New iPad-based 'early warning' system for hospital patient monitoring

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[Doctor talking to a patient]


Since 2011 the vital signs of thousands of patients from Oxford and Banbury are now routinely recorded using paper based track and trigger charts, which help identify when medical care needs to be escalated. These charts have already improved patient outcomes as problems are spotted more quickly, but the paper based system is by no means perfect and so a research team led by Professor Lionel Tarrasenko at the University of Oxford’s Institute of Biomedical Engineering has come up with an electronic version of the track and trigger system. With funding from the Engineering and Physical Sciences Research Council, the team set out to design a simple computer driven system that could record more accurately a patient’s vital signs, while at the same time easing the pressure on nurses. And now that system is going to be tried across Oxford hospitals thanks to new funding from the NHS Safer Wards Safer Hospitals Initiative. In developing the electronic system Dr Peter Watkinson, Intensive Care Physician at Oxford University Hospitals NHS Trust, studied the human factors involved in recording vital signs and considered what might hinder that process for nursing staff.

Dr Peter Watkinson – Intensive Care Physician, OUH NHS Trust [PW]

We found that in a significant proportion of the times, they spent some time looking for the patients’ paper charts before they could start. Then if you look at the way they interact with the chart its almost inevitable, however carefully you try and design the chart, that when you go to your look up table you will make errors and when you sum the scores for the various vital signs you will also make errors and, both in our research and in others, it’s shown that there is a significant rate of both summation error and assignment error, as those two errors are called.


So with such human factors under consideration it became apparent that the electronic version of the track and trigger system needed to be simple as well as accurate. While computers on trolleys, or laptops based at nursing stations could have been the way forward, the researchers understood that something like an iPad, highly portable, easy to use and effective in recording information, would be vital if the process was to be improved.

Dr Lionel Tarrasenko – Institute of Bioengineering, University of Oxford [LT]

We have developed a system based around barcode scanners because all patients now have barcodes for identification and in about three or four seconds the patient is scanned, the nurse is scanned and she can do the observations. Having barcoded the patient and having barcoded her own identification, she can use this iPad mounted on the trolley right next to where the blood pressure monitors and the heart rate monitors are positioned to enter this information. What she will do to identify how poorly the patient might be, is to take five or six or sometimes seven of these observations and our computer system produces a score of how normal the observation is for a typical adult patient. You build up this score and if this score, which is a score of abnormality, is above a certain threshold, then there is an alert and an escalation of care.


With the prototypes in place the team discovered that after only two or three patient observations, nurses were picking up scores high enough to trigger an alert, meaning that they were not having to waste vital time taking other measurements. As well as saving time by the bedside, the system was also engineered to feed information into the patient’s electronic record, giving doctors ready access to essential information that could lead to earlier interventions, which in some cases could be the difference between life and death. There are also cost savings associated with electronic track and trigger, if a patient can be helped back to health more quickly, aided by more accurate information, the increasingly valuable hospital bed can be freed up for someone else.


If a patient is really progressing well and faster than the average patient with that condition, or after that operation, then there is absolutely no reason why they shouldn’t be discharged early. But of course you’ve got to produce the evidence to the consultant who is managing that patient for them to allow them to be released early. There is a whole health economic argument as well, which is part of our research, because the most expensive part of healthcare is a hospital bed. So if we can allow our patients to be discharged early as a result of being able to track the recovery process and say quite clearly that this patient is recovering faster than the average patient following this type of surgery, for example, then we will begin to be able to let people go home earlier.


Now that additional NHS funding means the iPads will be rolled out across Oxford wards, Professor Tarrasenko and his fellow researchers are hopeful that within ten years the majority of acute hospitals will have a system like this on their wards. An achievement that could prove revolutionary in the way medical teams monitor and record the vital signs of seriously ill patients.


To walk around a ward and see patients who are being monitored using computer software that you have helped design, is proof that the research that you have done which has been translated into software has actually had a real impact and I think that is why most of us engineers want to see the fruits of our work, which in our case involves academic research, making a difference as a result of the gadget, piece of software or whatever, being used by the target audience for that particular technology.


The UK design could also end up in hospitals all over the world as medical teams realise the benefits for improved patient care and those in charge of the funds recognise potential efficiencies. For Professor Tarrasenko and Dr Peter Watkinson it has been a rewarding experience.


It is probably one of the most exciting projects that I have been involved in. Particularly because I believe that we are bringing into clinical practice a system which improves the working lives of my clinical colleagues and most importantly allows us to better recognise patients in the early stages of deterioration within hospital.