Last year, Leeds Teaching Hospitals developed and implemented a new way of recording physiological observations and identifying children at risk of clinical deterioration. For HTN Now, Lead Nurse for Digital Informatics David Pickles and Senior Developer Jonny Dyson joined us to discuss the benefits of their new solution.
David begins their session by providing an overview of the electronic observation system at Leeds Children’s Hospital. “E-obs is a digital solution for the recording of patients’ vital signs,” he says. “It’s predominantly been designed to be captured on a mobile device, in our Children’s Hospital, generally iPads. This feature can be used to capture all of the physiological observations and it’s fully integrated into Leeds Teaching Hospitals electronic health record (EHR).”
The system has the ability to provide an advanced paediatric warning score (ePAWS) for patients, built on top of existing functionality; “it’s a graded response strategy, based on the patient’s observations,” says David, “and allows for early identification of potential deterioration in a patient’s condition.”
David goes on to discuss how the EHR was developed in-house by a multi-disciplinary team including software developers, business analysts and an implementation team, which brought clinical personal into the mix. “There’s close collaboration between the clinical colleagues so that the solution is designed by the people who will use it.”
When it came to the implementation of electronic observations within the EHR, there was an initial pilot phase to generate feedback and further development. David points out that the business analysts sit within the EHR development team, so they are “involved with the whole life-cycle of the product, facilitating conversations between technical and clinical teams, and keeping a tight rein on the scope.”
David shares some of the activities undertaken by the business analysts so that they could understand the necessary system requirements; the current adult system was demonstrated to the paediatric teams, we made contact with other children’s hospitals who were also using electronic systems, observed the existing paper charts that were in use during ward walks and facilitated workshops with staff. David highlights that the development of the solution was supported by “strong and engaged leadership at the top of the Children’s Hospital.” To further the collaborative nature of the project, a paediatric technical steering group was set up which comprised of clinicians with an interest in the project, who were able to make decisions and provide the EHR team with guidance.
Business analysts also worked closely with a number of the trust’s clinical leadership fellows, David explains, and received help from specialty teams.
When it came to challenges, David comments on the difficulty of aligning scorings and response strategies within the paediatric setting, as they differ depending on the patient’s age. It was necessary to be able to within patient’s observation ranges, for patients “who for physiological reasons have a norm outside what’s deemed to be normal.” David notes that the IT nursing team provided additional guidance on this.
Once the high-level requirements were understood, it was time to move on to designing the system. “A design session was held to agree a technical approach,” says David. “Developers, testers and the implementation team discussed the proposed scope, the background, current and future states, and get an early look at possible future solutions with mock-ups. That gives the implementation team some advance notice for planning resources.”
David moves on to discuss how requirements were documented and prioritised as “must do, should do, could do, won’t do”. Sessions were then held “so that everybody understands what is trying to be built, and what the expected behaviours of the functionality are.
“In terms of the roll-out plan,” David says, “a project of this magnitude requires careful planning; there was detailed planning in terms of which wards would be going live with this functionality and when.” Feedback received during the pilot phase helped to guide the development of the system; responses included one nurse commented that they found it practically difficult to move some of the pilot system’s slider functionality, and another pointing out a need for a ‘no observations required’ option.
“I think it’s also worth noting that we don’t develop and implement software features in isolation,” says David. “There are other things that happen within the hospital – of course, COVID is a major factor – another key factor here for us was the downtime of a key system. Our patient administration system is used in conjunction with [EHR] PPM+, there is data flow between the systems, and our trust was using an old, unsupported version of that software that needed to be stabilised and modernised. So some downtime was factored in while this upgrade took place and our roll-out of the electronic observations had to take account of this. It doesn’t take place in a vacuum.”
David discusses the communication strategies developed to cover the roll-out activities. “We adopted a clinical service unit (CSU) first approach,” he says. “We gave plenty of notice to each ward before the functionality would be enabled and we provided plenty of updates in terms of the completion of e-learning, because we wanted the personnel on each ward to be familiar with the functionality before they started using it, in order to not compromise clinical care.”
He highlights the importance of recognising that ePAWS was not suitable for every ward, using the dialysis unit as an example. Alongside their general observations, “they make reporting of observations on a national system which feeds national reporting, and adding that to their existing workload would not have conferred any additional clinical benefits. The Clinical Research Facility was also similarly not in a position to take the functionality, because different clinical trial protocols quire different observation periods.”
E-learning packages bespoke to different roles were created, with ward managers contacted four weeks before roll-out. “We agreed with senior ward managers that a target of 80 percent was reasonable,” says David, “in order to provide that assurance that there were sufficiently trained staff before the functionality was live on the ward.”
David notes that they held discussions on what would happen if the EHR PPM+ went offline, to ensure that nursing teams were familiar with the back-up process.
David then runs through a brief overview of how the ePAWS functionality works, including the digital observation form that clinicians need to complete and submit and the paediatric advance warning score generated as a result of those observations, depending on the child’s age and physiological parameters. He shows how the functionality suggests next steps for clinicians if the scores are elevated as part of its graded response strategy.
Interventions can be documented on the system; “if a non-registered health professional takes some observations and there is an elevated score, in order to acknowledge that score, a countersignature is required from a registered nurse,” David explains. “The mobile device locks and you can’t proceed until that countersignature has been obtained. This provides some assurance that there is oversight of their work and that any potential deteriorating patients are brought to the attention of a registered nurse.”
David shows how the functionality has default settings, but they can be changed, for example changing the frequency of observations if the patient had returned from theatre and needed close monitoring, or perhaps required less frequent observations.
“The results are presented in different ways,” says David, showing an example of a table view versus a chart view “which replicates more closely the traditional observations chart, where various physiological observations are displayed all at once on a single sheet, and one can review those. Some people find those easier and more helpful to look at in terms of [recognising] a trend, and look at changing values over time.”
The functionality also has a front-end audit train, David says, which provides “a detailed breakdown of the activity that has taken place, so you can see who has recorded an observation, what interventions have been recorded, whether any changes have happened to the settings. In addition, the current PAWS score and the time at which the next observations are due are displayed on the ward’s e-whiteboards, a large monitor that’s displayed on the wall of each of the clinical areas, [supporting] better care and safety for patients.”
David details the training provided for staff, from on and off-ward support to user guides made available on the PPM+ site. David notes that when it came to face-to-face training, “staff were much more open about issues, quality feedback was provided, and this was highly valued by the teams.” The training highlighted some unanticipated issues; for example, the level of PPM+ access and authority could differ at times between registered nursing staff, leading to potential confusion.
Feedback from the wards indicated that ePAWS made a positive impact; “it’s improved the observation process, making it easier,” noted one member of staff, whilst another said, “it has meant that observations are recorded in a more timely manner – there are less delays to taking observations as the PPM+ whiteboard highlights when they are due, so it is a good visual reminder.”
Celia McKenzie, Head of Nursing at Leeds Children’s Hospital, commented, “ePAWS is a real step forward compared to our previous paper version. Feedback so far has been great…. we’re really embracing digital because it can make a real difference, helping reduce manual effort and time taken to complete paperwork, improve data accuracy, and ultimately improve the care we provide for children and young people.”
At this point, Senior Developer Jonny Dyson joins David to provide a live demonstration of the ePAWS functionality. The demonstration can be viewed from 34:05 on the video below.
Many thanks to David and Jonny for sharing their time and thoughts.
