surgery and Paediatric Intensive Care Unit (PICU) patients will be excluded. The intervention is the implementation of Careflow Vitals and Connect (System C) to document vital signs and sepsis screening. The underpinning age-specific Paediatric Early Warning Score (PEWS) risk model calculates PEWS and provides associated clinical decision support. Real-time data of deterioration risk are immediately visible to the entire clinical team to optimise situation awareness, the chronology of the escalation and response are captured with automated reporting of the organisational safety profile. Baseline data will be collected prospectively for 1 year preceding the intervention. Following a 3 month implementation period, 1 year of post-intervention data will be collected. The primary outcome is unplanned transfers to critical care (HDU and/or PICU). The secondary outcomes are critical deterioration events (CDE), the timeliness of critical care transfer, the critical care interventions required, critical care length of stay and outcome. The clinical effectiveness will be measured by prevalence of CDE per 1000 hospital admissions and per 1000 non-PICU bed days. Observation, field notes, e-surveys and focused interviews will be used to establish the clinical utility of the technology to healthcare professionals and the acceptability to in-patient families. The cost-effectiveness will be analysed using Health Related Group costs per day for the critical care and hospital stay for up to 90 days post CDE. DISCUSSION: If the technology is effective at reducing CDE in hospitalised children it could be deployed widely, to reduce morbidity and mortality, and associated costs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN61279068 , date of registration 03.06.19, retrospectively registered.

Accuracy and Efficiency of Recording Pediatric Early Warning Scores Using an Electronic Physiological Surveillance System Compared With Traditional Paper-Based Documentation.

Pediatric Early Warning Scores are advocated to assist health professionals to identify early signs of serious illness or deterioration in hospitalized children. Scores are derived from the weighting applied to recorded vital signs and clinical observations reflecting deviation from a predetermined "norm." Higher aggregate scores trigger an escalation in care aimed at preventing critical deterioration. Process errors made while recording these data, including plotting or calculation errors, have the potential to impede the reliability of the score. To test this hypothesis, we conducted a controlled study of documentation using five clinical vignettes. We measured the accuracy of vital sign recording, score calculation, and time taken to complete documentation using a handheld electronic physiological surveillance system, VitalPAC Pediatric, compared with traditional paper-based charts. We explored the user acceptability of both methods using a Web-based survey. Twenty-three staff participated in the controlled study. The electronic physiological surveillance system improved the accuracy of vital sign recording, 98.5% versus 85.6%, P < .02, Pediatric Early Warning Score calculation, 94.6% versus 55.7%, P < .02, and saved time, 68 versus 98 seconds, compared with paper-based documentation, P < .002. Twenty-nine staff completed the Web-based survey. They perceived that the electronic physiological surveillance system offered safety benefits by reducing human error while providing instant visibility of recorded data to the entire clinical team.

Impact of introducing an electronic physiological surveillance system on hospital mortality.

BACKGROUND: Avoidable hospital mortality is often attributable to inadequate patient vital signs monitoring, and failure to recognise or respond to clinical deterioration. The processes involved with vital sign collection and charting; their integration, interpretation and analysis; and the delivery of decision support regarding subsequent clinical care are subject to potential error and/or failure. OBJECTIVE: To determine whether introducing an electronic physiological surveillance system (EPSS), specifically designed to improve the collection and clinical use of vital signs data, reduced hospital mortality. METHODS: A pragmatic, retrospective, observational study of seasonally adjusted in-hospital mortality rates in three main hospital specialties was undertaken before, during and after the sequential deployment and ongoing use of a hospital-wide EPSS in two large unconnected acute general hospitals in England. The EPSS, which uses wireless handheld computing devices, replaced a paper-based vital sign charting and clinical escalation system. RESULTS: During EPSS implementation, crude mortality fell from a baseline of 7.75% (2168/27,959) to 6.42% (1904/29,676) in one hospital (estimated 397 fewer deaths), and from 7.57% (1648/21,771) to 6.15% (1614/26,241) at the second (estimated 372 fewer deaths). At both hospitals, multiyear statistical process control analyses revealed abrupt and sustained mortality reductions, coincident with the deployment and increasing use of the system. The cumulative total of excess deaths reduced in all specialties with increasing use of the system across the hospital. CONCLUSIONS: The use of technology specifically designed to improve the accuracy, reliability and availability of patients' vital signs and early warning scores, and thereby the recognition of and response to patient deterioration, is associated with reduced mortality in this study.

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.