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The primary role of the patient bedside observation chart is to make clinicians aware of the deteriorating patient. Despite this, its performance has not been scrutinised. Many versions exist with different styles of data entry but the optimal format remains elusive. This paper hypothesised that chart design measurably influences function and that...
Contexts in source publication
Context 1
... was introduced to all wards with training in its use performed over a three week period. Reassessment showed that accuracy of plotting was considerably improved compared with existing charts (fig 2). Table 2 shows the objective performance of the new chart. ...
Context 2
... identified with existing charts were ( fig 2A): temperature points are not always joined together as a graphical plot and writing in over the point obscures the value; charting of blood pressure and pulse together on the same overlain axes is easily correlated but difficult to read unless all the pulse values are joined together accurately- writing in over the point also obscures the reading; individual points are often joined together as a curved rather than straight line; the percentage oxygen is not always recorded when measuring oxygen saturations; respiratory rate, the only parameter typically measured without an electronic machine is too frequently recorded as ''20'' suggesting approximation. ...
Context 3
... features for making clinical staff aware of physiolo- gical decline based on objective and subjective testing were used to re-design a new observation chart that was standardised on all medical wards. Accurate detection of physiological deterioration is reliant on a chart that is well plotted and indeed in this study training of clinical staff in plotting observations based on defined standards resulted in significant improvements in the quality of the observation chart plot (compare fig 2A and 2B) and in detection rates of most parameters. Parameters poorly identified on existing charts namely tachypnoea and hypoxia were significantly better detected on the new chart: there was a 41% and 45% increase in the detection rate of tachypnoea and hypoxia respectively by clinical staff. ...
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Citations
... Ils sont principalement déployés dans les hôpitaux anglo-saxons à l'heure actuelle. Plusieurs études ont mis en évidence que la mise en oeuvre d'un SAP a permis d'améliorer les taux de détection (Chatterjee et al., 2005), l'appréciation du niveau de gravité (Higgins et al., 2008), la documentation des paramètres vitaux (Mackintosh et al., 2012 ;McKay et al., 2013) et en particulier la fréquence respiratoire (Chen et al., 2009b ;Kyriacos et al., 2015), le taux d'appel de l'EUIH (Etter et al., 2014 ;Herod et al., 2014 ;Frost et al., 2015). ...
La formation par simulation interprofessionnelle s’est imposée ces dernières années avec pour perspective le développement des compétences relatives à la sécurité des patients. Néanmoins, l’incidence des événements indésirables liés aux soins concerne encore un patient hospitalisé sur dix. Cette thèse contribue à éclairer le rapport travail- formation, plus précisément le rapport entre la configuration didactico-pédagogique et le potentiel d’apprentissage organisationnel. Elle s’appuie sur une méthode mixte intégrée, combinant un ensemble d’analyses qui traite des composantes de l’acte éducatif, de la pluralité des situations professionnelles qui en constitue la référence, de l’évolution des compétences perçues qui en découlent. Le dispositif étudié est caractérisé par un mode transmissif davantage qu’interactif, par un faible partage de la réflexivité de la part des apprenants, et par des débats centrés très largement sur des éléments favorables à un apprentissage simple boucle plutôt que double boucle. Le suivi en quatre temps de l’évolution des compétences perçues montre un développement limité dans le temps de la plupart des domaines de compétences relatives à la sécurité des patients. Exploiter le potentiel d’apprentissage organisationnel en simulation interprofessionnelle et renforcer les compétences relatives à la sécurité des patients par leur ampleur et leur durée, impliquent une consolidation de l’articulation entre le travail et la formation, d’une part en soutenant le positionnement des apprenants à partir de leurs richesses d’expérience, d’autre part en abordant l’environnement de simulation comme un lieu de réflexivité sur l’activité, propice à la transformation des pratiques.
... Research from both high-and low-and middleincome settings has shown that vital signs are often poorly documented in observation charts. Detection of deteriorating physiological signs in hospitalized patients is suboptimal either because of poor chart design [23] or poor understanding of why vital signs are measured and documented [24,25]. However, little attention has been paid to the design of inpatient monitoring charts [26] and their contribution to the completeness of documentation and quality of care. ...
... They were concerned about the level of detail in a comprehensive chart. In contrast, observation charts found in the literature, used during the inpatient stay, do not typically combine various monitoring tasks but only focus on vital signs [23,[54][55][56]. This makes our chart design unique. ...
Introduction
Job aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries work towards reducing neonatal mortality. However, inpatient vital sign readings are often poorly documented and little attention has been paid to the process of chart design as a method of improving care quality. Poorly designed charts do not meet user needs leading to increased mental effort, duplication, suboptimal documentation and fragmentation. We provide a detailed account of a process of designing a monitoring chart.
Methods
We used a Human-Centred Design (HCD) approach to co-design a newborn monitoring chart between March and May 2019 in three workshops attended by 16–21 participants each (nurses and doctors) drawn from 14 hospitals in Kenya. We used personas, user story mapping during the workshops and observed chart completion to identify challenges with current charts and design requirements. Two new charts were piloted in four hospitals between June 2019 and February 2020 and revised in a cyclical manner.
Results
Challenges were identified regarding the chart design and supply, and how staff used existing charts. Challenges to use included limited staffing, a knowledge deficit among junior staff, poor interprofessional communication, and lack of appropriate and working equipment. We identified a strong preference from participants for one chart to capture vital signs, assessment of the baby, and feed and fluid prescription and monitoring; data that were previously captured on several charts.
Discussion
Adopting a Human-Centred Design approach, we designed a new comprehensive newborn monitoring chart that is unlike observation charts in the literature that only focus on vital signs. While the new chart does not address all needs, we believe that once implemented, it can help build a clearer picture of the care given to newborns.
Conclusion
The chart was co-designed and piloted with the user and context in mind resulting in a unique monitoring chart that can be adopted in similar settings.
... A 2012 Australian study indicated that more accurate decisions were made by health professionals when using a well-designed yet unfamiliar chart than decisions made (by the same users) when they used a familiar yet poorly designed chart [22]. Testing for some parameters improved detection by up to 45% [23]. ...
Strong evidence now demonstrates that recognition and response systems using standardised early warning scores can help prevent harm associated with in‐hospital clinical deterioration in non‐pregnant adult patients. However, a standardised maternity‐specific early warning system has not yet been agreed in the UK. In Aotearoa New Zealand, following the nationwide implementation of the standardised New Zealand Early Warning Score (NZEWS) for adult inpatients, a modified maternity‐specific variation (NZMEWS) was piloted in a major tertiary hospital in Auckland, before national rollout. Following implementation in July 2018, we observed a significant and sustained reduction in severe maternal morbidity as measured by emergency response calls to women who were very unwell (emergency response team call), and a non‐significant reduction in cardiorespiratory arrest team calls. Emergency response team calls to maternity wards fell from a median of 0.8 per 100 births at baseline (January 2017–May 2018) to 0.6 per 100 births monthly (from March 2019 to December 2020) (p < 0.0001). Cardiorespiratory arrest team calls to maternity wards fell from 0.14 per 100 births per quarter (quarter 1 2017–quarter 2 2018) to 0.09 calls per 100 births per quarter after NZMEWS was introduced (quarter 3 2018–quarter 4 2020) (p = 0.2593). These early results provide evidence that NZMEWS can detect and prevent deterioration of pregnant women, although there are multiple factors that may have contributed to the reduction in emergency response calls noted.
... Like paper-based bedside observation charts (Chatterjee et al., 2005;Preece et al., 2013), insulin forms have typically been developed by clinicians for use in their own hospital or regional health service, resulting in substantial design differences between institutions (Christofidis et al., 2012). Nevertheless, only a handful of publications describe the clinician-led development and implementation of a subcutaneous insulin chart (Cheung et al., 2011;Lehnbom et al., 2009;McIver et al., 2009;Rushmer and Voigt, 2008;Wong et al., 2016). ...
Insulin is a high-risk medicine that has been implicated in serious adverse events for hospital inpatients, including medication-error related deaths. Most insulin errors occur during administration, and “wrong dose” is the most common type. A paper-based subcutaneous insulin chart (the “NSIC”) was developed for the Australian Commission on Safety and Quality in Health Care, using a range of human factors methods, with the aim of reducing the opportunity for errors. The present lab-based study empirically assessed whether the NSIC's human factors design translates into improved user-performance in the determination of insulin doses, compared with a pre-existing chart. Forty-one experienced nurses and 48 novice chart-users completed 60 experimental trials (30 per chart), in which they determined doses to administer to patients. Both groups determined insulin doses faster, and made fewer dose errors, when using the NSIC. These results support the utility of the usability heuristics employed in developing the chart.
... All studies were published between the year 1992 and 2017. The charts identified were either admission and/or discharge charts (Hill et al., 2014;North & Serkes, 1996;Okaisu et al., 2014;Street et al., 2017;Torakis & Smigielski, 2000;Vander Meer & Gabert, 1993) that capture one-time events in the inpatient period, or were observation charts (also called flowsheets) (Cahill et al., 2011;Chatterjee et al., 2005;Gordon et al., 2008;Kuc, 2009;Robb & Seddon, 2010) that are used multiple times during the inpatient stay. The studies were descriptive case studies that employed a before and after study design. ...
... The charts covered a range of clinical areas: adult surgical/medical or emergency care (Cahill et al., 2011;Gordon et al., 2008;Hill et al., 2014;Street et al., 2017), paediatric care (Okaisu et al., 2014;Torakis & Smigielski, 2000;Vander Meer & Gabert, 1993), and specialised seizure care (Kuc, 2009). In three studies, the charts covered all nursing units in the hospital (Chatterjee et al., 2005;North & Serkes, 1996;Robb & Seddon, 2010). We inferred the population to be adult, based on the cut-off values of vital signs on the observation charts in two studies (Chatterjee et al., 2005;Robb & Seddon, 2010) and we found no nursing observation charts for newborn inpatient care. ...
... In three studies, the charts covered all nursing units in the hospital (Chatterjee et al., 2005;North & Serkes, 1996;Robb & Seddon, 2010). We inferred the population to be adult, based on the cut-off values of vital signs on the observation charts in two studies (Chatterjee et al., 2005;Robb & Seddon, 2010) and we found no nursing observation charts for newborn inpatient care. Uniquely, DiBlasi and Savage (1992) developed a complete documentation system comprising of: nursing admission assessment, a nursing care flowsheet and a re-organised nursing care plan. ...
Background
Inpatient nursing documentation facilitates multi‐disciplinary team care and tracking of patient progress. In both high‐ and low‐ and middle‐income settings, it is largely paper‐based and may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed.
Objective
To synthesise evidence on how paper‐based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care.
Design
A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA‐ScR guidelines.
Eligibility criteria
We included studies that described the process of designing paper‐based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019.
Sources of evidence
PubMed, CINAHL, Web of Science and Cochrane supplemented by free‐text searches on Google Scholar and snowballing the reference sections of included papers.
Results
12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges.
Conclusions
The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human‐centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes.
Relevance to clinical practice
Paper‐based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation.
... To monitor and track the proposed NSIs may require better tools to support nursing care documentation, for instance, structured nursing notes. Similar efforts of codesigning structured nursing forms in Uganda and the United Kingdom have shown improvements in communication between nurses and other professionals whilst reducing time spent on documentation [43,44]. ...
Background:
The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce.
Main body:
We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals.
Conclusions:
Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning.
... Paper observation charts are often found on a clipboard at the end of a patient's bed and have been described as "the mainstay of detecting patient deterioration" (Chatterjee et al., 2005). Indeed, a 1956 book on the practice of nursing describes the importance of recording a patient's temperature, blood pressure, and heart rate for the purpose of observing changes over time (Gration and Holland, 1956). ...
... Observation charts have been iterated over decades and have adopted characteristics which ensure patient safety. For example, Chatterjee et al. (2005) found plotted values on observation charts are better detected than written values, thereby preventing misinterpretation and subsequent medical errors. On using a line chart over other forms, Student Nurse 1 explained that time constraints limit a nurse's ability to, for example, plot a bar chart. ...
Fitbit and Apple Health are two popular consumer technologies amongst a growing plethora of health wearables and smartphone apps. These devices have empowered a new kind of patient – the quantified patient – to collect data on diverse aspects of their own health. From heart rate and physical activity, to sleep and mood, these data have the potential to help clinicians diagnose disease, personalise treatments to individual patients, and avoid delivering unnecessary medical procedures. Realising this potential is vital as we enter an era of ageing population, chronic disease epidemics, and soaring healthcare costs. However, these self-tracked data are new to medicine, so it is unknown how clinicians might use such unfamiliar data.
This research aimed to understand clinicians’ experiences with self-tracked data in their clinical workflows, such that future use of such data can be enabled through appropriate technology design and consideration of clinicians’ work practices. Interviews were conducted with 13 clinicians of a broad spectrum of clinical roles, including cardiology, general practice, and mental health. This was followed by workshops with five clinicians in the co-design of a software-based tool for using self-tracked data within the management of chronic heart conditions. These studies revealed that there are common clinical workflows for using self-tracked data, delineating a process of evaluating data usability while collaborating with the patient to ensure mutual understanding. However, constraints of the clinical settings and of data usability presented barriers to this workflow, limiting the potential for self-tracked data. The co-designed prototype unveiled several design principles for overcoming these barriers, reflecting the importance of clinicians’ participation in future research of self-tracked data. This research contributes an understanding of the diverse opportunities for self-tracked data and design principles for overcoming the barriers to using such data in a future data-driven medicine.
... Whether monitored or unmonitored area, where monitored events are certainly detected rapidly, while ward patients without monitoring have had a time of deterioration or arrest before they have been recognized [4,5,6,7,8,9,10,11,12]. ...
... Consequently, they have the potential to play a critical role in assisting nurses and doctors in the early recognition of deteriorating patients, if their designs are optimized to fulfil this objective. Indeed, there is a growing body of empirical evidence demonstrating that observation chart design can have a substantial impact on chart-users' ability to detect abnormal observations that may indicate clinical deterioration (Chatterjee et al., 2005;Preece et al., 2012b;Christofidis et al., 2013Christofidis et al., , 2014Christofidis et al., , 2015Christofidis et al., , 2016. ...
... Hospital observation charts have traditionally been designed by local clinical staff perceived to have relevant knowledge or expertise. Consequently, the design (and design quality) of these forms has tended to vary substantially between different local area hospital services, different hospitals, and even different wards within individual facilities (Chatterjee et al., 2005;Preece et al., 2013). Although the importance of regular patient observations has been recognized by clinicians since at least the time of Florence Nightingale (1860), it was not until the 21st century that the first study was published in which an "evidencebased approach" to observation chart design had been employed (i.e. ...
... Although the importance of regular patient observations has been recognized by clinicians since at least the time of Florence Nightingale (1860), it was not until the 21st century that the first study was published in which an "evidencebased approach" to observation chart design had been employed (i.e. Chatterjee et al., 2005). Chatterjee et al. (2005) were a team of medical and nursing staff who set out to design a chart with the explicit aim of improving the detection of patient deterioration. ...
Particular design features intended to improve usability – including graphically displayed observations and integrated colour-based scoring-systems – have been shown to increase the speed and accuracy with which users of hospital observation charts detect abnormal patient observations. We used eye-tracking to evaluate two potential cognitive mechanisms underlying these effects. Novice chart-users completed a series of experimental trials in which they viewed patient data presented on one of three observation chart designs (varied within-subjects), and indicated which observation was abnormal (or that none were). A chart that incorporated both graphically displayed observations and an integrated colour-based scoring-system yielded faster, more accurate responses and fewer, shorter fixations than a graphical chart without a colour-based scoring-system. The latter, in turn, yielded the same advantages over a tabular chart (which incorporated neither design feature). These results suggest that both colour-based scoring-systems and graphically displayed observations improve search efficiency and reduce the cognitive resources required to process vital sign data.
... Therefore, they ignore the observational trends by failing to compare to previous sets of observations. Chatterjee et al (2005) discuss the importance of observational trends in the design of observation charts in recognising patient deterioration. ...
The second article on the use of track and trigger scoring (TTS) and National Early Warning Scoring Systems (NEWS 1 and 2) discusses how their use in relation to some patients can be too sensitive and in the case of others it merely detects late deterioration. This raises concerns that TTS and NEWS focus on a single set of observations at one point in time. They, therefore, ignore the observational trends by failing to compare the latest readings against previous sets of vital signs. It is therefore important that nurses do not rely solely on these tools, but use them in conjunction with their physiological knowledge and clinical assessment to identify deteriorating patients, as well as those who do not require unnecessary escalation of care.
