At Anywhere Hospital it is 7:30 a.m. and the

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1 focus Quality Outcomes ad Patiet Safety Vital Time Savigs Evaluatig the Use of a Automated Vital Sigs Documetatio System o a Medical/Surgical Uit By Meg Meccariello; Dave Perkis; Loretta G. Quigley, RN, MS; Agie Rock, MBA, CCRP; ad Jiejig Qiu, MS Keywords Vital sigs, vital sig, automated dowload, safety, ursig documetatio, documetatio errors, time studies, work flow studies, computer trasfer, computer chartig. Abstract Vital sigs documetatio was the focus of this study, because multiplicatio errors, trascriptio errors, illegible results, late data etry, misidetificatio of the patiet, udocumeted readigs ad missed readigs ca lead to faulty data, as well as uecessary ad potetially dagerous itervetios or withholdig of treatmets. Techology is ow available to medical/surgical uits that automate the vital sigs documetatio process. This study compared the accuracy ad time efficiecy of maual-etry vital sigs documetatio with workflows that use a data maagemet system to automatically trasfer vital sigs assessmets from a bedside vital sigs device ito the electroic medical record. The study foud that the automated vital sigs documetatio system was more accurate tha maual documetatio ad errors were reduced by 75 percet. The wireless automated vital sigs documetatio system saved time compared to maual documetatio: ad combied vital-sigs acquisitio/ documetatio times were reduced o average by 96 secods per readig. At Aywhere Hospital it is 7:30 a.m. ad the day shift is just begiig. Sue, a urse s aide, begis to collect patiets vital sig assessmets. She starts with room 5106 ad moves through her assigmet. She gathers the results ad writes them o her assigmet sheet to be documeted i the electroic medical record (EMR) after she completes each of her five patiets. Mr. Couldbeu is i room 5108 by the widow. Sue otes that some of Mr. Couldbeu s readigs are above his baselie, however the patiet looks fie. She will metio it to the charge urse whe she sees her. Sue moves o to her ext patiet, but she is iterrupted by Joa, a urse takig care of patiets o the other side of the uit. Sue is asked to help move a patiet o the other side of the uit to a chair. At 7:39 a.m. Mr. Couldbeu pushes his call butto. He has chest pai. The RN who aswers his call takes his vital sigs, admiisters his medicatio ad checks the EMR to compare his curret status to his morig assessmets. They have ot bee charted ad she caot fid Sue. Vital sigs (blood pressure, pulse, respiratio, oxyge saturatio ad temperature) are idicators of body system health. They provide iformatio o how patiets are adaptig to the chages brought o by illess ad disease. 1 Treatmet decisios are routiely made subsequet to the assessmet of vital sigs, oe of the hallmarks of ursig care. 46 jhim FALL 2010 volume 24 / Number 4

2 I additio, Vital sigs are a tool used to commuicate patiet deterioratio to healthcare providers. 2 (p478) Edacott, Kidd, Chaboyer, ad Edigto foud that both urses ad doctors relied o vital sigs whe idetifyig patiet deterioratio. 3 Assurig accurate ad timely vital sigs documetatio may lead to improved patiet care. Vital sigs documetatio accuracy ad cliicia time efficiecy were the focus of this study because techology is ow available to medical/surgical uits that automates vital sigs documetatio, trasferrig results from the automated bedside vital sig machie to the electroic medical record. Review of Literature Hospitals have applied medical techology to reduce errors, but util recetly have focused o the most critical care areas. Experiece has show that may hospitals udertake the move to ew techology without fully uderstadig the impact o workload, patiet safety ad data accuracy. Healthcare providers are ofte told that a ew piece of equipmet will be safer for patiets ad a time saver for staff, oly to fid out that the system has a steep learig curve or takes more time tha the old way. This ofte results i frustratio for frotlie staff ad a waste of scarce resources. I a era of spiralig costs, competitio ad the advet of evidece-based practice, healthcare practitioers expect research studies to aid them i their cliical practice decisios. Evas, Hodgkiso, ad Berry4 foud little evidece of study i the area of use of advaced techology i vital sigs measuremet ad oted that these techologies have the potetial to chage curret practice. Lockwood, Coroy-Hiller ad Page 5 (p208) also oted the eed to research the role of ew techology i patiet moitorig. Accuracy i Documetatio While the vital sigs acquisitios ad documetatio process is taught i the early weeks of most ursig programs, the documetatio of vital sigs ca be fraught with problems. Patiet idetificatio is completed by askig the patiet his or her ame, ad comparig oe of two log series of umbers (potetial patiet misidetificatio). Results are gathered i 15- or 30-secod timeframes ad are documeted as per-miute results (potetial multiplicatio error). Cliicias memorize vital sig results (potetial for forgettig result or rememberig icorrectly), the, after the measuremets are complete, write them dow o scrap paper or paper towel (potetial illegible result), later trasferrig them to paper forms or maually eterig them ito the electroic medical record (potetial trascriptio errors ad traspositio of results). Whe documetig a full set of vital sigs (blood pressure (systolic/diastolic), pulse, respiratio, oxyge saturatio ad temperature), there are six potetial areas or errors. Further, what is ofte double documetatio, first documetig o paper the i the electroic medical record, creates eve more chaces for huma error. The most precise vital sigs assessmet may ot lead to a accurate respose if it is ot documeted correctly ad i a timely maer. Cioffi, Salter, Wilkes, Vou-Boriceau ad Scott, i their study of a emergecy departmet, foud that iadequate documetatio was oe of the mai reasos cliicias failed to respod to patiets with abormal vital sigs. 6 McGai et al., whe lookig at vital sigs documetatio durig the first seve days after surgery, foud sigificat levels of icomplete documetatio. 7 Multiplicatio errors, trascriptio errors, illegible results, late data etry, misidetificatio of the patiet, udocumeted readigs ad missed readigs ca lead to faulty data, as well as uecessary ad potetially dagerous itervetios or withholdig of treatmets. Che et al., evaluatig the Merit Study ivestigators, foud i Experiece has show that may hospitals udertake the move to ew techology without fully uderstadig the impact o workload, patiet safety ad data accuracy. their radomized multi-site study eve i the hospitals that kew they were a part of cliical trials moitorig, documetatio, resposes to chages i vital sigs were ot adequate. 8 (p2096) The authors further evaluated the Merit Study data ad foud that 77 percet of the patiets studied were missig oe vital sig measuremet prior to a adverse cliical evet. The use of techology may help decrease these errors. Techology has bee applied to prevet errors i other areas of ursig care. Bar-codig is ow beig used to decrease the huma error factor at the poit of care, prevetig misidetificatio of patiets. Foote ad Colema foud that, whe used for medicatio admiistratio, bar code techology reduced errors by 80 percet. 9 Addig the use of bar code techology to vital sigs documetatio could assure correct patiet idetificatio, makig certai results are charted i the correct electroic medical record. The advet of the electroic medical record system has helped the accuracy of patiet documetatio. Gearig et al., evaluated the use of the electroic record i vital sigs documetatio. 10 They foud that out of 613 sets of vital sigs take o a medical/ surgical uit ad maually documeted usig paper records, 25.6 percet of the medical records had at least oe error related to trascriptio or result omissio. As for a cardiac step-dow uit that utilized a electroic medical record system, 14.9 percet of the 623 records had oe or more errors related to trascriptio or result omissio. Smith et al. completed a post implemetatio study to usig the Gearig results to determie the accuracy of a automated system that seds the vital sig measuremets from the vital sig moitor to a PDA ad the uploads them i the medical record. 11 They foud that the error rate decreased to less tha 1 percet. Cliicia Time Cliicia time is oe of the most valued ad costly resources i healthcare. Because vital sig measuremet i hospitalized patiets is a frequetly performed procedure, ivestigatig the potetial of cost cotaimet i this practice is clearly warrated. 12 (p244) A recet time ad motio study showed that urses spet 35.3 percet of their workig time completig all types of documetatio volume 24 / umber 4 FALL 2010 jhim 47

3 Storfjell, Omoike, ad Ohlso looked at the costs of urses completig patiet care activities i 14 medical/surgical uits i three hospitals. 14 They idetified activities that did ot beefit patiet care ad their associated costs. They foud cliical record maagemet was oe of the activities with the highest amout of time wasted. There were differet reasos for the wasted time for electroic ad paper documetatio, but o time differece. It was determied that the wasted time icluded i the cliical record task was $210,853 aually for a average medical/surgical uit. The time associated with vital sigs documetatio was evaluated by Doati et al. while they were researchig the impact of cliical iformatio systems i the itesive care uit. 15 They foud that the ICU urses spet 12 miutes per patiet per day maually chartig vital sigs results. After the implemetatio of the cliical iformatio system that automated vital sig documetatio, the time spet dropped to two miutes per patiet, per day. Time spet o double documetig vital sigs is time away from patiets. RESEARCH DESIGN A quasi-experimetal desig was used to gather data pre- ad postimplemetatio of a comprehesive automated vital sig capture ad documetatio system. This study icluded a review of curret hospital procedures, observatios of curret practices ad a workflow aalysis as it relates to vital sig capture ad documetatio. The study compared automated documetatio workflows with the maual etry documetatio workflow curretly i use o the uit as they related to the accuracy of documetatio ad timeliess. Factors evaluated were workflow time studies ad documetatio error idetificatio. Process Time ad motio studies were chose for accuracy i obtaiig more precise times for each activity. 16 It was felt that this method, although time itesive, would provide the most accurate ad cosistet results. Fikler, Kickma, Hedrickso, Lipki ad Thompso compared work samplig ad time ad motio techiques, fidig that the work-samplig approach, as commoly employed, may ot provide a acceptably precise approximatio of the result that would be obtaied by time ad motio observatios. 17 (p577) Potetial errors i vital sig documetatio were researched ad quatified. Prior to the study, the potetial errors were categorized as Trascriptio error. Trasposed digits: e.g., writig 15 istead of 51. Typographic error. Types i computer icorrectly. Needed to repeat VS due to forgettig result which icludes omissio of result. Picked wrog patiet o computer. Other. Uaticipated issuers resultig i errors. Research documetatio sheets were created for each workflow, ad checkboxes were created to assure iter-rater reliability. For the purpose of this study, a set of blood pressure, pulse, respiratio, temperature, ad oxyge saturatio is cosidered as oe data poit. SettigThe study was coducted o a acute care medical/surgical uit at a midsize hospital from December 2007 to Jauary The time ad motio study was completed durig two time periods 7 a.m. to 8:30 a.m., ad 10 a.m. to 12 p.m. four days a week for four weeks. The hospital s istitutioal review board approved the study prior to erollig ay subjects. As required, iformed coset was obtaied from the participatig patiets ad uit staff prior to performig ay study-related procedures. Sample A coveiece samplig of uit cliicias was ivited to participate. There were o repercussios for ot participatig ad o cliicia ames were collected durig the study. A attempt was made to utilize the same cliicias for each documetatio method; some cliicias did ot participate i each of the workflows due to shift swigs or staffig eeds, while others utilized each method. A coveiece samplig of hospitalized patiets was ivited to participate. I ordered to be icluded i the study willig patiets had to be capable of givig iformed coset. Coset was valid util revoked ad several patiets participated more tha oce. The uit cliicias, registered urses, licesed practical urses ad urse s aides were observed, ad time studies were completed durig routie vital sig assessmets o cosetig patiets. Fiftyfive patiets were erolled ad 25 uit cliicias participated. Methods The study compared the accuracy ad time efficiecy of: 1. The curret vital sig machie ad maual documetatio workflow. This ivolved the use of a vital sig machie to obtai blood pressure, pulse, temperature ad oximetry readigs. Pai ad respiratio results were obtaied maually. Paper ad pe were used to record vital sigs assessmets, which were the maually trasferred ito the electroic medical record usig computers i the uit hallway. Or assessmets were maually etered directly ito the electroic medical record usig a bedside computer. Hadheld devices were available for maual iput ad automated trasfer ito the electroic medical record, but they were ot preferred by the cliicias thus oly oe readig was completed with this tool. 11. The study vital sig machie ad automated vital sigs documetatio system. The vital sig machie s bar-code scaer was used to idetify the patiet ad cliicia, ad the machie was the used to obtai blood pressure, pulse, temperature ad oximetry readigs. The pai ad respiratio results were obtaied maually ad etered ito the vital sig machie. The cliicia had the opportuity to verify the accuracy of the vital sig readigs, ad the pressed a butto to sed the results to the electroic chart. This system automatically trasferred the vital sig results from the bedside to the electroic medical record, elimiatig the eed to maually documet. Automated Vital Sigs Documetatio System The automated vital sigs documetatio system utilized i this study was a commercially available product that has received 510(k) clearace from the FDA. With the software, vital sigs assessmets are automatically trasferred from the bedside vital 48 jhim FALL 2010 volume 24 / Number 4

4 sig machie ito the electroic medical record. The method utilizes bar code techology to sca the patiet s ID bracelet ad a automated vital sig machie to capture the heart rate, blood pressure, temperature ad oximetry. The cliicia assesses the patiet s pai level, ad observes ad measures the patiet s respiratios, eterig them both usig the automated vital sig machie or laptop. The automated vital sigs documetatio system uses three methods to trasfer vital sigs results from the bedside vital sig machie to the electroic medical record - wireless, computer based ad batch. The automated vital sigs documetatio system seds the iformatio to the patiet s electroic medical record i oe of three ways: 1. device to the electroic medical record. 2. Wireless method. Wireless trasfer of vital sigs from the Computer method. A mobile computer with a vital sig machie mouted o it trasfers vital sigs to the electroic medical record with bedside computer etry of pai ad respiratio assessmet. 3. Batch method. Readigs are stored i the vital sig machie, which is later maually docked at the computer statio, allowig all readigs to be imported ito the electroic medical record. The hospital s cliical systems aalysts ad iformatio techology departmet, alog with the maufacturers represetatives, worked together to iterface the hospital s EMR with the automated vital sigs documetatio software. Methodical testig was completed i both test ad live eviromets prior to research implemetatio. Research assistats, staff educators ad college of ursig faculty members were masters-prepared cliical experts, ad ot liked to the cliical uit staff i ay way. They adopted a oparticipat role whe observig for errors i vital sig documetatio. All research assistats were provided with descriptios of each error category, ad the pricipal ivestigator was available durig each observatio sessio to aswer questios cocerig the categories. Research assistats spet a maximum of two hours ad 30 miutes per observatio sessio. The research assistats used stopwatches to measure the time from applicatio of the cuff to the ed of the vital sig acquisitio ad documetatio activities occurrig i the patiet room. Some of the workflows required leavig the patiet s room for fial documetatio. For workflows requirig documetatio outside the room, a secod time testig occurred. For these workflows, the timig bega whe the uit cliicia logged ito the system ad eded whe they siged off. If the uit cliicia was documetig for more tha oe patiet, the total documetatio time was measured ad divided by the umber of patiets for which they were documetig. The documetatio result was added to the vital sigs acquisitio time to create the total time (Total Time = Vital Sig Acquisitio Time + Documetatio Time Outside the Room, if applicable). The time lag betwee the acquisitio of the vital sig measuremets ad Table 1: Documetatio Errors of Curret Maual Vital Sigs Documetatio Workflow ad Automated Vital Sigs Documetatio System. fial documetatio for those methods requirig the uit cliicia to leave the room to documet was ot timed. A complete study record icluded iformatio o the accuracy i documetatio of each vital sig (blood pressure, pulse, respiratio, temperature ad oxyge saturatio), otatio of the method that was beig evaluated, ad time result for vital sig acquisitio ad documetatio as the method required. For the purpose of this study, a set of blood pressure, pulse, respiratio, temperature ad oxyge saturatio is cosidered as oe data poit. Traiig Participatig cliicias did ot have experiece with the study vital sig machie ad automated vital sigs documetatio system prior to the study. Traiig occurred o the uit the day prior to the start of testig; cliicias atteded a oe-hour orietatio ad educatioal sessio, which icluded a brief demostratio ad hads-o sessio. All staff members had utilized other brads of mobile vital sig devices i the past. Statistical Methods The documetatio error rate of the maual vital sig documetatio system was compared with that of the automatic vital sig documetatio system by a Fisher s exact test sice oe expected cell frequecy is less tha five. Descriptive statistics were calculated for all time variables, followed by the Kolmogorov-Smirov test to check the ormality. Comparisos of total time by differet methods were aalyzed usig t-tests if the data follow a ormal distributio. For time variables with skewed distributio, the Ma-Whitey U test was employed to compare the medias. The SAS for Widows, v Cary, NC was used to coduct the data aalysis. All statistical aalyses were based o the sigificace level of Results Accuracy i Documetatio Maual Documetatio Method Out of 52 sets of vital sig, with each set icludig blood pres- volume 24 / umber 4 FALL 2010 jhim 49

5 sure, pulse, respiratio, temperature ad oxyge saturatio, seve (13.5 percet) errors occurred i the maual documetatio method four whe maually documetig utilizig the curret computer system preset o the uit (two typographical error, oe trascriptio error ad oe eed to repeat due to forgettig the result), ad three whe the cliicia documeted o scrap paper ad left the patiet s room to maually eter the results usig curret computer systems i the hallway (oe typographical error, oe trascriptio error ad oe eed to repeat due to forgettig the result). Automated Documetatio System Out of 92 sets of vital sig, with each set icludig blood pressure, pulse, respiratio, temperature, ad oxyge saturatio, three errors (3.3 percet) occurred i the automated documetatio system, oe error i each of the three workflows wireless (other error oe difficulty scaig patiet ID bracelet), batch (oe typographic error) ad computer method (other error oe omissio, failure to eter required vital sig assessmet). Software Fig. 1: Total Vital Sigs Time (acquisitio + documetatio) for Each Method. Durig the study, the software trasferred vital sigs results from the bedside vital sig machie to the electroic medical record with 100 percet accuracy. Whe compared to curret maual documetatio workflow, the automated documetatio workflows overall reduced documetatio errors by 75 percet (13.5 percet vs. 3.3 percet, Table 1, p = 0.02). Cliicia Time The study evaluated whether the time required for vital sigs acquisitio ad documetatio was differet betwee the methods. Documetatio for workflows requirig vital sigs etry outside the room required separate time testig. The result was added to the vital sigs acquisitio time to create the total time (Total Time = Vital Sig Acquisitio Time + Documetatio Time Outside the Room, if applicable). If the cliicia was documetig for more tha oe patiet, the total documetatio time was measured ad divided by the umber of cliets for which they were documetig. O average, cliicias spet the least time o capturig ad documetig the patiet s vital sigs by usig the wireless workflow ( secods ± 41.87). The maual documetatio method documetig o paper ad maually trasferrig the results to the electroic medical record was the most time itesive ( secods ± 62.88). The order of total time by differet methods is preseted i Figure 1. Combiig vital sigs acquisitio ad documetatio times, the wireless automated etry was the most time-efficiet. O average, it saved sigificatly more time tha the paper trasfer method ( secods ± vs secods ± 62.88; p < ). LIMITATIONS OF THE STUDY The timeframe for the post-implemetatio time ad motio outcome evaluatio was oe day after a oe-hour traiig sessio. This timeframe is less tha ideal, as Butler ad Beder emphasized the eed to allow a six-moth learig curve for adults prior to post-implemetatio studies. 18 The resultig time savigs i the automated documetatio wireless method suggest a shorter tha average learig curve. The computer hardware i which the automated vital sig documetatio software was loaded i the computer-based workflow was ew to the cliicias. A tablet-style computer was chose for use i the study, which required the use of a electroic pe to move through the applicatio. It proved to be difficult for the cliicias to utilize ad was ot eeded for the software to fuctio. This factor may have affected the documetatio times. Repeatig the study with a computer system that cliicias are more familiar with may lead to differet results. SUGGESTION FOR FUTURE STUDY The time lag betwee the acquisitio of the vital sig measuremets ad fial documetatio for those methods requirig the cliicia to leave the room to documet was ot timed i this study, but would be of iterest for future studies. Delays i eterig the vital sig results ito the electroic chart impede the ability of others to access the iformatio ad evaluate the results. DISCUSSION This study looked at potetial improvemets that ca be made 50 jhim FALL 2010 volume 24 / Number 4

6 i the care areas where the majority of the hospital s patiets reside medical/surgical uits. This study foud that the wireless automated vital sig documetatio system saved time ad was more accurate tha the maual documetatio methods. The automated vital sig documetatio system utilizig bar code techology at the poit of care may decrease the potetial for huma error. Although cliicias who participated i this study oly had oe hour of traiig o the use of the automated documetatio software, the vital sigs process showed sigificat time savigs. I this study, the automated documetatio method reduced errors by 75 percet whe compared to maual documetatio. Automatig the vital sigs documetatio process may reduce the labor required to documet the results, as well as providig more accurate ad timely data. The wireless method was the most time-efficiet i capturig ad documetig vital sigs. O average, it saved secods per readig over the maual documetatio method. O a 36-bed uit with vital sigs ordered o average of four times a day, this method could save almost 120 hours of staff time per moth. Chages i vital sigs have bee liked with icreased risk for cliically adverse evets. 19 If the documetatio of patiet vital sigs is icorrect or missig, these chages will ot be idetified. I a era where medical mistakes make frot-page ews, automatig the vital sigs documetatio process may speed vital sig results to care providers, allowig cliicias to more quickly react to importat chages i patiet health status. Ackowledgmets This study was fuded by a grat from the Metropolita Developmet Associatio (MDA) of Syracuse ad Cetral New York, Ic. We wish to thak the followig for their assistace: Mariae Markowitz, Sadra Zajac; Jeifer Johstoe, Kimberlee Reed, Kathlee Cook ad their staff; Felicia Corp; Sally Delay; Deborah Hopkis; Nacy Poole; the hospital s cliical systems aalysts ad iformatio techology departmet; ad the maufacturers represetatives. JHIM Meg Meccariello is a Associate Professor ad Cliical Learig Lab Maager at St. Joseph s College of Nursig at St. Joseph s Hospital Health Ceter. Dave Perkis has desiged Welch Ally medical devices for 22 years, curretly as marketig director for vital sigs systems focused o reducig effort ad errors for geeral care floors. Loretta G. Quigley, RN, MS, is the Associate Dea of St. Joseph s College of Nursig at St. Joseph s Hospital Health Ceter. Agie Rock, MBA, CCRP, is the Cliical Operatios Maager at Welch Ally ad Chair of the Orego State Chapter Society of Cliical Research Associates. Jiejig Qiu, MS, is the Seior Biostatisticia at Welch Ally Ic. Ms. Qiu was formerly a Biostatisticia at the Biostatistics Research Ceter at the Tufts Medical Ceter i Bosto, MA. Refereces 1. Perry A, Potter P. Cliical Nursig Skills & Techiques. 6th ed. St. Louis, Mo.: Mosby; Adrews T, Waterma H. Packagig: a grouded theory of how to report physiological deterioratio effectively. 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J Nurs Adm. 2000;30(3): Fikler SA, Kickma JR, Hedrickso G, Lipki M, Thompso WG. A compariso of work-samplig ad time-ad-motio techiques for studies i health services research. Health Serv Res. 1993;28(5): Butler M, Beder A. Itesive care uit bedside documetatio systems realizig cost savigs ad quality improvemets. Comput Nurs. 1999;17(1): Goldhill DR, McNarry AF. Physiological abormalities i early warig scores are related to mortality i adult ipatiets. Br J Aaesth. 2004;92: volume 24 / umber 4 FALL 2010 jhim 51