One of the factors that can contribute both to poor recording of observations and failure to interpret them correctly is the way in which observation charts are designed and used. A background paper summarising the use of observation charts to identify clinical deterioration (PDF 977 KB), including the use of different track and trigger systems, is available for download.
The goal of this initiative is to have all hospitals in Australia use an observation and response chart for patients on their general wards.
Observation and Response Charts
An observation and response chart is a system for recording patient observations and specifying actions to be taken in response to deterioration in the clinical state of the patient. The purpose of these charts is to support the accurate and timely recognition of clinical deterioration, and prompt action when deterioration is observed. An observation and response chart:- is designed according to human factors principles
- has the capacity to record information on the physiological parameters specified in Element 1.6 of the National Consensus Statement (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, level of consciousness)
- thresholds for each physiological parameter or combination of parameters that indicate abnormality
- specifies the physiological parameters and other factors that trigger an escalation of care
- includes the actions required when care is escalated.
Track and Trigger Systems
Track and trigger systems are formal systems that rely on routine periodic measurement of observations (tracking), with a predetermined action (trigger) when a certain threshold is reached. There are a large number and wide variety of track and trigger systems in place with differences in the parameters included, cut-off points to trigger responses and weighting of measures in scoring systems. The most commonly used track and trigger system in Australia is a single parameter system, while aggregate weighted scoring systems have been most commonly used in the United Kingdom. There is not yet sufficient robust evidence for the Commission to make a recommendation about which type of track and trigger system to use.Outputs of this Initiative
The Commission wants to ensure that the benefits of good design are incorporated into observation charts, irrespective of the type of track and trigger system they use. The main output of this work will be five observation and response chart templates that will be presented in a flexible format to allow for the adaptations that are necessary at a local level, and that have been clinically tested and piloted across a number of hospitals.From a patient safety perspective, it would be hoped that there would eventually be one standard observation and response chart for Australia, mirroring the success of the National Inpatient Medication Chart. For this to occur, however, there needs to be more published evidence about track and trigger systems, particularly regarding the benefits of one particular system over another. The Commission will continue to monitor this issue and may make recommendations on this topic in the future.
This initiative includes five phases to be undertaken during 2009 - 2011.
PHASE 1: Human Factors and Observation Chart Research Project
This phase has been completed and the reports on the outcomes of this research are now available.The first phase of this initiative was a research project conducted by the School of Psychology at the University of Queensland and funded by the Commission and the Patient Safety and Quality Improvement Service of Queensland Health that aimed to:
- compare a range of existing observation charts to identify which charts are the best for ease and accuracy of recording vital signs and likelihood of detecting deterioration in those vital signs
- examine performance using the different charts under different conditions
- create and evaluate a new chart that takes into account the best features of existing charts
- provide recommendations about the best observation chart for identifying deterioration based on human factors evidence.
An overview of methodology and results of the project is provided in this report (PDF 972KB).
The ADDS Chart
One of the main outputs of this project was the ADDS chart, which incorporated good design features present in existing observation charts and identified during the heuristic analysis phase of the project. The ADDS chart was developed primarily from the charts in place in the ACT (Compass) chart and at The Prince Charles Hospital in Brisbane, as well as the Children’s Early Warning Tool. ADDS stands for Adult Deterioration Detection System. Two versions of the ADDS chart were developed: one with a look-up table that took into account the patient’s normal systolic blood pressure, and one without this chart. These two charts are available in PDF for download.ADDS chart with blood pressure table (PDF 305KB)
ADDS chart without blood pressure table PDF (290KB)
Project Reports
The project involved a number of different activities, including a heuristic analysis of 25 observation charts, a survey of clinicians about observation charts, and a comparison of performance of a small number of charts, including the ADDS chart, in a simulation centre. The simulation evaluation was performed with two groups of participants: novices in the use of observation charts (university students) and experts (clinicians from within Queensland Health). The project found that the ADDS chart performed better than other selected examples of common chart types in supporting timely and accurate identification of deterioration.Reports of all phases of the project are now available to download.
Human factors research regarding observation charts: Research project overview (PDF 972KB)
This report provides an overview of the project that examined the design and use of observation charts in recognising and managing patient deterioration, including the design and evaluation of a new adult observation chart that incorporated human factors principles.
Heuristic analysis of 25 Australian and New Zealand adult general observation charts (PDF 3,028 KB)
The first phase of the project was a heuristic analysis of 25 existing observation charts. The heuristic analysis identified design and usability problems associated with the observation charts.
An online survey of health professionals: Opinions regarding observation charts (PDF 4,025 KB)
This report provides the results of a survey of health professionals about the design of observation charts and specific questions about nine observation charts.
The Development of the Adult Deterioration Detection System (ADDS) chart (PDF 1,575 KB)
This report describes the development of the ADDS chart.
Detecting abnormal vital signs on six observation charts: An experimental comparison (PDF 2,370 KB)
This report describes an experimental study focussed on error rates and response times of individuals when classifying physiological data presented on six charts as “normal” or “abnormal”.
Recording patient data on six observation charts: An experimental comparison (PDF 2,720 KB)
This report describes a second experimental study focussed on data-recording errors made by individuals when recording observations on six charts.
PHASE 2: Development of Observation and Response Charts
This phase has been completed and the charts developed as part of it are now available.In addition to the ADDS chart developed as part of the human factors research, the University of Queensland have also developed a three new observation and response charts that use different types of track and trigger systems. The Commission now has five observation and response charts that are available for use. These are:
- ADDS chart with blood pressure table (PDF 305KB) (note that some changes have been made to the ADDS charts since they were originally developed, and the most recent versions are available here)
- ADDS chart without blood pressure table PDF (290KB)
- single parameter system with four response categories (similar to the ADDS chart without the scoring system) (PDF 294KB)
- single parameter system with two response categories (such as a call to the home team and a call to the MET) (PDF 304KB)
- single parameter system with one response category (such as a call to the MET) (PDF 286KB).
While the ADDS charts have been the subject of some research, the other observation and response charts have not yet been tested in simulation experiments or used in a clinical environment. Therefore the new single parameter charts should be regarded as a draft at this stage. They are likely to change following the clinical and other research that will be conducted by the Commission in 2011.
The Commission, University of Queensland and Queensland Health do not accept any liability or responsibility for any of the observation and response charts or their use.
In addition to these charts, the University of Queensland have also prepared a developer’s guide (PDF 2,000KB) that discusses each element of an observation and response chart in detail, and describes what should and should not be changed in the chart to maintain the human factors and patient safety benefits. Reading and understanding the developer’s guide is essential for using the observation and response charts.
Using the observation and response charts
The observation and response charts provided by the Commission should be considered as templates because they need to be customised for local use. The Commission’s work with the observation and response charts focused on the design of the chart, and each chart needs to be customised according to the clinical and organisational systems in place within each facility. The clinical thresholds and responses included in the observation and response charts should be considered as placeholders only.Design files of the charts that can be modified can be obtained by contacting the Commission.
Facilities will need to consider what the thresholds or cut-off scores should be that indicate abnormality and what the organisational or clinical responses should be required when care is escalated. These will vary depending on characteristics of the facility such as size, location, patient mix and staff mix. For example, compared to a large tertiary hospital with an ICU, a small rural hospital that needs to transfer patients to a larger facility in cases of severe deterioration may set its cut-off scores lower so that deterioration is identified earlier.
Although the clinical and organisational aspects of the observation and response charts need to be customised for local use, the Commission does not recommend making changes to the design of the charts. These charts have been designed with the benefit of human factors expertise to ensure that they are user friendly, and fit for the purpose of supporting accurate and timely recognition of clinical deterioration. The developer’s guide provides information about potentially harmless and potentially harmful modifications. The guide should be used when customising the charts for local use. If further design changes are made to observation and response charts, it is important to demonstrate that the changes will not have a detrimental impact on patient safety.
In addition, public hospitals and health services will need to ensure that any actions they take to change their existing observation chart are consistent with any decisions or programs about observation charts that may have been made by the state or territory health department. For example, in NSW use of the Between the Flags Standard Adult General Observation Chart is required in most facilities.
PHASES 3 & 4: Usability Testing and Piloting
The usability testing will test that the observation and response charts are:- adequate for general clinical care (to be sure that they can “do the job” as part of a general observation chart, and to identify what might be missing from them)
- able to be used wherever adult general observation charts are currently used (such as wards, day centres, theatres)
- able to be used without specific training by all levels of clinical staff.
This will be followed by a pilot study that will be a contained roll out of the observation and response charts.
The University of Technology, Sydney has been contracted to conduct a project to undertake the usability testing and piloting. The project commenced in November 2010 and will continue until December 2011. A call for expressions of interest has been issued for sites to participate in this project. The call for expressions of interest closes at 4pm, Friday 4 February 2011.
