Charting a new future

E-observations are now well established at many trusts; and the quest is on to extend them to new areas. Daloni Carlisle reports.

The image of the nurse with her hand on the patient’s wrist, her eye on the watch dangling from her top pocket, and her other hand reaching for a pen to make a note on a bedside chart is history.

Today’s nurse will be wheeling a small trolley full of the machines that she will need to make observations and frequently will be using a tablet or smartphone to record them. Welcome to the brave new world of e-observations.

Achieving scale

There are now a number of hospitals that have rolled out e-observations at scale. Nottingham University Hospitals NHS Trust has placed more than 4,000 mobile devices in clinicians’ hands, for example.

In Fife, Leicester, Portsmouth, Central Manchester and many more, the mobile device has replaced the pen and chart.

Others are waiting. It is thought that about 50 NHS trusts applied to the Prime Minister’s Nursing Technology Fund for money to support the roll-out of e-observations; and that many of the local digital roadmaps that local health economies had to submit to NHS England by the end of June will feature e-observations.

Paul Volkaerts, founder and chief executive of Nervecentre, says: “That has created a demand. The trusts who wanted to do this and have not had the funds are trying to find other ways to finance it. “Having made the case that e-observations are needed, they cannot then just decide not to do it.”

Making the business case

Having said that, he says his company is seeing a new focus on the business case and on “understanding the return on investment, as opposed to a focus purely on quality.”

The data to support this is emerging. Work in Nottingham has demonstrated that using Nervecentre’s system for electronic observations saves about a minute per set of observations compared to pen and paper. At this vast hospital, nurses do more than 7,000 sets of observations a day.

You do the maths. At Central Manchester University Hospitals NHS Foundation Trust, clinicians and managers have carried out careful research as they have implemented e-observations from Patientrack, and can now demonstrate that the hospital is as safe at weekends as it is during the week.

For deteriorating patients, Central Manchester has shown how early detection of at risk patients using the e-observations followed by rapid intervention has reduced length of stay, reduced the risk of cardiac arrest and reduced the use of ITU.

This kind of work is prompting trusts to think about the operational benefits of e-observations, and how using handheld devices to understand patient flow in real time can be used to support bed management and patient discharge. And if there is an untoward incident, hospitals no longer have to go back to the paper record to build a story of what happened.

“With electronic systems, a hospital can type in the patient’s hospital number and print an audit log,” says Volkaerts. “It takes one minute. We have hospitals that tell us that the savings made on audit alone equate to four whole time equivalents.”

Sepsis alerts

While one dynamic in the development of e-observations is this focus on RoI, another is innovation.

In the patient safety space, the NHS has put considerable effort into venous thromboembolism assessment, and is now focusing on sepsis and acute kidney injury. A number of e-observation providers are working with demonstration sites on tools to help identify and escalate the treatment of patients at risk.

Nervecentre, for example, is working with Nottingham University Hospitals and Leicester University Hospitals NHS Trust on a system to spot sepsis, which affects 150,000 patients annually and causes 44,000 deaths, according to the UK Sepsis Trust.

It uses an algorithm based on NICE guidance to identify patients whose vital signs indicate that sepsis might be developing and to alert senior nurses or junior doctors. Any notes that they take can be drafted in the system and move with the patient if they are transferred – for example to ITU.

Similarly, IMS Maxims is working at Musgrove Park Hospital in Somerset on a sepsis application. The app to capture the data has been designed; the next step is to validate it and work with clinical teams on workflows. It should be piloted over the summer.

It’s very much part of a wider mhealth strategy that involves a dedicated mhealth server to support mobile innovation and applications at the trust. Jacinta Ni Suaird, product director for IMS Maxims says: “Our strategy is to deliver all our clinical functionality via mobile.”

AKI alerts

Patientrack is working with Western Sussex Hospitals NHS Foundation Trust on an application and associated workflow to detect and escalate the treatment of patients at risk of AKI, a condition responsible for 100,000 deaths a year in secondary care at a cost of £450 million.

Donald Kennedy is managing director of Patientrack. He says that some of the most interesting developments are not so much the technology but the human factors work – for example by creating systems and workflows that overcome the human reluctance to seek help when help is needed.

This chimes with the experience of iMDsoft. Its MetaVision SafeTrack product can already be used for e-observations, shift handover, and screening for conditions including VTE. Now, it is which is working on smart alerts for both sepsis and AKI, again using NICE guidelines.

This is being trialled at University Hospital Southampton NHS Foundation Trust, where Helen Neary, the division head of nursing and professions, says one of the key features is the accuracy of the observations.

“It takes out human error,” she says. “Taking away the human factor improves accuracy, which means patients are managed much more effectively and safely – and it increases the speed of escalation.”

Community cross-over

Companies and their NHS trust partners are also are looking to extend e-observations to new areas. Civica, for instance, has formed a partnership with Med ePad, which has an observation solution called Med eTrax.

Until recently, its focus was on community applications; Med eTrax applications supporting community nursing e-observations and telehealth applications for patients have been interfaced directly with the Paris electronic patient record.

Now, though, the company is working with Alder Hey Children’s NHS Foundation Trust to provide an electronic system for monitoring children on anti coagulation therapy – so they don’t have to visit the hospital so frequently. Another development is looking at e-observations at home prior to cardiac surgery, with the aim of making sure that patients are surgery fit – without them having to make a long journey into a regional centre for routine checks.

This community-acute cross over is likely to become more important in future, says Med ePad chief executive John Hopkins.

“The underlying platform is a secure communications platform,” he says. “The move into the community could give some really big wins – but it needs changes in the way people work and changes in the tariff to make it financially viable.”

A sector to watch

The scope of e-observations looks set to grow over the next year, driven by the spread of mobility in trusts, the creation of additional alerts, the spread of integrated care; and the ingenuity of clinicians themselves.

In Harrogate, another Patrientrack site, nurses are using e-observations to support end of life care. So rather than taking vital signs, nurses are using handheld devices to record mouth care or signs of distress.

“That’s one of the things that surprises me greatly and positively,” says Kennedy. “Once you start creating a set of tools for healthcare professionals, they will find fantastic ways to use them that the supplier never thought of.”