vitalpac: a means of hospital-wide physiological surveillance

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

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. 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? i.e. adapted and routinised i.e. adapted and routinised

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) McQuillan propspectively studied quality of care received by 50 consecutive, adult emergency patients before their admission to ITU in each of 2 centres between 1992-1993 so 100 in total. Opinions of 2 external assessors. Clinical deterioration often preceded by changes in physiological observations in period 6-24 hrs before the event NPSA analysed 1804 serious incidents that resulted in death, of these 576 were avoidable Of these 425 occurred in acute/general hospital and 64 related to deterioration not being recognised or acted upon A search of NRLS data for similar incidents with less severe outcomes was undertaken for the same time period. Fifty-eight further incidents were identified and classified into the same themes as above. Of the 58, for 24 no observations were taken, for 26 there was failure to recognise the significance of deteriorating observations, and for eight there was a delay in the patient receiving medical attention. These reports may represent only a very small proportion of incidents that actually occurred. McQuillan propspectively studied quality of care received by 50 consecutive, adult emergency patients before their admission to ITU in each of 2 centres between 1992-1993 so 100 in total. Opinions of 2 external assessors. Clinical deterioration often preceded by changes in physiological observations in period 6-24 hrs before the event NPSA analysed 1804 serious incidents that resulted in death, of these 576 were avoidable Of these 425 occurred in acute/general hospital and 64 related to deterioration not being recognised or acted upon A search of NRLS data for similar incidents with less severe outcomes was undertaken for the same time period. Fifty-eight further incidents were identified and classified into the same themes as above. Of the 58, for 24 no observations were taken, for 26 there was failure to recognise the significance of deteriorating observations, and for eight there was a delay in the patient receiving medical attention. These reports may represent only a very small proportion of incidents that actually occurred.

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. 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. 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) Algorithm usually monitors parameters of systolic BP, HR, RR, Sats, Algorithm usually monitors parameters of systolic BP, HR, RR, Sats,

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 (an intelligent assessment tool for clinicians using personal digital assistants, tablet PCs and hospital intranets to replace traditional observation charts with real-time data and high quality charting) Direct input of vital signs data into handheld personal digital assistant (PDA) Linked via wi-fi to central computer Raw physiology data together with EWS, vital signs charts can be made available to members of healthcare team via W-LAN or hospital intranet (an intelligent assessment tool for clinicians using personal digital assistants, tablet PCs and hospital intranets to replace traditional observation charts with real-time data and high quality charting) Direct input of vital signs data into handheld personal digital assistant (PDA) Linked via wi-fi to central computer Raw physiology data together with EWS, vital signs charts can be made available to members of healthcare team via W-LAN or hospital intranet

9. VitalPAC � the process

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 Challenge to ritualised practice e.g. avoidance of taking observations at night ?priority afforded to taking observations Incorrect EWS 28.6% of time, Prytherch et al 2006 (mostly due to incorrect ascribing of weighted values to individual physiological variables) Senior staff can set their own alerts Removes need for staff to know weightings for individual physiological variables Facilitates utilisation of complex algorithms which might otherwise lead to error e.g. changes in BP due to ageing Using objective criteria and automatic alerting removes any emotional component to the process � overrides hierarchies Challenge to ritualised practice e.g. avoidance of taking observations at night ?priority afforded to taking observations Incorrect EWS 28.6% of time, Prytherch et al 2006 (mostly due to incorrect ascribing of weighted values to individual physiological variables) Senior staff can set their own alerts Removes need for staff to know weightings for individual physiological variables Facilitates utilisation of complex algorithms which might otherwise lead to error e.g. changes in BP due to ageing Using objective criteria and automatic alerting removes any emotional component to the process � overrides hierarchies

11. VitalPAC � opportunity for performance feedback?

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) (due to incorrect input of physiological data) BUT this was in classroom situation (Prytherch 2006) EWS in a ward setting associated with lower accuracy than classroom (96% to 88%) although better than pen and paper (58%) (Mohammed et al 2009) False positives and negatives which can undermine confidence in EWS (due to incorrect input of physiological data) BUT this was in classroom situation (Prytherch 2006) EWS in a ward setting associated with lower accuracy than classroom (96% to 88%) although better than pen and paper (58%) (Mohammed et al 2009) False positives and negatives which can undermine confidence in EWS

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) Presumes technologies have specific effects as a result of their intrinsic properties, design and use. Minimises importance of the role of professional and economic interests in shaping technology. Abstracts technology from its context. Redundancy - redundancy is the duplication of critical components of a system with the intention of increasing reliability of the system, usually in the case of a backup or fail-safe. Presumes technologies have specific effects as a result of their intrinsic properties, design and use. Minimises importance of the role of professional and economic interests in shaping technology. Abstracts technology from its context. Redundancy - redundancy is the duplication of critical components of a system with the intention of increasing reliability of the system, usually in the case of a backup or fail-safe.

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. 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. 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 normalise routine-following at the expense of social decision making. �Bureaucratic systems can create extreme rule-mindedness that deflects individuals from actions that are most beneficial to the organisation� (Vaughan, 1999 p. 281). normalise routine-following at the expense of social decision making. �Bureaucratic systems can create extreme rule-mindedness that deflects individuals from actions that are most beneficial to the organisation� (Vaughan, 1999 p. 281).

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. �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) Foucault interested in the ways in which knowledge, power and social control were produced and reproduced through the clinic: the social �gaze� determines the basis on which identities are defined and classified, so sorting the mad from the sane and the medium through which people become an object for scientific subjectification. Without such discourses, these classifications and the divisions between normality and abnormality they create would not existFoucault interested in the ways in which knowledge, power and social control were produced and reproduced through the clinic: the social �gaze� determines the basis on which identities are defined and classified, so sorting the mad from the sane and the medium through which people become an object for scientific subjectification. Without such discourses, these classifications and the divisions between normality and abnormality they create would not exist

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. 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 Provides a �good story� - �good stories stand for or signify what the system likes to think it is doing and support and increase self-confidence (Cohen 1985) Provides a �good story� - �good stories stand for or signify what the system likes to think it is doing and support and increase self-confidence (Cohen 1985)

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