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 (ORC) for patients on their general wards.
ORCs
An ORC is a system for recording patient observations and specifying actions to be taken in response to deterioration in the clinical state of the patient. An ORC includes:- each of the essential design characteristics identified from the human factors research
- a graph for recording physiological observations over time
- 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
- actions required when thresholds are reached or deterioration is identified clinically
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 four ORCs 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 ORC 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 Centre in 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).
Based on the results of this project some general guidance has been prepared about improving the design of paper-based charts (PDF 464KB). It is strongly recommended that this information sheet be reviewed prior to making any modifications to current charts, adapting the ADDS chart for local use or adopting the ADDS chart.
The ADDS Chart
One of the main outputs of this project was the development of 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 The Prince Charles Hospital in Brisbane, as well as the Children's Early Warning Tool. ADDS stands for Adult Deterioration Detection System.A report on the development of the ADDS chart (PDF 1,575 KB) is available to download.
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.
ADDS chart with blood pressure table PDF 160KB
ADDS chart without blood pressure table PDF 153KB
When using the ADDS chart, or considering how it could be modified for specific facilities, there area number of points that need to be considered:
- 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.
- The evidence from the human factors research to date indicates that the ADDS chart performs better than some other charts in supporting timely and accurate identification of deterioration. Changing the design of the ADDS chart may reduce these benefits and increase risks to patient safety. Facilities should be cautious in making significant changes to the ADDS chart which would affect the integrity of the human factors design.
- The ADDS chart has only been tested in simulation experiments and has not yet been widely tested or used in a clinical environment. The Commission, University of Queensland and Queensland Health do not accept any liability or responsibility for the chart or its use. A retrospective validation study is currently underway in one hospital in Queensland, and preliminary results indicate that the ADDS chart is more effective in detecting deterioration and triggering an escalation of care appropriately.
- The thresholds included in the ADDS chart as indicating abnormal or deteriorating vital signs have been taken from existing observation charts and need to be reviewed to ensure that they are appropriate. Similarly, the required actions included in the ADDS chart are placeholders only, and will need to be modified as needed.
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).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 classify physiological data as "normal" or "abnormal" presented on six charts.
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
The next phase will develop a number of ORCs according to good design principles. Three new ORCs will be developed that reflect different types of track and trigger systems. This development work will take place in June 2010. At this stage it is likely that these templates will cover the following different types of systems:- single parameter system with four response categories (this is the similar to the existing ADDS chart, without the scoring system)
- single parameter system with two response categories (such as call to the home team or to a MET)
- single parameter system with one response category (such as a call to a MET).
PHASE 3: Simulation Testing
This phase is to examine the performance of the new ORCs. Appropriate simulation experiments will be undertaken to examine whether the ORCs perform better than the charts on which they are based for detecting deterioration. These experiments will take place in the second half of 2010 and into 2011.PHASE 4: Usability Testing
This phase of work will test that the ORCs 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.
For the usability testing, the ORCS would be used in parallel with existing hospital observation charts. For each site participating in this study, the ORC used would be chosen to match the track and trigger system already in place. The ORC would also be customised according to the thresholds and actions required when deterioration was identified. This usability testing would be conducted in a small number of sites, taking into account the need to obtain some variation in the type of site. Following the results of this usability testing the ORCs will be reviewed and modified as needed. It may be necessary to do another round of usability testing following these modifications.
PHASE 5: Pilot
This phase of work will conduct a contained roll out of ORCs. The pilot would be conducted in a larger number of sites. The intention would be that the ORCS are customised for each site and rolled out across the whole hospital. The pilot will be a before and after study that will look at:- rate of completion of the chart
- rate of recognition of abnormality
- rate of calling for assistance where indicated, and the response obtained
- the preferences and comments of staff
- patient outcomes, where available.
