Transcript Presentation Title - Scottish Patient Safety Research Network

VitalPAC: a means of hospital-wide
physiological surveillance?
SPSRN Burn June 2009
Nicola Mackintosh
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Outline
 Context & project overview
 The nature of the problem, ‘failure to rescue’ and
the proposed safety solution – VitalPAC
 What could be the problem with the solution?
 Examining the potential for unintended
consequences
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Research Context
 Context: Innovations Programme / NIHR King’s PSSQ Research
Centre
 Project: two year study examining the management of complications
in medicine and maternity in four wards of two foundation trusts
 Methods: ethnography (observations, interviews, documentary
review, analysis of routine data)
 Focus:
 How is deterioration socially framed, negotiated and managed?
 How have safety strategies such as VitalPAC been adopted and
what is their impact?
 What contextual features facilitate ‘mindful’ application of these
tools?
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Background Policy Context
 Widespread evidence of ‘failure to rescue’ i.e. failure not
only to recognise warning signs, but to interpret and
institute timely, appropriate clinical management once
deterioration is identified (NCEPOD 2005, NPSA 2007,
O’Neill 2008).
 Up to 50% of ward based patients received substandard
care prior to ICU admission; up to 41% of ICU admissions
were potentially avoidable (McQuillan 1998)
 Deterioration in a patient’s condition identified by WHO as
a key topic (Joint Commission 2008)
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Latent Failures & Error Producing Conditions
(NPSA 2007)
Work/environment factors e.g. lack
of guidelines, lack of training
Team factors e.g. hierarchies
Individual (staff) factors e.g.
inadequate handover
Task factors e.g. observations
rated as low priority
Patient factors e.g. signs of
deterioration not always visually
obvious
Failure to detect,
interpret and
respond to the
deteriorating patient
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Safety Solutions
 Early recognition e.g. Early Warning Scores (EWS),
intelligent assessment tools such as ‘VitalPAC’
 Graded response strategy for those at risk
 Access to personnel with core critical care competencies
and diagnostic skills e.g. Medical Emergency Team,
Critical Care Outreach Service
 Education and training / core competencies in monitoring,
measuring, interpreting and responding e.g. Immediate
Life Support Training
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Early Warning Scores
 EWS operate by allotting points to vital sign
measurements on basis of physiological derangement
from a ‘predetermined range’
 When score reaches an arbitrarily predefined threshold it
triggers ‘call for help’
 To date the extent to which the existing tools are valid or
reliable predictors of deterioration is unknown
(McGaughey et al 2007)
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VitalPAC – the rationale
 VitalPAC (intelligent assessment
tool) – may facilitate appropriate
graded medical response based
on the severity of the condition
of the patient. Alerts preset and
linked to a central surveillance
system; designing out variability
in practitioners’ responses to the
information
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VitalPAC – the process
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VitalPAC – potential for reduction of risks?
 Task
 Accurate and legible recording of data
 Individualised practice
 Correct ascription of weighted value according to physiological
derangement; arithmetic addition of weighted values to form EWS
 Team
 Remote access to aid medical prioritisation when medical team
‘offsite’
 License to overcome professional hierarchies
 Point of reference for junior staff
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VitalPAC – opportunity for performance feedback?
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VitalPAC – evidence of impact?
 Key questions – does VP trigger remedial actions at the right time?
Does it reduce rates of ‘failure to rescue’? Does it reduce avoidable
adverse events or death?
 Little empirical research to date
 Absence of data examining impact of VP on patient outcome
 EWS error rate of 28.6% compared to 9.5% with VP (Prytherch 2006)
 Even with track and trigger systems recording of vital signs, patient
chart completion and RRT activation remains sub-optimal (Hillman et
al 2005)
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Potential Problems With The Solution?
 ‘Technological determinism’ (Webster 2007) underpins
rationale for the tool
 Ignores technology’s capability as ‘one actor among many
in changing configurations of social and technical
elements’ (Law and Hassard 1999)
 Considers redundancy as a problem to be solved rather
than recognising duplication of effort in recording data as
source of reliability (Tjora and Scambler 2008)
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Boundaries Of Risk
 Tool focuses on individual behaviour; system design
failures are marginalised.
 Inadequate staffing levels, inappropriate skill mix, high workload
known to impact on levels of surveillance, sensitivity to warning
signs and capacity to respond to an emergency (Carr-Hill et al
2003)
 Inbuilt algorithm designed to influence nurses’ behaviour
– may have little impact on regulation of medical response
 Disjuncture regarding chain of command - observations
performed by care assistant; initiation of appropriate
escalation strategy by qualified staff
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Claiming Authority And Jurisdiction Over A
Contested Field
 Potential for technology to serve as tool to
demonstrate power, professional skills and
decision making
 VitalPAC could provide opportunity for boundary
work; may enable nurses to gain authority and
‘symbolic capital’ – improving social position
(Gieryn 1999, Bourdieu 1998)
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Potential Unintended Consequences (1)
 System failure – information inaccessible
 Impact of remote access on interprofessional
collaboration – removal of ‘key material structuring device’
and the face to face communication that often happens
around the ward round (Greenhalgh 2008)
 Apprenticeship – difficult for novices to develop key
assessment skills
 Impact on work practices: increase in workload due to
loss of ‘batching’ of observations, difficulties accessing
computers during busy times e.g. ward rounds
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Potential Unintended Consequences (2)
 Overdue observations? Normalisation of deviance – departures from
safety system that get recast as acceptable risk and become the
norm (Vaughan 1996)
 Devaluation of tacit knowledge and merit of subjective data in defining
patients at risk
 Necessity for pragmatism, application of contingent standards when
staff decide to over-ride the system e.g. around end of life care and
chronic illness - increasing the margin for error
 Colonisation - staff controlled by the very ICT installed to facilitate
working routines; ‘symbolic violence’ (Habermas 1987, Bourdieu 1977)
 Routinisation
 Construction of hierarchy of importance of vital signs according to
attribution of weighted value
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‘Medical Gaze’
 Technology of power - ‘e-panopticon’ (Foucault
1976)
 ‘The patient is rendered as a universalised
datum, disconnected from both any tangible,
corporeal body and the sentient human being,
becoming an image that can be moved through
computer networks anywhere around the world.
Understanding such a patient does not require
human touch’ (Samson 1999)
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The Tool As A means Of Surveillance
 Software warns if erroneous values are entered
 The system flags up when partial data consistently
entered or ‘unlikely observations’ entered or the same
data regularly recorded
 Aggregated data can provide an overview of the health
status of the hospital patient population
 Opportunities for performance monitoring / score cards
 Medico-legal and clinical negligence implications
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Operationalising New Modes of Surveillance
 Interpretation of numerical data becomes the
mode of framing generalisable knowledge about
social phenomena (May 2006)
 Performance management can become an
organisational ritual, ‘a dramaturgical
performance’ (Power 1997)
 Opportunities for blame of particular professional
groups
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Summary
 Codifying and standardising ‘the indeterminancy
of expert systems and knowledge will have
limited effect in practice’ (Webster 2007)
 Important to capture how the tool ‘mediates’
practice and influences pragmatic decision
making
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