The immediate fix is easy — just create a constant current awareness for the team and make sure that in the workflow, at the moment of the discharge decision, if the team missed the “current awareness,” there is a forced awareness of something that truly needs to be known by the team: Patient is being discharged with abnormal vital signs. The images below demonstrate what might be in the visual in the patient’s EMR and what a forced awareness might look like at discharge.
There are actually several other critical vital sign considerations, too many to include here. But another important one is creating an awareness of vital sign trending. Humans tend not to be great at connecting the dots. That is, given all the facts and circumstances surrounding patient care, it is sometimes difficult to recognize critical vital sign patterns.
Vital signs are often displayed in table format. Review the example below.
This is a 70-year-old woman who presented with a cough and history of fever. Does the problem jump right out at you? No, it doesn’t; these numbers don’t look too bad. The fact is that her mean arterial pressure has been dropping in the two hours she has been in the emergency department. It is far easier to recognize the trend in the following graphic presentation.
In addition, if we are in an electronic environment, let’s use it. Let the program do the math and let the practitioner know that there is a 20% or a 40% drop in mean arterial pressure over time. Similar logic holds for trends in pulse rate, pulse oximetry and respiratory rate. Let the EMR do the heavy lifting and then deliver the message through a method carefully designed to achieve recognition by the clinical team.
There are many features that can be built around vital signs in the EHR/EMR world. We have outlined 2 key areas that actually help facilitate 1) communication between clinicians about vital signs and patient status, and 2) clinical judgement and decision-making. In addition to these features, TSG has spent time building algorithms for early recognition of sepsis and pulmonary embolism based on pulse-temperature disparity rules. To learn more about these features, please contact Brant Roth at broth@thesullivangroup.com.
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