improving accuracy of vital signs capture using bedside computerized reminders for nurses –...
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Improving Accuracy of Vital Signs Improving Accuracy of Vital Signs Capture Using Bedside Capture Using Bedside
Computerized Reminders for Computerized Reminders for Nurses – Nurses –
Preliminary ResultsPreliminary Results
Philip J. Kroth, M.D.Philip J. Kroth, M.D.ARUP LaboratoriesARUP Laboratories
April 16, 2003April 16, 2003
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OverviewOverview
RationaleRationale PurposePurpose Bedside Gopher Workstation DemoBedside Gopher Workstation Demo MethodsMethods ResultsResults LimitationsLimitations ConclusionsConclusions
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Rationale – General
Problems associated with the capture of Problems associated with the capture of clinical, bedside measures are significantclinical, bedside measures are significant
Many are technique and skill dependentMany are technique and skill dependent Large data volume:Large data volume:
– 1 million bedside measures per year (96 beds)1 million bedside measures per year (96 beds)– 2700+ measures/day (96 beds)2700+ measures/day (96 beds)– ~30 measures/day/bed~30 measures/day/bed
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Rationale – General
Examples:Examples:– Weights: Notoriously change in large Weights: Notoriously change in large
increments that do not correlate with the increments that do not correlate with the clinical pictureclinical picture
– Blood pressures: Dependent on cuff size, cuff Blood pressures: Dependent on cuff size, cuff placement, and patient positionplacement, and patient position
– TemperaturesTemperatures
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Rationale – Our ProjectRationale – Our Project
Pilot internal study showed 7% of Pilot internal study showed 7% of temperatures stored on medical surgical temperatures stored on medical surgical wards were inaccurately low (wards were inaccurately low (96.4°F)96.4°F)
Causes of inaccuracy:Causes of inaccuracy:– Poor technique/Poor probe placementPoor technique/Poor probe placement– Recent ingestion of hot or cold beveragesRecent ingestion of hot or cold beverages– Recent smoking or bathingRecent smoking or bathing– Poor patient cooperation (i.e. poor mental status etc.)Poor patient cooperation (i.e. poor mental status etc.)
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PurposePurpose
To determine whether computerized, To determine whether computerized, bedside remindersbedside reminders (i.e. real-time bedside (i.e. real-time bedside feedback) can improve the accuracy of feedback) can improve the accuracy of bedside measures (bedside measures (temperature temperature measurementmeasurement))
To determine how the level of training (i.e. To determine how the level of training (i.e. RN, LPN, Aide, etc.) correlates with the RN, LPN, Aide, etc.) correlates with the accuracy of bedside measures accuracy of bedside measures ((temperature measurestemperature measures))
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Methods – Our ProjectMethods – Our Project
Assigned nurses to control or intervention Assigned nurses to control or intervention (reminder) groups by username check digit.(reminder) groups by username check digit.
Automatically included all nurses who worked at Automatically included all nurses who worked at least one shift on any of the four medical-least one shift on any of the four medical-surgical wards in Wishard Hospitalsurgical wards in Wishard Hospital
Preliminary data analyzed from 12:00 AM Preliminary data analyzed from 12:00 AM February 11 to 12:00 PM, March 9, 2003 – Study February 11 to 12:00 PM, March 9, 2003 – Study is ongoingis ongoing
Data from 70 bedside Gopher workstations that Data from 70 bedside Gopher workstations that serve 96 beds on all four Wishard medical-serve 96 beds on all four Wishard medical-surgical wardssurgical wards
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Methods – Intervention Methods – Intervention GroupGroup
A computerized reminder appears when A computerized reminder appears when the user attempts to store a temperature the user attempts to store a temperature 96.4 °F96.4 °F
The user can then either:The user can then either:1.1. Cancel temp and retakeCancel temp and retake
2.2. Cancel temp and do nothing Cancel temp and do nothing
3.3. Over-ride the reminder and store temperature but Over-ride the reminder and store temperature but then must provide a reason for doing sothen must provide a reason for doing so
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Methods – Control GroupMethods – Control Group
No reminder appears when trying to No reminder appears when trying to store a temperature store a temperature 96.4 °F but data 96.4 °F but data is still recorded in the usual manneris still recorded in the usual manner
This is the current standard of care in This is the current standard of care in the hospital today.the hospital today.
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Bedside Gopher WorkstationBedside Gopher Workstation
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Direct Data Capture
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Keyboard Entry
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Verify & Store Data
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Verify & Store Data
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Retake Temp
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Verify & Store Data
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Store & Override
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Store & Reason
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Return to Order Entry System
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Study ResultsStudy Results
191 unique nurses 191 unique nurses 7985 temperature measures7985 temperature measures 709 unique patients709 unique patients 42 temp’s/nurse42 temp’s/nurse 11 temp’s/patient11 temp’s/patient
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Results – Subjects By Nursing Results – Subjects By Nursing TypeType
Control Reminder
RN: 34 (58%) 25 (42%)
LPN: 16 (47%) 18 (53%)
Aides: 26 (45%) 32 (55%)
Other: 20 (50%) 20 (50%)
Total: 96 (50%) 95 (50%)
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Results -- OverallResults -- Overall
320 Low temps recorded320 Low temps recorded 0.45 Low temps/patient (average)0.45 Low temps/patient (average) 1.7 Low temps/nurse (average)1.7 Low temps/nurse (average) 85% of low temp’s repeated because of a 85% of low temp’s repeated because of a
reminder are in the normal range.reminder are in the normal range.
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ResultsResults
5.7% Low temps recorded in control group5.7% Low temps recorded in control group 2.9% Low temps recorded in reminder 2.9% Low temps recorded in reminder
groupgroup 2.8% overall 2.8% overall absoluteabsolute risk reduction risk reduction 51% overall 51% overall relativerelative risk reduction in risk reduction in
reminder vs. control group.reminder vs. control group.
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Results – By Temperature Results – By Temperature
All Temps (7985)
Temps in Control Group (3641)
Temps in Reminder Group (4344)
Other Temps (4220)
Low Temp’s (124) 2.9%
Other Temps (3445)
Low Temp’s (196) 5.7%
51% RelativeRisk Reduction
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Results – by Nursing TypeResults – by Nursing Type
RecordedTemperatures
Recorded Low Temperatures
Control Reminder
RN: 1186 (15%) 27 (2.3%) 10 (0.8%)
LPN: 589 (7%) 12 (2.0%) 8 (1.3%)
Aides: 5996 (75%) 150 (2.5%) 101 (1.7%)
Other: 214 (3%) 7 (3.3%) 5 (2.3%)
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Results – By Reminder Results – By Reminder
Number of Low Temp Conditions (466)
Not Prompted (203)Controls
Prompted (236)Intervention
Stored (120)
Canceled (143)
Not Repeated (20)
Repeated (123)
Temp > 96.4(104) 85%
Temp 96.4 (19) 15%
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ConclusionsConclusions
Inaccurately recorded bedside Inaccurately recorded bedside temperatures are very common (5.7%!)temperatures are very common (5.7%!)
Reminders for nurses at the beside can Reminders for nurses at the beside can improve the accuracy of temperature improve the accuracy of temperature measurementmeasurement
The effect of the reminder may be The effect of the reminder may be associated with the level of trainingassociated with the level of training
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LimitationsLimitations
Small n – but data collection is ongoing.Small n – but data collection is ongoing. No statistical power yet but should have No statistical power yet but should have
after three month’s of dataafter three month’s of data
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Future WorkFuture Work
Improve accuracy of other patient Improve accuracy of other patient measures, i.e. weight, blood pressuremeasures, i.e. weight, blood pressure
Capture additional bedside parameters, Capture additional bedside parameters, i.e. pain scale, peak flows, and othersi.e. pain scale, peak flows, and others
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Thanks toThanks to
Clement J. McDonald, M.D. Clement J. McDonald, M.D. Anne Belsito, M.S.Anne Belsito, M.S. Paul Dexter, M.D.Paul Dexter, M.D. J. Marc Overhage, M.D., PhD.J. Marc Overhage, M.D., PhD. Siu Hui, PhD.Siu Hui, PhD.
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Improving Accuracy of Vital Signs Improving Accuracy of Vital Signs Capture Using Bedside Capture Using Bedside
Computerized Reminders for Computerized Reminders for Nurses – Nurses –
Preliminary ResultsPreliminary Results
Philip J. Kroth, M.D.Philip J. Kroth, M.D.ARUP LaboratoriesARUP Laboratories
April 16, 2003April 16, 2003