Exploring the efficiency of automated vitals collection

Introduction
Established in 1948, the Oshawa Clinic has been providing quality health services to the Durham region community since its inception. The clinic has grown into the largest multidisciplinary medical group practice in Canada with over 130 physicians. The rapid growth of the community and the services the clinic has been able to provide has allowed for the expansion of the original Oshawa Clinic to include three additional patient care facilities– Taunton Health Centre and the Taunton Surgical Centre as well as in Courtice with the Courtice Health Centre. This grouping of clinics has become the largest multi-specialty medical group practice in the country delivering a broad range of innovative health services in coordination with the community.

Throughout the Oshawa Clinic sites, medical technology and devices such as Welch Allyn products are employed. Welch Allyn is a global medical device company founded in 1915 that provides health care institutions with practical diagnostic tools that help clinicians provide better care for their patients. Welch Allyn solutions are designed to help customers provide more advanced, comprehensive care, optimize time and skill, and improve patient outcomes. One of the primary focal points of the company’s solutions is the integration and digital transmission of vital signs and other patient information directly to electronic medical record (EMR) systems.

Electronic medical records are utilized to help to improve patient care by increasing access to clinical information, improving efficiency and workflow within health care providing centers, and reducing duplication of tests and clinical assessments, as well as to aid in enhancing patient privacy and confidentiality. The Welch Allyn Connex® Vital Signs Monitor (CVSM) is designed to help optimize utilization of electronic medical records through automated updating of patient vital signs information immediately following data recording.

This report has been generated to provide a holistic assessment of the implementation of the Welch Allyn Connex® Vital Signs Monitor (CVSM) at the Oshawa Clinic. Using a patient sample of 200, a comparative analysis was completed determining positives and negatives associated with both manual recording of vital signs performed by a health care professional versus recording vital signs using the automated method with the Welch Allyn device.

Background:
The Oshawa clinic tested the Welch Allyn CVSM and Connectivity Software Developers Kit (SDK) integration utility, which allows users to enter or select a patient ID, to work within a patient’s record, capture and store vital signs, and transmit patient readings via a wired connection to an EMR for viewing from any computer. The study was undertaken to determine the value of implementing these devices into daily practice at the Oshawa Clinic. It was hypothesized that utilization of automated documentation features and connectivity of the Welch Allyn CVSM device and software would decrease the clinician time associated with vital signs entry recording and provide more timely delivery of patient vital signs.

This study utilized the Welch Allyn CVSM and the SDK device integration utility in an ambulatory care facility. The Welch Allyn devices are compatible with the Oshawa Clinic’s electronic medical record system, Practice solutions by Telus Health 5.2.627 (Welch Allyn, 2011)via the SDK integration, and allow downloading of patient data directly from the point of care.

The Welch Allyn Connex® Vital Signs Monitor CVSM 6000 series of monitors is intended for use by clinicians and medically qualified personnel for monitoring of neonatal, pediatric, and adult patients for measuring and transmitting the following vital signs parameters:

  • noninvasive blood pressure (NIBP)
  • pulse rate (PR)
  • noninvasive functional oxygen saturation of arteriolar hemoglobin (SpO2) and
  • body temperature in normal and axillary modes

The most likely locations for patients to be monitored using these devices are general medical and surgical floors, general hospital, urgent care, and alternate care environments. Optional compatible weight scales (e.g., Health o meter®) can be used for height, weight, and BMI input.

Study Objective
The primary purpose of this study was to understand the difference between the time it takes to manually collect, document, transcribe, and have access to vital signs data in an EMR and the time it takes to collect, document, and have access to the data using Welch Allyn CVSM automated connectivity to the EMR. Clinicians were also asked to provide feedback on satisfaction and ease of use of the technology and software.

The primary objective of the study was to determine the average time from the start of measuring a patient’s vital signs until the results are available for viewing in the EMR , and to observe whether automated collection and entry decreases this average time compared to using traditional, manual methods. A secondary objective of this study was to determine clinician satisfaction with the Welch Allyn CVSM and automated vitals collection process.

Methodology
During the study, a research staff member familiar with the vitals data collection process and the Clinic’s computer-based medical record system observed a sampling of health care professionals conducting their current vital signs acquisition and documentation process. The research staff member observed the collection of the patients’ vital signs data and recorded the time from when the vital signs collection process began until the data was available in the EMR. This time was measured for both the manual process and the automated process across 100 patients in each process category. A comparison of the times from the manual collection and entry of vital signs and the automated collection and entry of vital signs was completed.

The study design included observation of vital signs monitoring collection or capture by clinicians, in this case registered nurses working for the physicians. The study was conducted by a qualified, selected research staff member familiar with the vitals data collection process and the Clinics’ computer-based medical record. Each clinician that was fully trained and participated in our study completed a post-study survey to assess clinician satisfaction and a direct comparison of the two processes. Three registered nurses who signed informed consent from the Oshawa Clinic recorded the vital signs for patients who agreed to participate in the study.

Study participants were patients over the age of 18 who had the ability to provide informed consent for participation in the study or had informed consent given by their legally authorized representative. The patients must not have shown any signs of severe pain or physical trauma, severe emotional distress, or agitation in order to be eligible for the study. Patients were introduced to the study while waiting in the clinic waiting room and asked if they were willing to participate in the study, and given an opportunity to sign an informed consent letter. During regular daily practice at the clinic, the registered nurse typically collects the vital signs before the patient has been assigned to a particular physician. This practice was followed for the study and as a result the study design did not affect the sequencing of patients seeking treatment.

The research staff member observed each clinician participating in the study while collecting patients’ vital signs data and documented the time between the start of vital signs collection and completion of entering the patient data into the EMR system. Completion occurred either at the time the data were sent from the Welch Allyn device or the time save was selected after manual data entry to the EMR. Each patient’s specific blood pressure, oxygen saturation levels, heart rate and temperature were not included in the study, the only information utilized was the time it took the clinician to collect these vitals and enter them into the EMR. Once the vitals were collected by the clinician and timing was recorded on the case sheet by the researcher, the clinical staff member either moved the patient to an appointment room or kept them in the same room where the vitals were recorded to see the physician. This is the same process currently used at the clinic. The case report form (CRF) was used to record the time to complete the process for each patient and included a patient number (1 through 200) and clinician number (1-3) for anonymous results. Vitals signs data collection was timed under two different scenarios: the first being the manual collection of vitals, and the second being the automated collection using the Welch Allyn CVSM. To ensure consistency in method, days at the clinic were randomly assigned for clinicians to use either the automated method or the manual data collection method. Data was collected from the first 100 patients for each data collection method who met the study inclusion criteria.

The manual method was conducted as follows: three recordings of blood pressure to remain consistent with the automated device, and one recording each of temperature, blood oxygen saturation and heart rate followed by manual entry of the vital signs by the clinician into the EMR. The second scenario was the automated collection of the vitals and automated entry by the CVSM into the EMR. The Blood Pressure Average Protocol used by the CVSM was configured to take 3 readings automatically with zero delay to start with an eighteen second delay in between each reading. The first reading was then eliminated and the second and third readings were averaged. It was the averaged reading that was sent to the EMR. This follows newly released guidelines by the Canadian Hypertension Society January 2015 (Daskalopoulou, Rabi, Zarnke K.B., et al., 2015). Manual vital sign collection was taken during multiple shifts with the clinician, on separate days from the automated collection of vitals.

Upon the completion of data collection, statistical analysis was conducted to analyze the temporal results between the 100 automated and the 100 manual data points of the study. These statistics included paired t-tests, analysis of variance tests, averages, minimum and maximum times, and standard deviations. A follow-up questionnaire with the three clinicians was also conducted upon the completion of the quantitative portion of the study. They were asked about each method, how comfortable they were with each process, what their impressions were of each process, and finally benefits, risks and improvements to the automated process. All questions were open-ended and are reported on using direct quotations.

Results and Discussion
Quantitative Study (Time Measurement)
The total time to complete the automated process for 100 patients was 188.6 minutes or an average of 1.89 minutes per patient. The total time to complete the manual process for 100 patients was 218.1 minutes or an average of 2.18 minutes per patient which is a total difference of 29.5 minutes. Extrapolating from this data, if an urgent care were to see 150 patients in a day, automating vital signs collection and documentation would save 43.5 minutes of staff time, or if 75 patients were seen this would save 21.8 minutes. These time savings could mean the ability to see more patients throughout the course of the day or allow for more time per patient enhancing patient care. Figure 1 displays the frequency of output based on time ranges seen throughout each 100 patient cohort.

The maximum recording time for the automated collection of the vital signs was 3 minutes and the manual maximum recording time was 4 minutes. Conversely, the minimum recording time for the automated collection was 1.5 minutes and the minimum for the manual collection was 1.7 minutes. Standard deviation was 0.32 minutes for both methods.

The automated method makes a difference when compared to the manual method, however the effect in decimal minutes is not large in absolute terms at the level of individual patients, equating to 0.3 minutes. The task in its entirety only takes around 2.2 minutes on average. A future test should be based on a task measurement sequence that, manually, takes a bit longer.

When times between groups were compared by Analysis of Variance, controlling for gender and clinician, gender was found to have no significant effect on the results (p-value = 0.444). Although the clinician might appear to have an effect (p-value = 0.00), specific clinicians remained anonymous; also, clinician identity did not impact the direction of the time differences based on automation versus manual recording. Clinician differences are potentially an aspect to consider in the future. A review of each clinician’s statistics can be seen in Tables 1-3.

auto-vitals-chart

Qualitative Study
Clinicians were asked for their impression of the manual documentation process. The responses included that the manual process is accurate-one can hear patient heartbeats while recording blood pressures; another stated that it is the standard practice and provides easy access the patient’s EMR without any issues; and finally another response stated that the manual process was time consuming and that one must be cognizant of transcription errors as sometimes other distractions may occur while recording patient vitals. A concern that the Welch Allyn device completely eliminates as the health care professional was expressed, because the professional need not be concerned with watching a device, writing down values and then entering them into the EMR.

Under manual data entry methods, there is a risk that clinicians may not enter all of the vital signs readings that they have measured into the patient’s EMR. By contrast, automated vital signs collection into the EMR automatically generates a historical record of the patient’s health which can be re-visited. With this data in place and available 100 percent of the time, of the time, trend analysis and other data mining approaches can be used to predict, monitor, and maintain the current health status of patients.

vitals-histogram

Overall the clinicians were very impressed with the automated system using the vital signs monitor as it made the process of triaging patients and getting them to see the doctor more rapid and efficient. All of the clinicians who were part of the study requested a monitor be put into place full-time in their respective locations with one clinician who was a novice user of the device stating “ I wish we could have the monitor here permanently.” .

Conclusion
In analyzing the results this study, efficiencies were found for using the automated Welch Allyn Connex® Vital Signs Monitor (CVSM) in contrast to conventional manual methods for recording three different vital signs and inputting these values into patients’ EMRs.

Positives to implementing the Welch Allyn CVSM permanently in urgent care and family practice environments within the Oshawa Clinic Organization include saving clinicians time as well as intangible, potential benefits of providing medical treatment in a more efficient manner, improving patient flow and ultimately access to quality care.

Acknowledgements
We would like to thank the Oshawa Clinic Group and Welch Allyn for their support of this research.

References
Daskalopoulou, S.S., Rabi D.M., Zarnke K.B., et al. (2015) The 2015 Canadian Hypertension Education Program Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention and Treatent of hypertension. Canadian Journal of Cardiology 31: 549-568.

Welch Allyn. (2011). Welch Allyn Connex ®Vital Signs sMonitor 6000 Series- Accurate Vitals to Your EMR from the Bedside. Retrieved from: http:// www.welchallyn.com/content/dam/ welchallyn/documents/sapdocuments/ LIT/80017/80017136LITPDF.pdf

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