Short summary

Patients of all sorts, and diagnoses, are treated in emergency departments around the world every single day. Despite elaborate track & triggering systems, a fraction of these patients unexpectedly deteriorate. Protocols, patient monitors, and information systems exist to mitigate this risk. However, it is unclear if the interplay between these function as intended. Perhaps a more rigorous approach to monitoring of vital signs and utilization of equipment can improve working procedures while also reducing the risk of deterioration. The aim of this quality improvement project is to assess the effectiveness of current patient monitoring practices. 

Rationale

Patients of all sorts and with a wide range of diagnoses are treated in emergency departments around the world every single day. Keeping track of such a diverse group of patients challenges both clinicians and information systems. Research shows that as many as 31 percent of acutely admitted patients who appear normal upon admission deteriorate during their stay - which is associated with high-risk outcomes. The risk of deterioration can be reduced by a more frequent and rigorous approach to monitoring of vital signs. Therefore, many departments utilize expensive patient monitoring equipment. However, most of the automatic measurements made with these monitors are never included in clinical decision making as the stream of information is simply too immense for clinicians to process. The consequence of this is that information that may have been used to identify impending deterioration, are at risk of not being noticed. This challenge is closely related to the ongoing discussion on the value of continuous vital sign monitoring in contrast to intermittent monitoring, which currently remain unresolved. Thus, there is a need to conduct further studies into the utility of continuous monitoring, and how it can support intermittent clinical assessment.

The settings

Patients arriving at the Emergency Department are initially triaged by a trained nurse and assigned a triage severity category. This category determines the urgency of the patient, and outlines how quickly a patient should be attended to. Part of the triage assessment is based on vital signs.

After being admitted to the department, patients are assigned an observation regimen by the attending physician. This regimen outlines the degree of monitoring and frequency of registration of vital signs in the patients electronic health record. When a patient is hooked up to a monitor, the staff has access to continuous information about the vitals, and any surpassing of thresholds generate auditory alarms. There is no data integration between the departments Philips IntelliVue monitors and the electronic health record. All registrations in the health record is done manually by the clinicians.

Aim

The aim of this project is to support the ongoing quality improvement of the Emergency Department at Odense University Hospital through gaining insight into the utilization of the departments' patient monitoring equipment.

The project includes the following sub-objectives:

1. Comparison of vital signs registered automatically for patients who unexpectedly deteriorate, expectedly deteriorate, and who pass through their admission without any major events.

2. To gain a better understanding of the utilization of patient monitoring equipment for patients admitted during the period to assess if certain groups of patients are not monitored according to existing guidelines.

3. To compare the severity of the automatically registered vital values with the concurrent severity score classification ordered by the attending physician.

4. Evaluation of the effectiveness of the existing observation regimens ability to identify deterioration.

Description of the cohort

All patients admitted to a bed during their stay at the Emergency Department from June 2018 until  April 2019.

Data and biological material

Vital signs registered using the patient monitors during admission

Collaborating researchers and departments

Emergency Department, Odense University Hospital

• Professor and Consultant Annmarie Lassen

Centre for Health Informatics & Technology, University of Southern Denmark

• Assistant Professor Thomas Schmidt