What is the nursing time and workload involved in taking and recording patients' vital signs? A systematic review.

AIMS AND OBJECTIVES: To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores. BACKGROUND: While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown. DESIGN: Systematic review. METHODS: A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist. RESULTS: Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed. CONCLUSIONS: Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible. RELEVANCE TO CLINICAL PRACTICE: There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown.

Impact of using data from electronic protocols in nursing performance management: A qualitative interview study.

AIM: To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol. BACKGROUND: Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses' practice in hospital wards. METHOD: Seventeen acute hospital nursing staff participated in semi-structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device. RESULTS: Before electronic EWS data was used to monitor compliance, staff combined protocol-led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration. CONCLUSIONS: Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.

National Early Warning Score Accurately Discriminates the Risk of Serious Adverse Events in Patients With Liver Disease.

BACKGROUND & AIMS: The National Early Warning Score (NEWS) is used to identify deteriorating adult hospital inpatients. However, it includes physiological parameters frequently altered in patients with cirrhosis. We aimed to assess the performance of the NEWS in acute and chronic liver diseases. METHODS: We collected vital signs, recorded in real time, from completed consecutive admissions of patients 16 years or older to a large acute-care hospital in Southern England, from January 1, 2010, through October 31, 2014. Using International Classification of Diseases, 10th revision, codes, we categorized patients as having primary liver disease, secondary liver disease, or none. For patients with liver disease, 2 analysis groups were developed: the first was based on clinical group (such as acute or chronic, alcohol-induced, or associated with portal hypertension), and the second was based on a summary of liver-related, hospital-level mortality indicator diagnoses. For each, we compared the abilities of the NEWS and 34 other early warning scores to discriminate 24-hour mortality, cardiac arrest, or unanticipated admission to the intensive care unit using the area under the receiver operating characteristic (AUROC) curve and early warning score efficiency curve analyses. RESULTS: The NEWS identified patients with primary, nonprimary, and no diagnoses of liver disease with AUROC values of 0.873 (95% CI, 0.860-0.886), 0.898 (95% CI, 0.891-0.905), and 0.879 (95% CI, 0.877-0.881), respectively. High AUROC values were also obtained for all clinical subgroups; the NEWS identified patients with alcohol-related liver disease with an AUROC value of 0.927 (95% CI, 0.912-0.941). The NEWS identified patients with liver diseases with higher AUROC values than other early warning scoring systems. CONCLUSIONS: The NEWS accurately discriminates patients at risk of death, admission to the intensive care unit, or cardiac arrest within a 24-hour period for a range of liver-related diagnoses. Its widespread use provides a ready-made, easy-to-use option for identifying patients with liver disease who require early assessment and intervention, without the need to modify parameters, weightings, or escalation criteria.

A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection.

OBJECTIVES: The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection. DESIGN: Retrospective cohort study. SETTING: Large U.K. General Hospital. PATIENTS: Adults hospitalized between January 1, 2010, and February 1, 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825-0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680-0.695]; primary infection, National Early Warning Score 0.805 [0.799-0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670-0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without. CONCLUSIONS: The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be reevaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.

The association between nurse staffing and omissions in nursing care: A systematic review.

AIMS: To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing. BACKGROUND: Research has established associations between nurse staffing levels and adverse patient outcomes including in-hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy. DESIGN: Systematic review. DATA SOURCES: We searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles. REVIEW METHODS: Two reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative. RESULTS: Eighteen studies gave subjective reports of missed care. Seventy-five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care. CONCLUSIONS: Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

A fundamental conflict of care: Nurses' accounts of balancing patients' sleep with taking vital sign observations at night.

AIMS AND OBJECTIVES: To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night. BACKGROUND: Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why. DESIGN: A qualitative interpretative design informed this study. METHODS: Seventeen semi-structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used. RESULTS: At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night-time frequency of these observations was determined by clinical judgement, ward-level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under-monitored, while patients nearing the end of life could be over-monitored. CONCLUSION: In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long-term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions. RELEVANCE TO CLINICAL PRACTICE: Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under-monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.

What impact does nursing care left undone have on patient outcomes? Review of the literature.

AIMS AND OBJECTIVES: Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes. BACKGROUND: A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear. DESIGN: Systematic review. METHODS: We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses' aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review. RESULTS: Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged. CONCLUSIONS: The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self-reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required. RELEVANCE TO CLINICAL PRACTICE: Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses' reports of missed care and consider routine monitoring as a quality and safety indicator.

A Comparison of the Ability of the Physiologic Components of Medical Emergency Team Criteria and the U.K. National Early Warning Score to Discriminate Patients at Risk of a Range of Adverse Clinical Outcomes.

OBJECTIVE: To compare the ability of medical emergency team criteria and the National Early Warning Score to discriminate cardiac arrest, unanticipated ICU admission and death within 24 hours of a vital signs measurement, and to quantify the associated workload. DESIGN: Retrospective cohort study. SETTING: A large U.K. National Health Service District General Hospital. PATIENTS: Adults hospitalized from May 25, 2011, to December 31, 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We applied the National Early Warning Score and 44 sets of medical emergency team criteria to a database of 2,245,778 vital signs sets (103,998 admissions). The National Early Warning Score's performance was assessed using the area under the receiver-operating characteristic curve and compared with sensitivity/specificity for different medical emergency team criteria. Area under the receiver-operating characteristic curve (95% CI) for the National Early Warning Score for the combined outcome (i.e., death, cardiac arrest, or unanticipated ICU admission) was 0.88 (0.88-0.88). A National Early Warning Score value of 7 had sensitivity/specificity values of 44.5% and 97.4%, respectively. For the 44 sets of medical emergency team criteria studied, sensitivity ranged from 19.6% to 71.2% and specificity from 71.5% to 98.5%. For all outcomes, the position of the National Early Warning Score receiver-operating characteristic curve was above and to the left of all medical emergency team criteria points, indicating better discrimination. Similarly, the positions of all medical emergency team criteria points were above and to the left of the National Early Warning Score efficiency curve, indicating higher workloads (trigger rates). CONCLUSIONS: When medical emergency team systems are compared to a National Early Warning Score value of greater than or equal to 7, some medical emergency team systems have a higher sensitivity than National Early Warning Score values of greater than or equal to 7. However, all of these medical emergency team systems have a lower specificity and would generate greater workloads.

Early warning scores: unravelling detection and escalation.

PURPOSE: The purpose of this paper is to increase understanding of how patient deterioration is detected and how clinical care escalates when early warning score (EWS) systems are used. DESIGN/METHODOLOGY/APPROACH: The authors critically review a recent National Early Warning Score paper published in IJHCQA using personal experience and EWS-related publications, and debate the difference between detection and escalation. FINDINGS: Incorrect EWS choice or poorly understood EWS escalation may result in unnecessary workloads forward and responding staff. PRACTICAL IMPLICATIONS: EWS system implementers may need to revisit their guidance materials; medical and nurse educators may need to expand the curriculum to improve EWS system understanding and use. ORIGINALITY/VALUE: The paper raises the EWS debate and alerts EWS users that scrutiny is required.

Pain: a quality of care issue during patients' admission to hospital.

AIM: To determine the extent of clinically significant pain suffered by hospitalized patients during their stay and at discharge. BACKGROUND: The management of pain in hospitals continues to be problematic, despite long-standing awareness of the problem and improvements, e.g. acute pain teams and patient-controlled analgesia, epidural analgesia. Poorly managed pain, especially acute pain, often leads to adverse physical and psychological outcomes including persistent pain and disability. A systems approach may improve the management of pain in hospitals. DESIGN: A descriptive cross-sectional exploratory design. METHOD: A large electronic pain score database of vital signs and pain scores was interrogated between 1st January 2010 and 31st December 2010 to establish the proportion of hospital inpatient stays with clinically significant pain during the hospital stay and at discharge. FINDINGS: A total of 810,774 pain scores were analysed, representing 38,451 patient stays. Clinically significant pain was present in 38·4% of patient stays. Across surgical categories, 54·0% of emergency admissions experienced clinically significant pain, compared with 48·0% of elective admissions. Medical areas had a summary figure of 26·5%. For 30% patients, clinically significant pain was followed by a consecutive clinically significant pain score. Only 0·2% of pain assessments were made independently of vital signs. CONCLUSION: Reducing the risk of long-term persistent pain should be seen as integral to improving patient safety and can be achieved by harnessing organizational pain management processes with quality improvement initiatives. The assessment of pain alongside vital signs should be reviewed. Setting quality targets for pain are essential for improving the patient's experience.

Intention Recognition With ProbLog.

In many scenarios where robots or autonomous systems may be deployed, the capacity to infer and reason about the intentions of other agents can improve the performance or utility of the system. For example, a smart home or assisted living facility is better able to select assistive services to deploy if it understands the goals of the occupants in advance. In this article, we present a framework for reasoning about intentions using probabilistic logic programming. We employ ProbLog, a probabilistic extension to Prolog, to infer the most probable intention given observations of the actions of the agent and sensor readings of important aspects of the environment. We evaluated our model on a domain modeling a smart home. The model achieved 0.75 accuracy at full observability. The model was robust to reduced observability.

Impact of the COVID-19 pandemic on in-hospital cardiac arrests in the UK.

AIMS: To compare in-hospital cardiac arrest (IHCA) rates and patient outcomes during the first COVID-19 wave in the United Kingdom (UK) in 2020 with the same period in previous years. METHODS: A retrospective, multicentre cohort study of 154 UK hospitals that participate in the National Cardiac Arrest Audit and have intensive care units participating in the Case Mix Programme national audit of intensive care. Hospital burden of COVID-19 was defined by the number of patients with confirmed SARS-CoV2 infection admitted to critical care per 10,000 hospital admissions. RESULTS: 16,474 patients with IHCA where a resuscitation team attended were included. Patients admitted to hospital during 2020 were younger, more often male, and of non-white ethnicity compared with 2016-2019. A decreasing trend in IHCA rates between 2016 and 2019 was reversed in 2020. Hospitals with higher burden of COVID-19 had the greatest difference in IHCA rates (21.8 per 10,000 admissions in April 2020 vs 14.9 per 10,000 in April 2019). The proportions of patients achieving ROSC ≥ 20 min and surviving to hospital discharge were lower in 2020 compared with 2016-19 (46.2% vs 51.2%; and 21.9% vs 22.9%, respectively). Among patients with IHCA, higher hospital burden of COVID-19 was associated with reduced survival to hospital discharge (OR = 0.95; 95% CI 0.93 to 0.98; p < 0.001). CONCLUSIONS: In comparison with 2016-2019, the first COVID-19 wave in 2020 was associated with a higher rate of IHCA and decreased survival among patients attended by resuscitation teams. These changes were greatest in hospitals with the highest COVID-19 burden.

Impact of the coronavirus pandemic on the patterns of vital signs recording and staff compliance with expected monitoring schedules on general wards.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) placed increased burdens on National Health Service hospitals and necessitated significant adjustments to their structures and processes. This research investigated if and how these changes affected the patterns of vital sign recording and staff compliance with expected monitoring schedules on general wards. METHODS: We compared the pattern of vital signs and early warning score (EWS) data collected from admissions to a single hospital during the initial phase of the COVID-19 pandemic with those in three control periods from 2018, 2019 and 2020. Main outcome measures were weekly and monthly hospital admissions; daily and hourly patterns of recorded vital signs and EWS values; time to next observation and; proportions of 'on time', 'late' and 'missed' vital signs observations sets. RESULTS: There were large falls in admissions at the beginning of the COVID-19 era. Admissions were older, more unwell on admission and throughout their stay, more often required supplementary oxygen, spent longer in hospital and had a higher in-hospital mortality compared to one or more of the control periods. More daily observation sets were performed during the COVID-19 era than in the control periods. However, there was no clear evidence that COVID-19 affected the pattern of vital signs collection across the 24-h period or the week. CONCLUSIONS: The increased burdens of the COVID-19 pandemic, and the alterations in healthcare structures and processes necessary to respond to it, did not adversely affect the hospitals' ability to monitor patients under its care and to comply with expected monitoring schedules.

The performance of the National Early Warning Score and National Early Warning Score 2 in hospitalised patients infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

INTRODUCTION: Since the introduction of the UK's National Early Warning Score (NEWS) and its modification, NEWS2, coronavirus disease 2019 (COVID-19), has caused a worldwide pandemic. NEWS and NEWS2 have good predictive abilities in patients with other infections and sepsis, however there is little evidence of their performance in COVID-19. METHODS: Using receiver-operating characteristics analyses, we used the area under the receiver operating characteristic (AUROC) curve to evaluate the performance of NEWS or NEWS2 to discriminate the combined outcome of either death or intensive care unit (ICU) admission within 24 h of a vital sign set in five cohorts (COVID-19 POSITIVE, n = 405; COVID-19 NOT DETECTED, n = 1716; COVID-19 NOT TESTED, n = 2686; CONTROL 2018, n = 6273; CONTROL 2019, n = 6523). RESULTS: The AUROC values for NEWS or NEWS2 for the combined outcome were: COVID-19 POSITIVE, 0.882 (0.868-0.895); COVID-19 NOT DETECTED, 0.875 (0.861-0.89); COVID-19 NOT TESTED, 0.876 (0.85-0.902); CONTROL 2018, 0.894 (0.884-0.904); CONTROL 2019, 0.842 (0.829-0.855). CONCLUSIONS: The finding that NEWS or NEWS2 performance was good and similar in all five cohorts (range = 0.842-0.894) suggests that amendments to NEWS or NEWS2, such as the addition of new covariates or the need to change the weighting of existing parameters, are unnecessary when evaluating patients with COVID-19. Our results support the national and international recommendations for the use of NEWS or NEWS2 for the assessment of acute-illness severity in patients with COVID-19.

Escalation triggers and expected responses in obstetric early warning systems used in UK consultant-led maternity units.

BACKGROUND: The use of obstetric early warning systems (OEWS) are recommended as an adjunct to reduce maternal morbidity and mortality. The aim of this review was to document the variation in OEWS trigger thresholds and the quality of information included within accompanying escalation protocols. METHODS: A review of OEWS charts and escalation policies across consultant-led maternity units in the UK (n = 147) was conducted. OEWS charts were analysed for variation in the values of physiological parameters triggering different levels of clinical escalation. Relevant data within the escalation protocols were also searched for: urgency of clinical response; seniority of responder; frequency of on-going clinical monitoring; and clinical setting recommended for on-going care. RESULTS: The values of physiological parameters triggering specific clinical responses varied significantly between OEWS. Only 99 OEWS charts (67.3%) had an escalation protocol as part of the chart. For 29 charts (19.7%), the only escalation information included was generic, for example to "contact a doctor if triggers". Only 76 (51.7%) charts detailed the required seniority of responder, 37 (25.2%) the frequency for on-going clinical monitoring, eight (5.4%) the urgency of clinical response and two (1.4%) the recommended clinical setting for on-going care. CONCLUSION: The observed variations in the trigger thresholds used in OEWS charts and the quality of information included within the accompanying escalation protocols is likely to lead to suboptimal detection and response to clinical deterioration during pregnancy and the post-partum period. The development of a national OEWS and escalation protocol would help to standardise care across obstetric units.

Health technology assessment review: remote monitoring of vital signs--current status and future challenges.

Recent developments in communications technologies and associated computing and digital electronics now permit patient data, including routine vital signs, to be surveyed at a distance. Remote monitoring, or telemonitoring, can be regarded as a subdivision of telemedicine - the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants. Depending on environment and purpose, the patient and the carer/system surveying, analysing or interpreting the data could be separated by as little as a few feet or be on different continents. Most telemonitoring systems will incorporate five components: data acquisition using an appropriate sensor; transmission of data from patient to clinician; integration of data with other data describing the state of the patient; synthesis of an appropriate action, or response or escalation in the care of the patient, and associated decision support; and storage of data. Telemonitoring is currently being used in community-based healthcare, at the scene of medical emergencies, by ambulance services and in hospitals. Current challenges in telemonitoring include: the lack of a full range of appropriate sensors, the bulk weight and size of the whole system or its components, battery life, available bandwidth, network coverage, and the costs of data transmission via public networks. Telemonitoring also has the ability to produce a mass of data - but this requires interpretation to be of clinical use and much necessary research work remains to be done.

Midwives' views towards women using mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature.

INTRODUCTION: There are many mobile telephone apps to help women self-monitor aspects of pregnancy and maternal health. This literature review aims to understand midwives' perspectives on women self-monitoring their pregnancy using eHealth and mHealth, and establish gaps in research. METHODS: MEDLINE, PubMed, Scopus, CINAHL and PsycINFO were systematically searched on midwifery, eHealth/mHealth and perspectives. Qualitative, quantitative and mixed-methods studies published in English were considered for inclusion in the review, without geographical limitations. Relevant articles were critically appraised and narrative synthesis was conducted. RESULTS: Twelve relevant papers covering midwives' perspectives of the use of eHealth and mHealth by pregnant women were obtained for inclusion in this review. Seven of these publications focused on midwives' views of eHealth, and five on their perspectives of mHealth interventions. The studies included demonstrate that midwives generally hold ambivalent views towards the use of eHealth and mHealth technologies in antenatal care. Often, midwives acknowledged the potential benefits of such technologies, such as their ability to modernise antenatal care and to help women make more informed decisions about their pregnancy. However, midwives were quick to point out the risks and limitations of these, such as the accuracy of conveyed information, and negative impacts on the patient-professional relationship. CONCLUSIONS: Post-COVID-19, where technology is continuously developing, there is a compelling need for studies that investigate the role of eHealth and mHealth in self-monitoring pregnancy, and the consequences this has for pregnant women, health professionals and organisations, as well as midwifery curricula.

The association between nurse staffing levels and a failure to respond to patients with deranged physiology: A retrospective observational study in the UK.

BACKGROUND: Responding to abnormalities in patients' vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study aimed to determine the association between Registered Nurse (RN) and Nursing Assistant (NA) staffing levels and the failure to respond promptly to patients' abnormal physiology. METHODS: This retrospective, observational study used routinely collected patients' vital signs and administrative data, including nursing staffing, from 32 general wards of an acute hospital in England between April 2012 and March 2015. Mixed-effects binomial regression was used to model the relationship between nurse staffing, measured as 'Hours per Patient Day' (HPPD), and a composite primary outcome representing failure to respond for patients with National Early Warning Score (NEWS) values ≥ 6 and ≥ 7. RESULTS: There were 189,123 NEWS values ≥ 6 and 114,504 NEWS values ≥ 7, affecting 28,098 patients. For patients with NEWS values ≥ 7, failure to respond was significantly associated with levels of RN HPPD ((IRR 0.98, 95% CI 0.96-0.99, p = 0.0001) but not NA HPPD (((IRR 0.99, 95%CI 0.96-1.01, p = 0.238). For patients with NEWS values ≥ 6, no such relationship existed. CONCLUSIONS: RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.

The impact of the Tracey judgment on the rates and outcomes of in-hospital cardiac arrests in UK hospitals participating in the National Cardiac Arrest Audit.

AIMS: The aim was to determine if the 17 June 2014 Tracey judgment regarding 'do not attempt cardiopulmonary resuscitation' decisions led to increases in the rate of in-hospital cardiac arrests resulting in a resuscitation attempt (IHCA) and/or proportion of resuscitation attempts deemed futile. METHOD: Using UK National Cardiac Arrest Audit data, the IHCA rate and proportion of resuscitation attempts deemed futile were compared for two periods (pre-judgment (01 July 2012 - 16 June 2014, inclusive) and post-judgment (01 July 2014 - 30 June 2016, inclusive)) using interrupted time series analyses. RESULTS: A total of 43,109 IHCAs (115 hospitals) were analysed. There were fewer IHCAs post- than pre-judgment (21,324 vs 21,785, respectively). The IHCA rate was declining over time before the judgment but there was an abrupt and statistically significant increase in the period immediately following the judgment (p<0.001). This was not sustained post-judgment. The proportion of resuscitation attempts deemed futile was smaller post-judgment than pre-judgment (8.2% vs 14.9%, respectively). The rate of attempts deemed futile decreased post-judgment (p<0.001). CONCLUSION: The IHCA rate increased immediately after the Tracey judgment while the proportion of resuscitation attempts deemed futile decreased. The precise mechanisms for these changes are unclear.