Author: Ayesha Babar Kanani Carine
Module Leader: Anita Mirijamdotter First Supervisor: Mexhid Ferati
Second Supervisor: Christina Mörtberg Examiner: Päivi Jokela
Semester: Spring 2020
Course name: Degree Project in Informatics Course code: 5IK50E, 30 Credits
Subject: Information Systems Level: Graduate
Date: 26.05.2020.
Department of Informatics
Master Thesis
Monitoring of Vital Signs Parameters
with ICTs - A Participatory Design
A
BSTRACT
The development of internet-based technologies, the design and adoption of wireless wearable and smart devices have been a growing study spot in all domains. The healthcare sector as many others is making technological progress to improve healthcare services and patients wellbeing and avoid or minimize the use of manual and traditional practices such as the use of paper notes to record the vital signs parameters data. The vital signs parameters are the most monitored physiology features, they produce a big amount of data and request a close follow up to define the health condition of a patient. Continuous vital signs monitoring involves the usage of different devices and systems, which if appropriate positively impact the activities involved, by enabling the continuous generation of data and information about the overall health status of patients and contribute to the wellbeing of individuals, in terms of preventing and reducing fatal risks. To investigate this situation, this research’s focus was in three parts; first, investigate recent research about patient’s health predictions based on vital signs parameters and the impacts of continuous monitoring on the care given. Second, explore the availability in terms of i.e. sensors used in devices that can continuously track vital signs parameters. Last, to provide a possible design recommendation to improve and/or replace the existing devices for vital signs parameters measuring and monitoring in emergency and post-operative care. A qualitative approach and participatory design approach were used to collect data. The qualitative part was achieved through interviews and the participatory design part was accomplished by the future workshop and two prototyping techniques, paper and digital prototypes. The findings of this research were analysed using conceptual analysis, and also discussed using those concepts. Together with the participants, this research resulted in three design suggestions which if implemented shall improve the vital signs continuous monitoring activities, by facilitating the healthcare professionals in their clinical responsibilities and improving the patients wellbeing while admitted in Emergency and Post-operative wards.
Keywords: healthcare, participatory design, eHealth, vital signs monitoring, continuous vital signs monitoring, smart health monitoring
A
CKNOWLEDGEMENTS
Writing this thesis has been a knowledgeable journey with twists and turns of challenges and satisfactions but it would not have been possible without the support of the persons mentioned below. First, we would like to express our gratitude to Linnaeus University and the Swedish Institute Scholarships for Studies and Research (SISSR) for the scholarships offered to us to pursue our studies in Sweden.
We want to thank our first supervisor Mexhid Ferati for his constructive and valuable advices, supporting our ideas and also instructing and encouraging us during the whole journey of this thesis. We especially express our gratitude to our second supervisor Professor Christina Mörtberg for introducing us to the company which supported us to conduct this research. We thank her for being our guide, so supportive, motivating, believing in our ideas, and instructing us during the whole research.
Without the support of both supervisors, this study would have been impossible to complete.
Our warmest gratitude to both Professor Anita Mirijamdotter the module leader and Päivi Jokela our examiner; for always guiding and clearing our doubts in writing the research proposal and during all the seminars.
We are thankful to the Director of Vinita AB, for giving us the opportunity and resources to conduct this research. Also believing in us and bearing patience in completing this research.
Our heartfelt thanks to all the participants who believed in our research and contributed to this study despite workloads and time limit they had as healthcare professionals. Special thanks to one of the participants, who arranged all the meetings, convinced her fellow colleagues to contribute to our study and providing us with all necessary information.
We also want to thank all our fellow students and friends during this two years study journey. Finally, our deepest love and gratitude goes to our families for the endless patience, continuous encouragement, and unfailing support during this long path. We know there were a lot of times you all needed us and we were not there. We owe you much respect.
T
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C
ONTENTS
1.
Introduction ... 1
1.1 Research Problem ... 2
1.2 Purpose and Research Questions ... 3
1.3 Topic Justification ... 4
1.4 Scope and Limitations ... 5
1.5 Responsibility of the Work ... 6
1.6 Structure of Thesis ... 6
2.
Healthcare And Vital Signs Monitoring - Literature Review ... 8
2.1 ICT and Healthcare in Sweden ... 8
2.2 ICTs in Healthcare ... 9
2.3 Vital Signs Parameters ... 11
2.4 Vital Signs Monitoring ... 11
2.4.1 Types of Vital Signs Monitoring Systems ... 12
2.4.1.1 Remote Vital Signs Monitoring... 13
2.4.1.2 Mobile Based Vital Signs Monitoring ... 14
2.4.1.3 Wearable Vital Signs Monitoring ... 14
2.4.2 Vital Signs Monitoring Systems in Emergency and Post-operative Wards ... 15
2.5 Sensors for Vital Signs Parameters... 17
2.6 Challenges of Current Vital Signs Monitoring Systems ... 18
2.7 Summary ... 18
3.
ICT Design Process and Design Approach ... 20
3.1 Design Process ... 20
3.2 Challenges when Designing with Healthcare Professionals ... 22
3.3 Participatory Design ... 22
3.3.1 Guiding Principles of Participatory Design ... 23
3.4 Summary ... 25
4.
Research Setting, Methodology and Methods ... 26
4.1 Research Setting ... 26
4.2 Research Paradigm ... 26
4.3 Why PD in this Research? ... 27
4.4 Methods ... 28
4.4.1 Participants ... 28
4.4.2 Data Collection Methods ... 29
4.4.2.1 Interviews ... 29
4.4.2.2 Future Workshop ... 30
4.5 Data Analysis ... 34
4.6 Trustworthiness ... 36
4.7 Ethical Considerations ... 37
4.8 Summary ... 38
5.
Empirical Findings ... 40
5.1 Findings with Respect to Concepts ... 40
5.1.1 Concept 1: Using Pen, Paper and Devices to Measure, Collect and Store Vital Signs Parameters ... 40
5.1.2 Concept 2: Triage and NEWS Scoring Systems Practices for Identifying Deteriorating Patients ... 43
5.1.3 Concept 3: Patient Care When Measuring and Monitoring Vital Sign Parameters 44 5.1.4 Concept 4: Impacts of Continuous Monitoring Systems and Practices ... 45
5.1.5 Concept 5: Co-Design with Healthcare Professionals ... 45
5.1.6 Concept 6: Desired Improvements and Suggestions in Vital Signs Monitoring Practices ... 46
5.2 Findings of the Prototype Workshop ... 48
5.2.1 Paper Prototype ... 49
5.2.1.1 Device 1: Smart Wearable Measuring Band ... 49
5.2.1.2 Device 2: Smart Monitoring Phone for Healthcare Professionals... 50
5.2.1.3 Device 3: Bedside Monitoring Screen ... 52
5.2.2 Digital Prototype ... 54
5.2.2.1 Device 1: Smart Wearable Measuring Band ... 54
5.2.2.2 Device 2: Smart Monitoring Phone for Healthcare Professionals... 55
5.2.2.3 Device 3: Bedside Monitoring Screen ... 57
5.3 Summary ... 59
6.
Discussion ... 61
6.1 Discussion of Concepts in Relation to Research Questions ... 61
6.1.1 Vital Signs Parameters Measuring and Monitoring Practices ... 61
6.1.1.1 Using Pen, Paper and Devices to Measure, Collect and Store Vital Signs Parameters ... 62
6.1.1.2 Triage and NEWS Scoring Systems Practices for Identifying Deteriorating Patients 63 6.1.1.3 Patient Care When Measuring and Monitoring Vital Sign Parameters .. 64
6.1.1.4 Impacts of Continuous Monitoring Systems and Practices ... 65
6.2 Healthcare Professionals’ Ideas and Needs to Improve Vital Signs Parameters Monitoring Systems ... 65
6.2.1 Co-Designing with Healthcare professionals ... 65
6.2.2 Desired Improvements and Suggestions in Vital Signs Monitoring Practices ... 66
6.3 Reflections on Design Process... 67
6.4 Reflection on the Design Analysis of the Prototyping Devices ... 68
6.5 Reflection on the Methods ... 70
6.6 Summary ... 72
7.
Conclusion and Future Research ... 74
7.1 Research Contributions ... 75
8.
References ... 79
9.
Appendices ... 90
9.1 Appendix A – National Early Warning Score ... 90
9.2 Appendix B – Six Vital Signs Parameters Used In NEWS ... 93
9.3 Appendix C – Vital Signs Monitoring Devices ... 95
9.4 Appendix D – Sensors ... 96
9.5 Appendix E – Consent Form ... 97
9.6 Appendix F – Interview Guide for Nurses ... 100
9.7 Appendix G – Interview Guide for Doctors ... 101
9.8 Appendix H – Example of Coding ... 102
T
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F
IGURES
Figure 1: Vital signs monitoring system relationship diagram ... 12
Figure 2: Patient Health Monitoring Systems Classification ... 13
Figure 3: Levels of Design Process ... 20
Figure 4: Three circles of involvement ... 21
Figure 5: Future workshop post-it sticky notes. ... 31
Figure 6: Three Cs Analysis used in this research: Codes, Categories, and Concepts ... 35
Figure 7: Concepts, Categories, Codes and Methods used in data analysis ... 41
Figure 8: Smart Wearable Measuring Band ... 49
Figure 9: Smart Monitoring Phone for Healthcare Professionals ... 51
Figure 10: Bedside Monitoring Screen ... 52
Figure 11: Device 1 - Smart Wearable Measuring Band ... 54
Figure 12: Device 2 - Smart Monitoring Phone ... 56
Figure 13: Device 3 - Bedside Monitoring Screen ... 57
Figure 14: Smart Continuous Measuring and Monitoring System ... 58
T
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T
ABLES
Table 1: List of Participants ... 28Table 2: Time taken by each phase ... 30
Table 3: List of identified problems and solutions proposed by participants during the Future Workshop ... 32
L
IST OF
A
BBREVIATIONS
ACVPU Alertness, Confusion, Voice, Pain, Unresponsive
BP Blood Pressure
BSN Body Sensor Network CEO Chief Executive Officer CT Computerized Tomography ECG Electrocardiography
EDA Electrodermal Activity EHR Electronic Health Record EMG Electromyogram
EMR Electronic Medical Record EPR Electronic Patient Record GPRS General Packet Radio Service GSM Global System for Mobile GUI Graphical User Interface HR Heart Rate
HRV Heart Rate Variability
ICT Information Communication Technology ICU Intensive Care Unit
ID Identification
IS Information Systems
IT Information Technology LCD Liquid Crystal Display
MEMS Micro Electro Mechanical Systems MEWS Modified Early Warning Scores MHMS Mobile Health Monitoring Systems NEWS National Early Warning Score NFC Near-Field Communication PD Participatory Design PDA Personal Digital Assistant
PHMS Patient Health Monitoring Systems PHR Personal Health Record
PMS Patient Monitoring System
PPG Photoplethysmogram
PR Pulse Rate
RFID Radio Frequency Identification RHMS Remote Health Monitoring System RR Respiratory Rate
SEND System Electronic Notification and Documentation SHMS Smart Health Monitoring Systems
SKR Sverige Kommuner och Regioner SMS Short Media Service
SpO2 Oxygen Saturation
WBSN Wireless Body Sensor Networks WHMS Wearable Health Monitoring System WiFi Wireless Fidelity
1. I
NTRODUCTION
Information and communication technologies (ICTs) are becoming pervasive and ubiquitous and used in all domains, both in personal activities as well as working lives (Walsham, 2012). ICTs and all technology are for and designed by humans, therefore, should facilitate and improve the quality of life and wellbeing that will have high possibilities of leading towards a good society for all (Bradley, 2017). Thus, the health sector is no exception and healthcare systems should also be useful to facilitate people’s daily work, life and wellbeing contributing to a good ICT society.
According to Walsham (2012, p.89):
“Medics want to help people live longer and healthier lives, engineers want to build
more effective technological systems to improve efficiency…
IS scholars and practitioners should be concerned with how to use ICTs to help make a better world, where everybody has the opportunity and capability to use technologies to make better lives for themselves, their communities and the world in general”.
Hence, digital transformations depending on the design and use of ICTs have brought new prospects and opportunities for the healthcare sector, making it more useful and sustainable. For instance, ICT innovative services and systems integrated with health and care services help to improve the quality of life of chronic patients which in return reduces admissions and visits to the hospitals (Guagliardo, 2018).
Healthcare is one of the important sectors of any country according to The Swedish Vision for eHealth 2025 (Regeringskansliet, 2016). In addition the Sweden’s work on global health – implementing the 2030 Agenda emphasizes to promote long and healthy lives to align with the Global Health Sustainable Development objective to create viable healthcare systems toward equal access to appropriate health services (Regeringskansliet, 2018). In fact, the European Union has identified the development of eHealth as one of the strongest areas of growth in Europe. The European countries including Sweden are also facing challenges in eHealth, ICT systems and services of healthcare (Regeringskansliet, 2016), the healthcare sector is striving to overcome the challenges in result from the growth of chronic diseases, increase in ageing population and rise of technological possibilities. The significant technological change in daily lives and healthcare activities by the usage of ICTs combined with healthcare technologies serves healthcare researchers in different ways. For instance, support to improve the patient health monitoring systems in hospitals, homes, social care centres and outdoors (Cook, 2012), by using customized measuring and monitoring systems according to the individual’s needs.
Healthcare professionals are able to track, collect and monitor patients’ vital signs parameters and health conditions in general by using different medical devices, sensors, wearable devices and receive alerts or messages about the health information on their PDAs, smartphones, tablets, laptops and personal computer. These ICTs not only support in real-time monitoring of data, but also transfer the data to the processing and analysis at remote servers for storing and generating alarms or alerts activations for other devices (Klingeberg and Schilling, 2012). Also, the progress of ICTs in healthcare has enabled healthcare providers to face complex medical challenges, reduce inaccuracies and decrease the cost of medical needs (Cook, 2012), through the use of electronic reminders, SMS
Vigoda, 2012). Wireless and/or wearable monitoring systems and devices using body sensors are the main focus of current healthcare research. They play an important role in Patient Health Monitoring Systems (PHMS) by contributing in prediction, anticipation, early detection, decision making and support delivery (Lin, 2012).
Another area of innovation in healthcare is the monitoring system in hospitals, especially the monitoring of vital signs parameters such as respiratory rate, oxygen saturation, body temperature, systolic blood pressure, pulse rate, and level of consciousness. They are the most critical part of a good clinical assessment. Advancements in ICTs such as electronic materials, smart devices and wireless and cloud systems have empowered the wearable technologies in providing a significant impact on the future of the digital and personalized healthcare. Thus, using these ICTs opens up huge opportunities for monitoring devices that can continuously measure vital signs parameters and assist healthcare professionals in their daily activities. This results in reducing the degradation risks of patients’ lives and also providing data for future analysis and diagnosis of a disease or complication in advance (Weenk, et al., 2019).
1.1 Research Problem
A normal day at post-operative care ward in any hospital starts with nurses attending all patients and monitoring the vital signs parameters. There is a standard model to look after patient’s general condition to avoid rapid degradation causing the need for intensive care, or risk of cardiac arrest, or in the worst case, death. The common way to assess the results of the vital signs parameters measurements in all hospitals around the globe and also in Sweden, is to use the National Early Warning Score (NEWS) initially developed in Great Britain by the Royal College of Physicians (Royal College of Physicians, 2017).
The vital signs parameters measured in NEWS are respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate, and level of consciousness. The vital signs parameters are often measured by hand or using multiple wired medical devices attached to patients, noted on a piece of paper and then transferred to the electronic health records (EHRs) system on a computer (Anzanpour, et al., 2015). Depending on the NEWS score, vital signs parameters need to be measured either every 12/24 hours, every 4-6 hours, every hour or continuously depending on why the patient has been taken in for care due to his/her clinical condition.
The hospital medical wards are using NEWS to avoid higher mortality rates and re-admittance to Intensive Care Unit (ICU) due to critical patient’s health deterioration that is missed by healthcare professionals (Cardona-Morrell, et al., 2016; Osborne, et al., 2015). But still, patients may experience condition degradation between monitoring intervals. In some cases, the vital signs observation process and scoring system are susceptible of missing or false values, or delaying of data collection during busy times when the availability of staff is lower, like on weekends or evenings (Buist and Stevens, 2013; Hands, et al., 2013). The NEWS observation chart is highly dependent on the perception of healthcare professionals, since it is filled by hand that is prone to human errors and mistakes. For example, sometimes nurses forget to transfer the notes to EHR, they write a wrong score or result, they have many patients to asses, etc. And in other cases, data may be incorrectly measured, which can lead to false alarms, to false treatments and increase unnecessary workload (Blankush et al., 2017).
Recent research and development in telecommunications, microelectronics, sensor manufacturing and data analysis techniques have opened up new possibilities of using wearable technologies to monitor almost all the vital signs parameters (Sungmee and Jayaraman, 2010). These prospects are
affecting the entire healthcare work practice by the usage of new ICT services and systems in both positive and negative ways. For instance, their high cost, the increase and decrease of workload and the adaptability/knowledge of healthcare professionals to use them. The adaptability depends on which types of devices and systems are being used.
If NEWS can be implemented as a continuous smart patient health monitoring system, it would reduce the workload on the hospital staff in the emergency and post-operative wards, increase the sensitivity of alarm system, which in return will benefit the patients, healthcare professionals and the entire healthcare system (Spångfors, Molt and Samuelson, 2019; Vincent et al., 2018).
1.2 Purpose and Research Questions
The previous research has identified the need for improvement in healthcare systems especially for measuring and monitoring vital signs parameters. It is significant in order to provide patients with the best care in emergency and post-operative care. The main research questions (RQ) to be addressed in this research are:
RQ1: What are the main concerns or issues that healthcare professionals face when measuring or monitoring the patient’s vital signs parameters?
RQ2: What kind of ideas, demands, needs and functional requirements do healthcare professionals express for future improvements in the healthcare system related to vital signs parameters monitoring?
The project intends to better understand the daily work of healthcare professionals at post-operative and emergency wards and how they interact with different ICT devices for measuring and monitoring patients’ vital signs parameters.
This research will identify the demands, desires and problems of the users (healthcare professionals) and then propose a design suggestion of vital signs parameters measuring and monitoring systems and services with the help of participatory design involving healthcare professionals as co-designers. The aim is to design with and for healthcare professionals in order to give healthcare professionals the possibility to express their expectations and ideas for possible design suggestion for vital signs measuring and monitoring systems. This approach could also help them to adapt to the new systems and services easily as they will have already contributed to what they want in the design which will make it easier for them to learn and work with.
This research will result in a design suggestion of measuring and monitoring device/artefact that in the future could help healthcare professionals in their daily job of vital signs parameters. The device/system usage will facilitate in improving the daily care given, reducing human errors, and help in remotely interacting with the healthcare systems and visual presentation of the health data. Also, alarm system support could assist in avoiding and preventing serious conditions of patients in emergency and post-operative care. The result in return will be beneficial for the hospitals, healthcare professionals and healthcare system.
Bradley (2017) states that the aim of the design of new ICTs should be toward shaping, enhancing and redesigning a good ICT society for all. This research also aims to contribute for the vision of a good ICT society, in which designing ICT with and for healthcare professionals will enhance the use and adoption of the systems.
proposed research project was broad with a number of parts and phases, however, this research will cover the following parts: firstly, it will reflect on the latest researches about the measuring and monitoring vital signs parameters. What predictions of patients’ future health can be done and how would continuous monitoring affect care given in i.e. emergency care and post-operative care? Secondly, explore the recently developed and available sensors and devices that can continuously monitor vital signs parameters. And thirdly, together with involvement of the healthcare professionals, recommendation will be suggested concerning the development of the design suggestion of smart measuring and monitoring devices incorporating the feedback of users received through participatory design methods.
Hence, this research will bring forward comprehension of the work practices and how digital services and systems may or may not facilitate health care professionals’ daily work and the needs, ideas and new systems and services for patient’s vital signs parameters measuring and monitoring in emergency and post-operative care. The research results will be adding on to the existing research in this context and used to support in improving the design of the existing and new measuring and monitoring systems and devices for the health and social care work.
1.3 Topic Justification
The research is built on previous works and how inconsistencies in data collection of vital signs in emergency and post-operative care risk to lead to degradation or different problems regarding health conditions. As stated by Kroll, et al (2017), post-operative recovery studies are not providing enough data concerning the post-operative stay, because the data collection is restricted to irregular measurements or inexistent visits. Thus, the collection of data needs continuous new strategies to better describe the post-operative status in both patient’s homes and wards conditions (Kroll, et al., 2017). In the post-operative ward, the frequency and correctness of vital signs parameters measurements can be inadequate to indicate degradation of patient’s condition, especially at night and on a busy day (Helfand, Christensen and Anderson, 2016).
According to Kroll, et al. (2017), future research should focus on improving, monitoring and assessing patients in post-operative wards, integrating the data collected by wearable devices in studies related to post-operative recovery and determining the effect of using and adapting smart devices into the healthcare system.
Darbyshire (2004) claims that previous researches have shown that healthcare professionals are dissatisfied due to ineffective and inefficiency of existing systems in terms of design and adaptability towards the technological changes. However, patient’s safety is much related to the recording quality of their data; thus, it is highly recommended to have accurate and relevant information stored in appropriate technology systems (Lising and Kennedy 2005).
Researchers of the University of Oxford’s Institute of Biomedical Engineering and clinical staff at the Oxford University Hospital Trust, developed an iPad-based early warning system named System Electronic Notification and Documentation (SEND). This system consists of an automatic score calculation that indicates the patient’s health condition from the vital signs provided information in order to point out if nurses need to medically intervene. Its major role is to help nurses to provide the needed care in an efficient and effective manner (Wong, et al., 2015).
SensiumVitals is another warning system used in hospitals. It is a peel-and-stick wireless system now available through Sensium Healthcare's own salesforce in the UK, France and Germany, and via distributors in North America, Scandinavia, Portugal, the Middle East, Australia and New Zealand. It is a non-reusable wearable patch that continuously (every 2 minutes) monitors patient’s vital signs
(heart rate, respiration rate and temperature) and transfers the information via the hospital IT system (Hernandez-Silveira et al., 2015). It enables early intervention and alerts the caregiver when needed/pre-set thresholds are exceeded. The application of the patch is said to be painful as it is supposed to stick to the patient’s chest and may require the preparation of the skin area, i.e. shaving. And in some cases, the patch fails to send the signals. (Hernandez-Silveira, et al., 2015). Likewise, Modified Early Warning Scores (MEWS) provides real-time vital signs (oxygen saturation, heart rate, respiratory rate, systolic blood pressure, and temperature) status and reduces Intensive Care Unit (ICU) admissions in post-operative patients and helps predict a critical disorder. However, some of the failures may occur when physiological data is not measured correctly which leads to false alerts and increased workload (Blankush, et al., 2017).
The implementation of ICTs in healthcare sectors enables the growth of availability, accessibility and adoption of smart devices, systems, services and applications. However, a good number of research studies focus on the availability of those technologies and few of them address the problems related to their reliability, efficiency, functionality and how they facilitate healthcare professionals in their daily work practices. Firouzi, et al. (2018) claim that there is a lot to do in the technological healthcare sector in order to solve these issues, which requires close collaboration between designers, developers, and healthcare professionals.
Another previous research, conducted a comparative study about technological healthcare systems between a junior and a senior position perspective and claimed that they basically lack understanding of healthcare abilities from the junior to senior position perspective. They also say that the existing manual and electronic systems have gaps in meeting nurses’ expectations in terms of technical and medical requirements that could enhance their daily activities (Mackintosh, Rainey and Sandall, 2012). Previous research also highlights the importance of involving healthcare professionals as the future users of the systems in order to clearly understand how those systems shall impact their daily activities and identify what could have been considered to get better outcomes. Hence in this research, the aim is to learn from these research experiences, identify healthcare professionals’ main concerns and include the health professionals’ knowledge while designing the proposed device. The involvement of future users is a major aspect of the design process.
1.4 Scope and Limitations
This research will only be performed in two hospitals in South Sweden. This is an initial research in which first ideas and needs from the healthcare professionals are gathered and then a design suggestion is recommended. This research will only focus on the design suggestions of the systems or services built on the personnel in emergency and post-operative care needs and wishes from the healthcare monitoring systems. This research will not include a closer look into the technical specifications and integration and implementation of the system or service suggested. The initial phase of this research considered only the healthcare professionals as participants and the second phase in future will include patients. Also the research participants were limited to healthcare professionals as they are the main users of ICT systems used in emergency and post-operative wards and inclusion of patients are the secondary users.
One hindrance for this research is the language. We do not speak the native Swedish language and most people better express their ideas and feelings in their first language. Hence, in this case, it might sometimes be difficult for healthcare professionals to express their feelings in English. Also, ethical implications (see section 4.7) will be considered while working with healthcare professionals.
1.5 Responsibility of the Work
In this study the decision to work collaboratively as pair was firstly derived from the company’s interest. As the requirement of this research work was two students. And secondly, both of us had common interest to work on healthcare sector and participatory design subject.
The division of the work started during writing the proposal and then carried on till the end of thesis. During this study, firstly while writing and reviewing the literature, the researchers decided on topics and started to research and write down what was important from the papers. The finalization of literature review chapter was done mutually, while sitting together. Secondly, the work was divided again while writing the research methodology chapter and transcribing the recorded interviews. Both researchers transcribed half of the recordings and then the verbatim transcribed documents were swiped between each other to ensure accuracy of our work. Fourthly, initial codes and categories generation and developing potential concepts from interview data was done together after negotiations and discussion. But again the work was divided among researchers when checking if the codes, categories and concepts generated were in line with the data from future workshop and prototyping workshops. Similarly, in the end, the final concepts were refined mutually after negotiation and discussion between the researchers.
As, the researchers were located in two different cities, the best way to save time and write a good report was to divide the topics and start writing. It was not an easy path, but as the interviews and participatory design workshops were conducted together. The decision of mutually conducting the methods was to ensure both researchers had same reflections and transparency while writing the findings and discussion chapters. The writing process was also split taking in consideration the three methods. There were couple of biases but, both researchers aim was the same i.e. to write a good quality thesis. Even though, there were some biases, the researchers always swiped the work before going to the next step, to be in sync while writing reflections that both had in mind, proofreading and monitoring each other’s work. Hence, each word of this research is mutual contribution of both researchers.
Lastly, it was beneficial to work together in two different ways, starting together on campus and then moving and working as distance students. They were two different levels of experiences for both researchers that taught us many different ways of working, and stimulated the motivation to proceed and finish our thesis.
1.6 Structure of Thesis
The content of this thesis is divided into seven chapters.
Chapter 1 Introduction - presents the research problem, research questions, topic justification, scope,
limitations of this research study and responsibility of the work.
Chapter 2 Healthcare and Vital Signs Monitoring Literature Review - an extensive examination of
the literature of the previous and current researches on ICT in healthcare and its perspective in Sweden. Vital signs parameters monitoring, the systems and devices for monitoring, vital signs monitoring in emergency and post-operative wards, perspective on the sensors used for measuring the vital signs parameters and the challenges related to monitoring are presented.
Chapter 3 ICT Design Process and Design Approach - a detailed perspective of the design process,
the challenges designing with the healthcare professionals, participatory design as the design approach and its main guiding principles related to this research are presented.
Chapter 4 Research Setting, Methodology and Methods - an overview of the research setting, research
paradigm, methodology and methods used in this research are presented. Also explains the reasons for selecting the participatory design approach. Further, the methods used for data collection and analysis are described. In the end, ethical considerations, trustworthiness criteria assessing the validity and reliability aspects related to this research are presented.
Chapter 5 Empirical Findings - the findings of the data analysis according to the concepts are
presented. They are generated from the data collected through different methods in this research.
Chapter 6 Discussion - the findings and discussion of the research in relation to the literature review
presented in chapter 2 and 3 are presented. Also illustrates the reflections on design process, design analysis of the prototype devices and methods.
Chapter 7 Conclusion and Future Research - concludes the research with regard to the research
questions, methods used to answer these questions and how the research has enriched the field with empirical data. In the end, the research contributions and recommendations for future research are presented.
2. H
EALTHCARE
A
ND
V
ITAL
S
IGNS
M
ONITORING
-L
ITERATURE
R
EVIEW
In order to have a good basis for this research, this chapter will provide an overview of the previous and current research that focus on the following parts: ICT and Healthcare, Vital signs parameters, Vital signs monitoring and types of vital signs monitoring, Emergency and post-operative vital signs monitoring systems and Sensors for vital signs monitoring.
2.1 ICT and Healthcare in Sweden
The first strategy to implement ICT in Healthcare policy in Sweden was approved in 2006 and it was updated in 2010. A number of different activities took place in the alignment of that strategy which improved the information, communication and technology in healthcare over the past years i.e. after almost a decade there has been a significant change. However, there is still need of technology-based actions in the Swedish healthcare sector and also involving all stakeholders in the regions and local authorities to have a mutual approach and clear identification of responsibilities and accountabilities (Regeringskansliet, 2016).
The Swedish central government, the regional council, and the local authorities are the three levels that are responsible for the Swedish Healthcare system. The government is in charge of the healthcare policy and law designing and supervising the accomplishment of these policies and laws. The regional council is in charge of the healthcare organisation to make it accessible to all citizens on an equal level. The elderly care and support of patients that are discharged from hospitals are under the local authorities i.e. municipality responsibility. In comparison to other nations, Swedish healthcare is cost-effective and equally accessible to all citizens and is also known for having only few patients per doctor per day. This is due to the fact that in Sweden, many tasks are done by nurses, which is not the case in other countries where doctors are responsible for most of the tasks (Albinsson and Arnesson, 2017).
Like many other nations, Swedish population uses digitalized processes both in private and public services. The aim of the Government and the Swedish Association of Local Authorities and Regions is to actively support the use of accessible digital potentials in healthcare and social services. In this context, they have an authorized eHealth vision till 2025, stating:
“In 2025, Sweden will be the best in the world at using the opportunities offered by
digitisation and eHealth to make it easier for people to achieve good and equal health and welfare, and to develop and strengthen their own resources for increased independence and participation in the life of society” (Regeringskansliet, 2016, p.3).
This vision is believed to positively contribute to gender equality, efficiency, effectiveness, usefulness and accessibility of healthcare and social services (Regeringskansliet, 2016).
Similarly, SKR (Sverige Kommuner och Regioner; The Swedish Association of Local Authorities and Regions), the Swedish employer organization operating in all municipalities, counties, councils and regions have presented different key points for the technological healthcare to guide healthcare professionals all over the country. The key points aim to improve the care services offered to people in need to support better health conditions while efficiently improving the business (SKR, 2018). To maximize the opportunities in the healthcare sector provided by technology, some of the requirements
proposed by the SKR to maximize the opportunities provided by technology in the healthcare sector are:
Attention should be paid to patients and users’ needs.
Healthcare professionals should be involved in the design and development of new healthcare systems.
Privacy and security of medical data are to be assured.
Technology involvement in healthcare and safety should support in developing the business in order to achieve better healthcare and care in general.
The Swedish healthcare is now going through a number of digitalization processes in order to improve its efficiency, in some services like form filling, transfers of any data such as vital signs parameters to and from systems. In many cases these activities are manually done using paper (Nergårdh, et al., 2020; Gulliksen, Persson-Stenbord and Backlund, 2016; Stiernstedt, Zetterberg, and Ingmanson, 2016). However, as argued byStiernstedt, Zetterberg, and Ingmanson (2016), many projects related to digitalization fail because they are huge and complex, and tested outside the reality i.e. not in real operating settings. They also provide a list of guideline principles to improve such situations for the healthcare systems designing. These guidelines are in line with SKR (2018) stating that users’ needs should be first identified. Using the participatory design approach will improve the result of the ICT systems or services related to the vital signs collection, monitoring and analysis of the parameters.
2.2 ICTs in Healthcare
Due to the increasing number of the ageing population, along with the population suffering from chronic diseases, especially the elderly, there is a significant challenge related to the wellbeing of humans and the public healthcare systems (Tkatch, et al., 2016). The demand for healthcare resources and services is ever-growing which implicates the importance of the use of ICT in reducing the shortages and deficiencies that are seen in the daily healthcare activities. ICT plays a major role in healthcare management by enabling and helping for curing, caring and preventing (Harding, 2016). Its adoption is also motivated by the need of transforming and enhancing the delivery of healthcare services and communication and thus improve the quality, flow of information, process of decision making and productivity for healthcare professionals (Goldschmidt, 2005). The use of ICT in healthcare is inspiring a number of researchers and developers in exploring this growing sector. Chaudhry, et al., (2007) argued that there are proofs indicating that the use of ICT in healthcare plays a major role in decreasing healthcare errors while increasing the usage of technology-based healthcare.
There are several different types of ICTs used in the healthcare sector to support the needs such as electronic medical and health records (EMRs/EHRs), tele monitoring systems, patient personal health records (PHRs) and others (Evans, 2016). Similarly, the healthcare sector involves different healthcare professionals with various roles and routines, however, they share the same purpose which is to treat and provide care to the patients. ICT’s role in healthcare is to support these routines and help healthcare professionals achieve their objectives. On the other hand, ICT has also empowered the patients in taking responsibility for their own health and quality of life, leading to better communication and participation with healthcare professionals in the prevention and treatment processes. Among many technological changes, healthcare professionals adopted the electronic patient records, facilitating the recording of clinical data. It has increased the complexity of the
For continuous health monitoring, usage of ICT in healthcare settings has a number of benefits such as providing early detection of clinical deterioration through real-time patient monitoring and enabling large scale field studies of chronic diseases through the data collected from these devices (Ko, et al., 2010). Moreover, the Internet of Things combined with these ICTs are creating smart environments that are enabling a preventive and collaborative form of patient healthcare monitoring where the responsibility for healthcare is shared among patients and healthcare professionals (Metcalf, et al., 2016). Electronic data storage and sharing among healthcare professionals is a well-known healthcare shift, whereby the shift from paper-based storage to EHR has significantly helped the cost-cutting (Hillestad, et al. 2005) and easy access to information and improvement of efficiency in healthcare practices (good eHealth report) that has enabled the storage of mega and global amount of data (Haux, 2010). The establishment of a national health record system is believed to improve healthcare practices as access to information becomes fast and from different parties who need it. A number of researches reveal that the implementation of ICT in healthcare positively and negatively affects the service delivery, collaboration and communication between healthcare professionals and patients (Fagerström, et al., 2016). ICT supports healthcare professionals in their daily tasks and in the standardisation of health services. Some of the actions and services are: the exchange of information and communication (Nordmark, Söderberg and Skär, 2015; Ålander and Scandurra, 2015), decreasing medical errors (Star, et al., 2013), patient’s evaluation (Ålander and Scandurra, 2015) and increase the level of confidence in ICT (Nilsson, Eriksén and Borg, 2014).
The access to information through ICT systems is believed to enhance the acquisition of knowledge and skills of healthcare professionals and thus contributes to the development of professionalism (Stevenson and Nilsson, 2012). Nevertheless, despite all the advantages of the use of ICT in the healthcare sector, it also makes mistakes and reduces the patient’s safety when misused (Ridelberg, Roback and Nilsen, 2014; Stevenson and Nilsson, 2012).
Nilsson, Eriksén and Borg (2014) argue that Healthcare professionals are concerned about the fact that the development and use of ICT is leading to automatized care service which may put the quality of healthcare services in compromise and affects working conditions when functional issues occur. Lindberg, Axelsson and Öhrling (2009) argue that the implementation of ICT in healthcare leads to physical meetings limitations between healthcare professionals and patients. Physical touch is more likely to be disregarded when ICT is used as a mediator in healthcare practices and may negatively impact the relationship between healthcare professionals and patients by influencing the loss of connection between the two parties. Several studies also explain that communication through ICT is more useful between healthcare professionals than healthcare professionals and patients relationship. For patients, ICT is more useful when it is used to complement the physical meetings (Johansson, Petersson and Nilsson, 2011; Nilsson, Eriksén and Borg, 2014; Nilsson, Skär and Söderberg, 2010). Though ICT adoption does support healthcare professionals’ development, it may also hold back that development by hindering critical thinking and thus their judgement and decision making (Ernesäter, Holmström and Engström, 2009). In other words, ICT usage can discourage independent thought, let go of the expertise and turn them into passive professionals (Ernesäter, Holmström and Engström, 2009). However, While and Dewsbury (2011) argue that if healthcare professionals feel that they are not involved or not participating in the use and development of ICT systems, their uncertainties grow. To design and implement ICTs to measure and monitor vital signs parameters is of importance in eHealth and the digitalization of healthcare.
2.3 Vital Signs Parameters
Vital signs refer to physiological parameters. They represent a set of data used to define and interpret the general status of the patient’s body and health conditions. They guide and enable healthcare professionals to make decisions concerning each patient (Johnson, et al., 2014). Vital signs parameters have been defined as a fundamental part of the treatment evaluation and an early warning indication of patient’s degradation (Johnson, et al., 2014). Vital signs can be measured in different settings: hospitals, homes, primary healthcare centres, etc. and by different means i.e. manually and automatically connected devices. For example, various kinds of smart devices such as wearables, mobile based, and others discussed in section 2.4.1 and manually by healthcare professionals, patients and individuals i.e. personal assistants.
We define here vital signs, what measurements are expected and how they are monitored.
Hospitals in Sweden monitor six measurable vital signs in all wards. They are evaluated subjectively by healthcare professionals using the National Early Warning Score (Karolinska, 2017). 1The six vital signs parameters used in NEWS are the Respiration Rate, Oxygen Saturation, Systolic Blood Pressure, Pulse Rate, Temperature and Level of Consciousness. NEWS is a widely adopted scoring mechanism used to monitor vital signs for early warning generation, and identifying and responding to patients at risk of deteriorating. This is a simple scoring system where a score is assigned according to derangement in any of the physiological measurements routinely recorded and then the weighted score is aggregated to calculate the overall NEWS that indicates the level of clinical risk. If supplemental oxygen is required to maintain oxygen saturations, two additional points are added to the total. A score of 0-4 indicates low risk, 5-6 is medium risk and 7 or more is high risk. The higher scores depict greater severity in health condition, risk of adverse outcomes and clinical deterioration (Uppanisakorn, et al., 2018). The standard used in NEWS are NEWS score table that define the range of the vital signs in hospital settings, NEWS observation chart used to record the measurements and NEWS clinical response triggers are illustrated in Appendix A (NEWS2, 2018).
2.4 Vital Signs Monitoring
Monitoring the six vital signs parameters of patients is a basic health assessment performed to determine the overall patient’s health status. For ages, vital signs monitoring is considered as a main and critical practice that provides information about the health condition of patients in any given situation (Johnson, et al., 2014). Continuous vital signs monitoring benefits the treatment and prevention of a number of health issues. Lau, et al., (2010) define four qualities of perfect vital signs monitoring system:
Ability in the collection of high-quality data through devices and sensors.
Ability in interpretation and presentation of the gathered data in a significant and valuable way.
Enable decision support by using professional knowledge to deal with actual conditions. Ability to make suitable decisions and actions with healthcare professionals’ comments based
on the provided data.
Figure 1: Vital signs monitoring system relationship diagram (modified from Baig and Gholamhosseini, 2013)
Yilmaz, Foster and Hao (2010) argue that earlier in hospitals expensive and huge equipment was used by the healthcare professionals. Nowadays, a significant improvement has been made in the design and development of small and wearable gadgets, which upgrades the vital signs monitoring, to both patients and healthcare professionals, in terms of practicability, cost and flexibility. The current trends of vital signs monitoring systems including its types, user categories, places, devices and online integration are shown in Figure 1. The vital signs monitoring systems can be used in different places, have different settings and thresholds based on categories of people. These measuring and monitoring systems are of different types that utilize different devices via various connectivity communication services to serve one purpose.
In emergency and post-operative wards, vital signs monitoring is the most regular task, however, there is still a limitation regarding the ideal rate of how much the vital signs should be assessed. In most cases, this rate depends on the hospital regulations, healthcare professionals’ judgement or instruction, and also based on the patient’s perception and grievance (Johnson, et al., 2014).
Different types of vital signs monitoring systems such as wearable, mobile based and remote systems are briefly presented below. The following details will give us an overview about the development and work done for various range of vital signs monitoring systems in order to improve the monitoring processes and thus the delivery of healthcare services in that area.
2.4.1 Types of Vital Signs Monitoring Systems
A number of continuous improvements and upgrades have been made towards vital signs monitoring, in terms of collection equipment, transmission systems and display protocols in order to facilitate the information sharing and understanding among health professionals. These improvements made by engineers, scientists and healthcare professionals are motivated from several factors such as high
Vital Signs Monitoring Systems Hospital Rehabilitation Home Outdoor Places Children Adults Older People People with Disabilities Categories Traditional Wired Remote Wireless Wearable Types Personal Computer Laptop PDA/Tablets Smartphone Devices WiFi GPRS GSM NFC Bluetooth 3G/4G Connectivity Patients Personal Accounts Doctors Caregivers/Nurses Family Members
healthcare cost, elderly population growth, and technology adoption leading to “always online and connected” lifestyle.
The patient monitoring systems (PMS in Figure 2) are categorized into various types according to their functions. Remote health monitoring systems (RHMS) have the remote access to systems that send and receive data from the remote location, covering single or multiple vital signs parameters. Mobile health monitoring systems (MHMS) are developed on smartphones, personal computers and personal digital assistants (PDAs). RHMS and MHMS are cost-efficient and convenient compared to traditional hospital care, as they provide patients with healthcare services at the convenience of their homes. Wearable health monitoring system (WHMS) are devices built using sensors that patients can wear. Smart health monitoring systems (SHMS) are advanced smart devices used for healthcare and vital signs monitoring that include RHMS, MHMS and WHMS (Baig and Gholamhosseini, 2013). All these systems (Figure 2) can be utilized in vital signs monitoring. These systems and devices are generally connected to two major areas: online networks and healthcare professionals (Mansoor Baig, et al., 2014). It is essential that vital signs parameters data is accurate and complete to enable the early detection of health related issues.
Figure 2: Patient Health Monitoring Systems Classification (Baig and Gholamhosseini, 2013) Different types of vital signs monitoring systems and devices can be used in hospitals (Ren, et al., 2010), homes (Taleb, et al., 2009) and outdoor (Rajagopalan and Rahmat-Samii, 2010). Some of these systems are: LOBIN that transmits data through wearable textile; ViSi mobile, a wearable wrist-based device, and HealthPatch, a wearable adhesive patch device (see Appendix C).
These various monitoring systems are presented in the following subsections. 2.4.1.1 Remote Vital Signs Monitoring
Remote health monitoring systems (RHMSs) refers to the usage of electronic information and communication technology to sustain and improve healthcare quality when healthcare professionals and patients are not physically together. With RHMs, vital signs data are timely transmitted from a remote location to healthcare professionals for a regular checking (Fernandes, Afonso and Simões, 2011).
The main factor that influences researchers in remote based monitoring systems area is to make the persons being monitored feel safe and the systems’ accessibility features, in terms of communication and data transmission (Mansoor Baig, et al., 2014). However, RHMs are said to usually delay data transmission due to real-time data processing or/and wireless data transmission. Data security and privacy concerning patient’s credentials and confidentiality of health information is an important
Patient HMS Traditional HMS Smart HMS Remote HMS Mobile HMS Wearable HMS
challenge to the systems that is not fully addressed but has to be improved in the designing and structuring in order to comply with healthcare and ethical principles (Chin-Teng Lin, et al., 2010). 2.4.1.2 Mobile Based Vital Signs Monitoring
Mobile based vital signs monitoring in particular, and health applications, in general, are emerging as valuable and beneficial technologies for accurate healthcare delivery, especially in monitoring and collection of vital signs parameters data (Mansoor Baig, et al., 2014). The acceptance of a technology based on GSM (Global System for Mobile) systems is influenced by the speedy growth of smartphone usage, bandwidth with 3G and 4G mobile data network enhancement and also the capability embedded in smartphones enabling them to perform as much and as good as computers. Vital signs monitoring is a specific sector that greatly benefits from these devices by enabling healthcare professionals in their daily activities (Topol, 2010).
Fernandes, Afonso and Simões, (2011) present two main design types of mobile based vital signs monitoring systems that use mobile devices wirelessly connected to wearable sensors. The first type refers to mobile devices that are used to collect and transmit all the vital signs parameters data provided by sensors to be analysed by healthcare professionals. Some of these systems/devices have recording and displaying features. The second type includes designs that analyse processes between sensors and healthcare services in order to continuously monitor the delivered vital signs parameters to detect anomalies, and in that case activate alarms to notify the concerned personnel.
A number of different vital signs monitoring mobile devices have been developed to collect and process physiological parameters. For instance, a smartphone healthcare system with an alarm mechanism through the mobile phone can send an alarm by SMS (Lee, et al., 2007). Continuous vital signs monitoring is also possible through AirStrip ONE digital healthcare platform that can be used via smartphones, tablets and PCs (Airstrip.com, 2018). Oresko, et al., (2010) developed a smartphone based system that detects cardiovascular illness, called HeartToGo, which operates with Windows Operating System. Many of mobile based vital signs monitoring systems use Bluetooth technology when receiving information sent from different devices; and internet or wireless (WiFi) in information transmission. However, Bluetooth operations have limitations such as range limit and power (Fernandes, Afonso and Simões, 2011).
2.4.1.3 Wearable Vital Signs Monitoring
The wearable vital signs monitoring systems positively influence the wellbeing of users, by being comfortable and appropriately monitoring an individual without disturbing their daily activities (Fox and Duggan, 2013). Anyone who has experienced the vital signs measurements practice knows that in some cases it can be painful; i.e. when means like pull up tapes are used. Also, various demographic changes with regards to world populations, especially in western countries, are influencing the adoption of WBSNs (Wireless Body Sensor Networks) usage in vital signs monitoring (Yilmaz, Foster and Hao, 2010). Wearable vital signs monitoring based on sensors’ systems includes a number of various sensors that can be incorporated into textile fabrics, clothes and elastic bands or attached directly to the human body. Wireless wearable sensors can unobtrusively monitor and collect physiological parameters such as the electrocardiogram (ECG), electromyogram (EMG), HR, body temperature, electrodermal activity (EDA), arterial SpO2, BP and RR (Pantelopoulos and Bourbakis, 2010). These systems are generally made of different electronic and Micro Electro Mechanical Systems (MEMS) sensors, wireless communication features, signals processors and actuators (Majumder, Mondal and Deen, 2017). Vital signs monitoring sensors usually communicate directly or through routers, forming a body area network and connecting to a monitoring device, i.e. computer, mobile phone or tablet, or another network access. The monitoring
system sets up a web server and decision making methods to provide various alarm signals and wirelessly transmit messages to concerned healthcare professionals (Sungmee and Jayaraman, 2010). They use wireless communication protocols that are of low cost, low power consumption and flexible range such as: Bluetooth, to connect and store data in the server, and Zigbee, to build sensor networks and collect vital signs data (Ramlee, Tang and Ismail, 2012).
The main objective of wearable monitoring sensors is to incorporate a combined wireless communication and body sensor network (BSN) that timely transmit the obtained or collected measurements by sensors to a close processing node with the help of an appropriate communication protocol (Castillejo, et al., 2013). A user identification (ID) allows sensors to interpret their data in order to ensure protection and data security in hospital settings with many users (Chin-Teng Lin, et al., 2010). In vital signs monitoring, privacy and security of data are one of the main critical challenges faced by the use of wireless wearable monitoring systems (Al Ameen, Liu and Kwak, 2010). The significant role played by the wireless wearable systems in vital signs monitoring is the critical fact that motivates researchers, tech designers’ healthcare professionals in the present era (Majumder, Mondal and Deen, 2017).
There are many different wearable, remote and mobile vital signs monitoring devices on the market but only a few of them are listed in Appendix C. We list the types, what vital signs parameters are measured, location of use and their deficiencies. However, this research can be listed under mobile and wearable health monitoring systems.
2.4.2 Vital Signs Monitoring Systems in Emergency and Post-operative Wards
The regular monitoring of vital signs in emergency and post-operative wards is a tradition which consists of collecting the physiological data for the patient’s progress observation. For evidence practices, the collection of vital signs parameters remains an obvious practice (Zeitz and McCutcheon, 2006).
Post-operative care is mainly given by perioperative (is the time the patient is given care before and after surgery) nurses usually skilled or specialised in surgery and needs to pay much attention to guidelines, regulations and evidence-based actions. Patients admitted in the post-operative ward have to be carefully monitored and evaluated for any condition degradation, and appropriate post-operative care strategies and solutions implemented. The National Confidential Enquiry into Patient Outcome and Death (Cain and Ackland, 2012) and Khanna, et al., (2019) reported that patients with deteriorated health conditions were not usually recognized and provided with appropriate care in post-operative care. However, it is important to know that post-operative patients are at risk of health degradation and hence they should be closely observed. Also, other symptoms and indications that show degradation, such as abdominal soreness, urine output, etc. are to be observed (Royal College of Nursing, 2011).
In the United Kingdom, Sweden and Europe, the track and trigger or early warning systems are the most used information to recognize patients in deteriorating conditions. They monitor the HR, RR, Temperature, Systolic BP, and Level of consciousness. Apart from that, they also monitor the pain assessment, level of administered oxygen, SpO2, etc. (Liddle, 2013; Spångfors, Molt and Samuelson, 2019). When the vital signs are monitored with the National Early Warning Score (NEWS), it is highly recommended to assess the patient’s haemorrhage, impacts of analgesia and anaesthetic and sepsis. When the patient has received intravenous opiates, his/her vital signs may be compromised in case the level of infusion is elevated. Hence, the pain regulator has to be well controlled by the anaesthetist and other block teams. Also, Cain and Ackland, (2012) and Khanna, et al., (2019)
recommend that healthcare professionals should frequently observe patients under post-operative care.
The assessment of the vital signs should be executed in agreement with local procedures and related to information or data collected before surgery, during surgery and in the recovery zone. Parameters of the said information and the normalities of the patients should be known by the healthcare professionals (Royal College of Nursing, 2011).
Different vital signs are assessed in post-operative and emergency wards depending on the health condition of patients. The first vital signs to be assessed in many cases is the RR when change occurs in cardiac or neurological condition. Sometimes RR is also named as “airway”. The signs to be recorded in RR are pulse and depth in terms of the symmetric movements of the chest and the depression of respiration. It is important that this assessment is done correctly and accurately, but researches have shown that it is usually assessed in poor and misled ways (National Patient Safety Agency (NPSA), 2007; Adam and Odell, 2005). Oxygen is prescribed to a patient with an “epidural, patient-controlled analgesia or morphine infusion” in order to facilitate the anaesthetic gases to be conducted out of the body. Healthcare professionals record Oxygen Therapy to know if the administered oxygen is at the correct level (Liddle, 2013).
Healthcare professionals regularly monitor and observe the pulse oximetry used to measure PR to make sure that “the finger probe is clean”, and the probe’s position is changed on a regular basis to avoid fingers’ tenderness. For HR, BP and capillary refill time, nurses have to check the frequency, rhythm and volume of the pulse; capillary top-up time to evaluate circulation condition together with the temperature and shade of the limbs. Systolic BP is closely watched due to the fact that when it decreases, it may be an indication of bleeding and/or shock. In some cases, a heart disease like hypertension can be caused by the anaesthetic or inappropriate pain regulation. Patients who spend much time in a surgery room may be at risk of hypothermia; caused by anaesthesia or high temperature that indicates infection. However, the body temperature needs to be closely monitored and decisions are to be taken in case it needs to be returned to normal rate. Patients in the post-operative ward should also be able to react to vocal stimulation, like by responding to asked questions, and recognize who surrounds them before they are conducted to the ward and during the post-operative session. Deviation in these are indications of changes in the consciousness level (Liddle, 2013).
Post-operative healthcare staff can be under pressure to quickly release patients, which may lead to vital signs being neglected that results in delayed recovery. Otherwise, patients are meant to be discharged when they don’t have any postoperative problems, many of them can be identified and eluded with accurate and continuous vital signs monitoring. Postoperative healthcare professionals are recommended to not rely too much on electronic means rather than improving their aptitudes, i.e. observational and listening skills; and combine both for the patient’s care (Liddle, 2013).
Vital signs collection and monitoring are the most performed actions in the emergency department in order to control changes that may imminently affect patient’s health conditions. (Lighthall, Markar and Hsiung, 2009). The Vital signs collection and monitoring frequency depends on the hospital rules, healthcare professionals’ decision and also on patient’s insight and objection. It is also related to the crowding factor in Emergency wards, where by it is said to decrease healthcare professionals’ attention in vital signs monitoring. The Emergency wards crowding refers to insufficient resources to meet the requirements of patients at any time (Johnson, et al., 2014).
