human factors design and observation charts
DESCRIPTION
Melany Christofidis, PhD/MBBS Scholar, School of Psychology, The University of Queensland delivered this presentation at the 2013 Managing the Deteriorating Patient conference. The management of patients in clinical deterioration has become a chief concern for Australian hospitals, with a patient’s potential for deterioration existing in every hospital ward and health service across the country. This annual event focusses on improving education for staff caring for these patients, and improving the policies and protocols in place to maintain patient safety. For more information, please visit the event website: www.healthcareconferences.com.au/deterioratingpatientsTRANSCRIPT
Human factors
design and observation charts
Melany Christofidis
Dr Andrew Hill Associate Professor Mark Horswill
Associate Professor Marcus Watson
Paper-based observation charts are the principal means of recording and monitoring vital signs
(Preece et al., 2012).
However, observations are not always correctly recorded or appropriately acted upon
(Chatterjee et al., 2005).
Poor chart design may contribute to these failures.
In Australia (and elsewhere), charts are typically designed by hospital staff at individual institutions or individual area health service level
(Preece et al., 2012).
There have been recent efforts to improve the design of observation
charts using
evidence-based approaches
(Chatterjee et al., 2005; Mitchell et al., 2010; Preece et al., 2012).
The ADDS charts, developed from
a human factors perspective, explicitly aim to facilitate the recognition of patient deterioration in a
user-friendly manner (Horswill et al., 2010).
All information required to use the system is included on one page.
Extraneous material
is on the outside of the chart.
Essential material
is on the inside of the chart.
Vital signs are presented separately
rather than as overlapping plots,
to reduce the likelihood of deterioration being obscured by visual clutter.
Each vital sign is presented graphically, rather than numerically, so
that users don’t have to mentally visualise the observations to see physiological trends.
In single and multiple parameter colour coded
track-and-trigger systems,
visual cues
are used to remind users of the criteria for abnormal
observations, eliminating the need for them to memorise
this information.
Early warning scores are
grouped together
to facilitate quick and accurate addition and recognition,
rather than separated underneath each
corresponding vital sign.
In an experimental study, novices and experienced health
professionals made fewer errors and responded more quickly when
using the new
user-friendly ADDS charts versus four existing
designs, suggesting that variability in chart design quality had a
substantial impact on performance
(Preece et al., 2012).
However,
previous experience with a particular chart design was not
controlled for.
Study 1
Christofidis MJ, Hill A, Horswill MS, & Watson MO (2013). A human factors approach to observation chart design can trump health professionals’ prior chart experience. Resuscitation 84, 657-665.
This study examined whether experienced health professionals recognised patient deterioration more
accurately and efficiently with novel charts that
were designed to be more
user-friendly,
when compared with observation charts that
they had
long term experience with.
“User friendly”
1. ADDS chart Without Systolic Blood Pressure Table
2. ADDS chart With Systolic Blood Pressure Table
Six charts were presented to participants:
“Well designed” 4. Single parameter
track-and-trigger chart 3. Multiple parameter track-and-trigger chart
“Average design” “Poorly designed”
5. No track-and-trigger graphical chart
6. No track-and-trigger numerical chart
Participants included (1) health professionals highly
experienced in using the
multiple parameter track-and-trigger chart,
and (2) health professionals highly experienced in using a
no track-and-trigger graphical
chart.
Each participant was presented with cases of de-identified patient data randomly
assigned to all six chart designs.
In each trial, the participant was required to specify whether all of the observations were
normal or whether any of the observations were abnormal.
0
5
10
15
20
25
30
Resp
on
se t
ime (
secon
ds)
a
d bd
c
No
track-and-
trigger
numerical
chart
Multiple parameter track-and-trigger chart
experienced participants
e bc
ADDS
chart
with
systolic
blood
pressure
table
ADDS
chart
without
systolic
blood
pressure
table
Multiple
parameter
track-and-
trigger
chart
Single
parameter
track-and-
trigger
chart
No
track-and-
trigger
graphical
chart
No track-and-trigger graphical chart
experienced participants
b a
c d
a a
ADDS
chart
with
systolic
blood
pressure
table
ADDS
chart
without
systolic
blood
pressure
table
Multiple
parameter
track-and-
trigger
chart
Single
parameter
track-and-
trigger
chart
No
track-and-
trigger
graphical
chart
No
track-and-
trigger
numerical
chart
Both chart experience groups responded more quickly when
using a version of the ADDS chart versus the other designs, including the charts participants were highly experienced in using.
0
5
10
15
20
25
30
35
40
45
50
Perc
en
tag
e e
rro
rs
a a
d
d
b
c
a
a
b
c cd
bd
No track-and-trigger graphical chart
experienced participants
Multiple parameter track-and-trigger chart
experienced participants
ADDS
chart
with
systolic
blood
pressure
table
ADDS
chart
without
systolic
blood
pressure
table
ADDS
chart
without
systolic
blood
pressure
table
ADDS
chart
with
systolic
blood
pressure
table
Multiple
parameter
track-and-
trigger
chart
Multiple
parameter
track-and-
trigger
chart
Single
parameter
track-and-
trigger
chart
Single
parameter
track-and-
trigger
chart
No
track-and-
trigger
graphical
chart
No
track-and-
trigger
graphical
chart
No
track-and-
trigger
numerical
chart
No
track-and-
trigger
numerical
chart
Both groups also made fewer errors when using the ADDS charts
versus the other designs.
the multiple parameter track-and-trigger chart
yielded 1.6 times as
many errors by the multiple parameter track-and-
trigger chart group;
and the no track-and-trigger graphical chart
yielded 5.4 times as
many errors by the no track-and-trigger graphical
chart group.
Compared with the best performing ADDS chart,
Conclusions
These results suggest that the advantages of human
factors designed charts may outweigh potential negative
effects that can be associated with
chart user transfer.
Rather than disadvantage staff, the findings suggest
that the implementation of a well-designed chart may
actually advantage health professionals,
regardless of their prior chart experience.
Study 2
Christofidis MJ, Hill A, Horswill MS, Watson MO (in press). Observation charts with overlapping blood pressure and heart rate graphs do not yield the performance advantage that health professionals assume: an experimental study. Journal of Advanced Nursing.
Many health professionals report that they
(a) prefer and (b) find it easier to detect deterioration
when blood pressure and heart rate are plotted together on the same graph
rather than separate (Preece et al., 2010)
One justification is the use of a visual cue called the ‘Seagull Sign’ to detect
physiological abnormalities
The Seagull Sign occurs when heart rate and systolic blood pressure are presented as overlapping plots on the same graph using the same axes:
If heart rate is ever observed plotted above
systolic blood pressure at the same time,
then this is a cue that the patient may require attention (Compass, 2011).
Health professionals’ perception of the Seagull Sign as a practically useful tool may be partially explained by the memorable nature of the metaphor that it represents;
just as it is abnormal for a patient’s heart rate observation to be plotted above a systolic
blood pressure observation, it is abnormal for a
seagull (represented by a ‘v’) to defy gravity by defecating (represented
by a dot) upwards.
This study empirically evaluated the
effectiveness of the Seagull Sign and its impact in the presence or absence of an integrated colour track-and-trigger system.
Four observation chart designs were created for comparison.
Cases of de-identified patient data (with and without Seagull Signs) were randomly
assigned to the four chart designs.
(1) Clinicians trained and experienced in the Seagull Sign,
(2) novices trained in the Seagull Sign, and
(3) untrained novices were required to assess observations recorded on
the charts and judge whether they were physiologically normal or abnormal.
0
2
4
6
8
10
12
14
Integrated colour
track-and-trigger
system
No track-and-trigger
system
Integrated colour
track-and-trigger
system
No track-and-trigger
system
Res
po
nse
tim
e (s
eco
nd
s)
Overlapping BP and HR graphs (Seagull Sign could occur)
Separate BP and HR graphs
(B) Seagull Sign 'available' only cases
and Seagull Sign trained participants
(A) All cases and participants
Over all patient cases, all groups responded faster in classifying abnormal
observations when blood pressure and heart rate were presented on separate graphs (rather than overlapping plots on the same graph), irrespective of the presence or
absence of a colour track-and-trigger system.
0
2
4
6
8
10
12
14
Integrated colour
track-and-trigger
system
No track-and-trigger
system
Integrated colour
track-and-trigger
system
No track-and-trigger
system
Res
po
nse
tim
e (s
eco
nd
s)
Overlapping BP and HR graphs (Seagull Sign could occur)
Separate BP and HR graphs
(B) Seagull Sign 'available' only cases
and Seagull Sign trained participants
(A) All cases and participants
However, the effect was greater when such a system was present.
This effect was also demonstrated when considering only Seagull Sign ‘available’ cases and only those participants who reported actively searching for the Seagull Sign during
the experiment.
0
5
10
15
20
25
30
Integrated colour
track-and-trigger
system
No track-and-trigger
system
Integrated colour
track-and-trigger
system
No track-and-trigger
system
Per
cen
tag
e er
rors
Overlapping BP and HR graphs (Seagull Sign could occur)
Separate BP and HR graphs
(A) All cases and participants (B) Seagull Sign 'available' only cases
and Seagull Sign trained participants
Participants also made fewer errors when blood pressure and heart rate
were presented on separate graphs. Especially in the presence of a track-and-trigger system.
The overlapping plots required for the Seagull Sign created visual clutter,
impeding recognition of patient deterioration (Wickens & Carswell, 1995);
even for nurses experienced in the Seagull Sign.
Conclusions
Contrary to
culturally supported belief
(Darby et al., 2012),
the findings suggest that charts should be designed so
that blood pressure and heart rate observations are
plotted separately, precluding use of the Seagull
Sign.
Demonstrates the dangers of relying on
opinion-based evidence
to determine the efficacy of a system.
Study 3
A systematic evaluation of the impact of observation chart design features on the detection of patient deterioration
This study systematically compared (1) track-and-trigger system-type; (2) data-recording format; and (3) scoring-row
placement.
Which chart features improve user performance?
Novice chart users were required to assess observations recorded on
the eight observation chart designs, and judge whether they were physiologically normal or abnormal.
Cases of de-identified patient data were randomly assigned to
eight chart designs which varied on the aforementioned dimensions.
Charts with
integrated colour
track-and-trigger systems outperformed charts without such integration
(i.e., tabular track-and-trigger
systems). 0
5
10
15
20
Res
po
nse
tim
e (s
econ
ds)
Drawn dot data-recording format Written number data-recording format
Scores
Res
pon
se t
ime
(sec
on
ds)
(a)
(b)
0
2
4
6
8
10
12
14
16
18
20 Integrated colour track-and-trigger system
Tabular track-and-trigger system
Scores
0
2
4
6
8
10
12
14
16
18
20
Per
cen
tage
erro
rs
Drawn dot data-recording format Written number data-recording format
Scores
Scores provided
Per
cen
tage
erro
rs
)
(a)
(b)
0
2
4
6
8
10
12
14
16
18
Grouped scoring-rows Separate scoring-rows
Integrated colour track-and-trigger system Tabular track-and-trigger system
Scoring-row placement
0
2
4
6
8
10
12
14
16
18
20 Integrated colour track-and-trigger system
Tabular track-and-trigger system
Scores
Per
cen
tage
erro
rs
(c)
Charts with
drawn dot observations
outperformed charts with
written number observations.
0
5
10
15
20
Res
pon
se t
ime
(sec
on
ds)
Drawn dot data-recording format Written number data-recording format
Scores
Res
pon
se t
ime
(sec
on
ds)
(a)
(b)
0
2
4
6
8
10
12
14
16
18
20 Integrated colour track-and-trigger system
Tabular track-and-trigger system
Scores
0
2
4
6
8
10
12
14
16
18
20
Per
cen
tage
erro
rs
Drawn dot data-recording format Written number data-recording format
Scores
Scores provided
Per
cen
tag
e er
rors
)
(a)
(b)
0
2
4
6
8
10
12
14
16
18
Grouped scoring-rows Separate scoring-rows
Integrated colour track-and-trigger system Tabular track-and-trigger system
Scoring-row placement
0
2
4
6
8
10
12
14
16
18
20 Integrated colour track-and-trigger system
Tabular track-and-trigger system
Scores P
erce
nta
ge
erro
rs
(c)
No significant difference
between grouped early warning scores rows
and separate early
warning scores.
Human factors guided chart
design can have a substantial impact on the decision accuracy
and response times of novice chart users’ abilities to recognise abnormal patient observations.
We recommend the use of
integrated colour
track-and-trigger systems and
drawn dot observations
on future chart designs.
Conclusions
Study 4
Less is more: The effect of track-and-trigger system design on chart users’ calculations of early warning scores
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 51–5 1–5< 1 < 1
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output
(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
ADDS
Scores
Respiratory Rate
ADDS
Scores
O2 Flow Rate
O2 Saturation
Systolic BP
Heart Rate
Temperature
4 Hour Urine Output
Consciousness
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Early warning scores allow health professionals to recognise when
a patient’s condition deteriorates and when additional intervention is required
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 51–5 1–5< 1 < 1
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output
(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
ADDS
Scores
Respiratory Rate
ADDS
Scores
O2 Flow Rate
O2 Saturation
Systolic BP
Heart Rate
Temperature
4 Hour Urine Output
Consciousness
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Early warning scores are susceptible to human error: (1) users must
accurately collect and record raw vital sign data
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 51–5 1–5< 1 < 1
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output
(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
ADDS
Scores
Respiratory Rate
ADDS
Scores
O2 Flow Rate
O2 Saturation
Systolic BP
Heart Rate
Temperature
4 Hour Urine Output
Consciousness
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Early warning scores are susceptible to human error: (2) users must
correctly determine an individual vital sign score for each observation
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 51–5 1–5< 1 < 1
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output
(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
ADDS
Scores
Respiratory Rate
ADDS
Scores
O2 Flow Rate
O2 Saturation
Systolic BP
Heart Rate
Temperature
4 Hour Urine Output
Consciousness
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Early warning scores are susceptible to human error: (2) users must
correctly sum the individual vital sign scores to form an overall early warning score
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 51–5 1–5< 1 < 1
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output
(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
ADDS
Scores
Respiratory Rate
ADDS
Scores
O2 Flow Rate
O2 Saturation
Systolic BP
Heart Rate
Temperature
4 Hour Urine Output
Consciousness
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Inaccuracies at any of these steps could influence the early warning score and the
effectiveness of the clinical response.
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 51–5 1–5< 1 < 1
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output
(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
ADDS
Scores
Respiratory Rate
ADDS
Scores
O2 Flow Rate
O2 Saturation
Systolic BP
Heart Rate
Temperature
4 Hour Urine Output
Consciousness
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Circle the column showing the patient’s usual systolic BP
190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
0 0 1 1 2 2 2 3 3 4 5 5
Sc
ore
cu
rren
t systo
lic B
P u
sin
g c
ircle
d c
olu
mn
0 0 0 1 1 1 2 2 3 3 4 4
0 0 0 0 0 1 1 2 2 3 3 4
1 0 0 0 0 1 1 2 2 3 3 3
1 1 0 0 0 0 0 1 1 2 2 2
1 1 1 0 0 0 0 0 1 1 2 2
2 1 1 1 0 0 0 0 0 1 1 1
2 2 1 1 0 0 0 0 0 0 0 1
2 2 2 1 1 0 0 0 0 0 0 0
3 2 2 2 1 1 0 0 0 0 0 0
3 3 3 2 2 2 1 1 0 0 0 0
4 3 3 3 2 2 2 2 1 1 0 0
1 0
MET Call
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
Respiratory Rate
O2 Flow Rate(L / min)
> 5 > 5
1–5 1–5
< 1 < 1
O2 Flow Rate
O2 Saturation(%)
93 9390–92 90–92
85–89 85–89
84 84
O2 Saturation
Blood
Pressure(mmHg)
Write 200 Write 200190s 190s
180s 180s
170s 170s
160s 160s
150s 150s
140s 140s
130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
If systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Systolic BP
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Heart Rate
Temperature(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
Temperature
4 Hour Urine
Output(mL)
800 800120–799 120–799
80–119 80–119
79 79
4 Hour Urine Output
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Consciousness
Increased pain
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate
(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 5
1–5 1–5< 1 < 1
O2 Saturation
(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sco
re c
urre
nt s
ysto
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature
(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
Rows for recording individual vital sign scores were either:
1. Grouped 2. Separated 3. Excluded
Cases of de-identified patient data were randomly assigned to the
three chart designs
Novice chart users were required to record the appropriate
scores for each set of observations, consecutively from one time point to the next (18 time-points per chart design)
Participants recorded scores
significantly faster using
no rows than separate rows
(and significantly faster to separate rows compared with grouped rows)
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate
(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 5
1–5 1–5< 1 < 1
O2 Saturation
(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sco
re c
urre
nt s
ysto
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature
(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
0
5
10
15
20
25
Grouped rows Separate rows No rows
Resp
on
se t
ime
(sec
on
ds)
Individual vital sign score row placement
Actions Required
Total ADDS Score 1–3
Record observations at least once
every 4 hours
Carry out appropriate interventions
as prescribed
Manage fever, pain or distress
Review O2 delivery
Consider informing Team Leader
Total ADDS Score 4 – 5
Ward doctor to review patient
within 30 minutes
Request review, and note on the
back of this form
Notify Team Leader
Record observations at least once
every 30 minutes
If patient must leave ward area,
Nurse must accompany patient
Total ADDS Score 6 – 7
Registrar to review patient within
30 minutes
Request review, and note on the
back of this form
Registrar to ensure consultant is
Ward doctor to attend
If patient must leave ward area,
Intern and Nurse must accompany
patient
Total ADDS Score 8
Consider MET call
Registrar to review patient within
10 minutes
Request review, and note on the
back of this form
Registrar to ensure Consultant is
If patient must leave ward
area, Registrar and Nurse must
accompany patient
Date
Time
Respiratory
Rate
(breaths / min)
37 3736 36
31–35 31–35
21–30 21–30
9–20 9–20
5–8 5–8
4 4
O2 Flow Rate(L / min)
> 5 > 5
1–5 1–5< 1 < 1
O2 Saturation
(%)
93 9390–92 90–92
85–89 85–89 Circle the column showing the patient’s usual systolic BP
84 84 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood
Pressure
(mmHg)
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5
Sco
re c
urre
nt s
ysto
lic B
P u
sin
g c
ircle
d c
olu
mn
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
140s 140s 2 1 1 1 0 0 0 0 0 1 1 1
130s 130s 2 2 1 1 0 0 0 0 0 0 0 1
120s 120s 2 2 2 1 1 0 0 0 0 0 0 0
110s 110s 3 2 2 2 1 1 0 0 0 0 0 0
100s 100s 3 3 3 2 2 2 1 1 0 0 0 0
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0
80s 80s 1 0
70s 70s
MET CallIf systolic BP 200,
write value in box
60s 60s
50s 50s
40s 40s
Heart Rate(beats / min)
Write 140 Write 140130s 130s
120s 120s
110s 110s
100s 100s
90s 90s
80s 80s
70s 70s
60s 60s
If heart rate 140,
write value in box
50s 50s
40s 40s
30s 30s
Temperature
(C)
38.6 38.638–38.5 38–38.5
36.1–37.9 36.1–37.9
35.1–36 35.1–36
34.1–35 34.1–35
34 34
4 Hour Urine
Output(mL)
800 800120–799 120–799
80–119 80–119
79 79
ConsciousnessIf necessary, wake
patient before scoring
Alert Alert
Voice Voice
Pain Pain
Unresp. Unresp.
Increased pain
TOTAL ADDS
Score 0
Score 1
Score 2
Score 3
4 4 4 4 Score 4
5 5 5 5 Score 5
MET call
If any observation is in a shaded area, add
up the Total ADDS Score and take action.
Adult Deterioration Detection
System (ADDS)
Medical Emergency
Team (MET) call if:
Any observation is in a purple area
Airway threat
Respiratory or cardiac arrest
New drop in O2 saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the
criteria
Usual systolic BP: Signature:
URN:
Family name:
Given names:
M F
134
0
1
2
3
4
5
6
7
8
9
Grouped rows Separate rows No rows
Perc
en
tag
e of
err
ors
Individual vital sign score row placement
Participants made significantly
fewer errors using charts with no rows compared to when rows
were grouped or separate
Conclusions
Less is more:
integrated colour track-and-trigger systems may
benefit from the
exclusion of individual vital sign
score rows
