Documentation of Vital Signs in Electronic Health Records: A Patient Safety Issue Jean E Stevenson PhD Thesis The University of Sheffield Faculty of Social Science Information School January 2016 ii Abstract Background and aim: Hospitals in the developed world are increasingly adopting digital systems such as electronic health records (EHRs) for all kinds of documentation. This move means that traditional paper case notes and nursing records are often documented in EHRs. Documentation of vital signs is important for monitoring a patient's physiological condition and how vital signs are presented in a clinical record can have a profound impact on the ability of clinicians to recognise changes, such as deterioration in a patient's condition. Vital signs have received minimal attention with regard to how they are documented in EHRs which suggests that there is an urgent need for this to be examined. Design, methodology and approach: A mixed methods study was conducted in a 372- bed county hospital in two phases. Phase one was a quantitative study, and was followed by a qualitative study in phase two. The aim of the quantitative study was to examine the vital signs documented in the electronic health records of patients who had previously suffered a cardiac arrest. The aim of the qualitative study was to investigate how medical and nursing staff measured, reported and retrieved information on vital signs. Observations were made and interviews were conducted in four clinical areas. Findings: The quantitative study found that documentation of vital signs was incomplete in relation to current universal standards for monitoring vital signs, and that vital signs were dispersed inconsistently throughout the EHR. The qualitative study provided a detailed understanding of the routines and practices for monitoring vital signs and demonstrated variation in routines and in methods of documentation in the four clinical areas. Documenting and retrieving vital signs in the EHR was problematic because of usability issues and led to workflow problems. Workflow problems were solved at ward level by the creation of paper workarounds. Contribution to knowledge: This thesis has shown that poor facilities for the documentation of vital signs in EHRs could have a negative impact on patient safety because it reduces the possibility of good record keeping. This leads to limited availability of easily accessible, up-to-date information, essential for identifying clinical deterioration and, thus, is a challenge to patient safety. Related to this, the thesis has identified possible solutions to usability problems in the EHR. Inconsistent routines and practices were also identified and suggestions were made for how this problem might be approached. Keywords: patient safety, vital signs, electronic health records i ii Acknowledgements Although this research was conceived and conducted by the author, it would not have been possible without the help, support and encouragement of the many individuals and organisations mentioned below: Professor Peter Bath, Information School, University of Sheffield, UK for being my main supervisor, offering guidance, encouragement, wisdom and excellent counsel. Professor Göran Petersson and Dr Gunilla Nilsson, eHealth Institute, Linnaeus University, Kalmar, Sweden for being my secondary supervisors, and providing guidance, encouragement and generous support. Friends and colleagues in the Department of Languages at Linnaeus University, Sweden, for their encouragement and support. The University of Sheffield, UK, for providing a full fee scholarship. The Department of Languages, Faculty for Arts and Humanities, Linnaeus University, Sweden for making time available for study leave, and giving their support. eHealth Institute, Linnaeus University, Kalmar, Sweden for assistance with funding. Kalmar County Hospital for assistance with funding. The nurses and doctors at the study hospital who welcomed me into their working environments and gave freely of their valuable time. Finally, to my family and friends for their invaluable encouragement, love and support. iii iv Contents Abstract ..................................................................................................................................................i Acknowledgements .........................................................................................................................iii Table of Contents ................................................................................................................................v List of tables ........................................................................................................................................xi List of figures ...................................................................................................................................xiv List of appendices ...........................................................................................................................xvi Abbreviations and acronyms ...................................................................................................xviii Related publications and presentations .................................................................................xx Prologue ..........................................................................................................................................xxiv Chapter 1 Introduction .................................................................................................... 1 1.1 Background ........................................................................................................................... 1 1.2 Historical background ....................................................................................................... 3 1.3 Rationale and motivation for this thesis ..................................................................... 3 1.4 Aims and objectives ............................................................................................................ 4 1.5 Structure of this thesis ....................................................................................................... 4 1.6 Conclusion ............................................................................................................................. 5 Chapter 2 Literature review ........................................................................................... 7 2.1 Introduction .......................................................................................................................... 7 2.2 Literature review methods .............................................................................................. 7 2.3 Background ........................................................................................................................... 7 2.4 Recognition of critical illness .......................................................................................... 8 2.4.1 Sub-optimal care ........................................................................................................................... 9 2.4.2 Predisposing factors to sub-optimal care ....................................................................... 10 2.5 The development of new systems to identify deteriorating patients .............. 12 2.5.1 Physiological track and trigger systems .......................................................................... 12 2.5.2 The quest for the perfect early warning score. ............................................................. 23 2.6 Rapid response teams ...................................................................................................... 26 2.6.1 Background .................................................................................................................................. 26 2.6.2 Medical emergency teams (MET) ....................................................................................... 27 2.6.3 Critical care outreach systems and critical care outreach teams ......................... 28 2.6.4 Rapid Response Teams (RRT) .............................................................................................. 31 2.6.5 Lack of positive outcomes ...................................................................................................... 32 2.6.6 Scepticism ..................................................................................................................................... 33 2.6.7 Positive outcomes ...................................................................................................................... 34 2.7 Documentation ................................................................................................................... 35 v 2.7.1 Introduction ................................................................................................................................. 35 2.7.2 Monitoring vital signs .............................................................................................................. 35 2.7.3 Observation charts .................................................................................................................... 36 2.7.4 Observation chart design ....................................................................................................... 36 2.7.5 Documenting early warning scores ................................................................................... 38 2.7.6 Electronic documentation .....................................................................................................