The implementation of an integrated observation chart with ...
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Chan Man Yi, NC (Neonatal Care) Dept. of Paed. & A.M., PMH 16 May 2017
The implementation of an integrated observation chart with Newborn Early Warning Signs (NEWS)
to facilitate observation of infants at risk of clinical deterioration
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Background
Different observation charts using in Special Care Baby Unit (SCBU)
BP, Temperature & Pulse Chart Newborn Observation Chart Neonatal Skin Assessment
Record Pain Assessment Record
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Background
No reference range of significant clinical signs in traditional observation chart Affect early recognition of infants at risk of clinical
deterioration Hinder effective team communication and take
appropriate interventions promptly
Early identify signs of deterioration
Prompt intervention and step up further
care
Reduce morbidity
(Duncan, 2007)
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Objectives
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Combine into one chart: Integrated Observation Chart with Newborn Early Warning Signs (NEWS)
To develop an integrated observation chart with NEWS to facilitate nurses for identifying infants at risk of clinical deterioration for taking appropriate interventions in SCBU
To evaluate the discrimination ability of NEWS in screening the infant for Neonatal Intensive Care Unit (NICU) admission
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Methodology
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Study Design Retrospective chart review diagnostic study
Settings Special Care Baby Unit (SCBU) in PMH
Period 1 Feb 2015 - 31 Jan 2016
Subjects All eligible cases and 1:2 matched controls in the 1 year study period
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Subjects
Inclusion Criteria Case Aged ≤ 28 days or 44 weeks
post-conception Transferred from SCBU to
NICU for clinical deterioration and step-up care
Matched control Admitted to SCBU within ± 3
days of the case’s SCBU transferal date
Length of stay in SCBU ≥ length of stay of the case
Without NICU admission
Exclusion Criteria Had previous NICU admission Electively transferred to NICU for procedure, monitoring or
management without clinical signs of deterioration
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Data Collection
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Subjects were identified from the admission records of NICU and SCBU, as well as Electronic Patient Record (ePR).
Demographics and clinical information were collected from medical records.
Example for data collection
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Data Analysis & Development of NEWS
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Step 1: Draft of NEWS Developed by a clinical expert
panel including neonatologist and neonatal nurses
Included five physiological items, temperature, cardiovascular status, respiratory status, neurological status and severity of abdominal distension
Three colour zone (white, yellow and red) to indicate the urgency in intervention
Red zone to indicate the need of immediate intervention for clinical deterioration
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Data Analysis & Development of NEWS
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Step 2: Data analysis for NEWS modification
Demographics and clinical information of the subjects were reported as mean ± SD, range or count (%).
Chi-square test, Fisher's exact test, Mann-Whitney U test, independent samples t-test were used for comparing variables among groups.
The subjects were divided into training set (~70%) for developing modified versions of NEWS and testing set (~30%) for testing the modified charts.
Sensitivity, specificity, accuracy, positive and negative predictive values of red zone in NEWS for screening infants with NICU admission were calculated.
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25 July 2017
Step 3: Finalizing NEWS
The modified versions of NEWS were discussed by the expert panel to develop the finalized version of NEWS.
Sensitivity, specificity, accuracy, positive and negative predictive values of red zone in NEWS for screening infants with NICU admission were calculated using all recruited subjects.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS version 22.0; SPSS, Chicago, IL, USA) and Open Source Epidemiologic Statistics for Public Health (OpenEpi version 3.01). P value <0.05 was considered as statistical significant.
Data Analysis & Development of NEWS
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Sample Size Estimation
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First study to evaluate NEWS
No prior information about its screening ability
Assume: Sensitivity = 90%; Specificity = 90% Precision = 10% Ratio of case to matched control = 1:2 Prevalence = 33% (=1/3) Confidence level = 95%
→ At least 104 samples would be needed
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Results – Recruitment
56 cases transferred to NICU
36 cases recruited
20 cases not eligible - 1 with age > 28 days or 44 weeks post-conception - 19 electively transferred for procedure, monitoring or management +
Recruitment flow chart
72 matched controls
108 patients recruited
Training set (n=75) 25 cases
50 matched controls
Testing set (n=33) 11 cases
22 matched controls
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Results – Baseline Characteristics
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Results – Baseline Characteristics
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Results – Baseline Characteristics
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Results – Baseline Characteristics
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Results – NEWS Modification
Training Set Version 1 (Draft) Version 2 Version 3 Version 4
Accuracy (%;95%CI) 85.3 (75.6 - 91.6) 93.3 (85.3 - 97.1) 94.7 (87.1 - 97.9) 100 (75.1 - 100)
Sensitivity (%;95%CI) 72.0 (52.4 - 85.7) 96.0 (80.5 - 99.3) 100 (86.7 - 100) 100 (86.7 - 100)
Specificity (%;95%CI) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 100 (92.9 - 100)
PPV (%;95%CI) 81.8 (61.5 - 92.7) 85.7 (68.5 - 94.3) 86.2 (69.4 - 94.5) 100 (86.7 - 100)
NPV (%;95%CI) 86.8 (75.2 - 93.5) 97.9 (88.9 - 99.6) 100 (92.3 - 100) 100 (92.9 - 100)
Items / Color Zone Version 1 Version 2 Version 3 Version 4 Mild & Moderate Retraction Mild & Moderate Abdominal Distension Temperature (°C)
35-35.9 <35
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Results – NEWS Modification
Testing Set Version 1 (Draft) Version 2 Version 3 Version 4
Accuracy (%) 75.8 84.8 90.9 100
Sensitivity (%) 54.5 81.8 100 100
Specificity (%) 86.4 86.4 86.4 100
PPV (%) 66.7 75.0 78.6 100
NPV (%) 79.2 90.5 100 100
Training Set Version 1 (Draft) Version 2 Version 3 Version 4
Accuracy (%;95%CI) 85.3 (75.6 - 91.6) 93.3 (85.3 - 97.1) 94.7 (87.1 - 97.9) 100 (75.1 - 100)
Sensitivity (%;95%CI) 72.0 (52.4 - 85.7) 96.0 (80.5 - 99.3) 100 (86.7 - 100) 100 (86.7 - 100)
Specificity (%;95%CI) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 100 (92.9 - 100)
PPV (%;95%CI) 81.8 (61.5 - 92.7) 85.7 (68.5 - 94.3) 86.2 (69.4 - 94.5) 100 (86.7 - 100)
NPV (%;95%CI) 86.8 (75.2 - 93.5) 97.9 (88.9 - 99.6) 100 (92.3 - 100) 100 (92.9 - 100)
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Results – Finalized NEWS
All Subjects Version 1 (Draft) Finalized Version of NEWS
Accuracy (%;95%CI) 82.4 (74.2 - 88.4) 87.0 (79.4 - 92.1) Sensitivity (%;95%CI) 66.7 (50.3 - 79.8) 80.6 (65.0 - 90.3) Specificity (%;95%CI) 90.3 (81.3 - 95.2) 90.3 (81.3 - 95.2) PPV (%;95%CI) 77.4 (60.2 - 88.6) 80.6 (65.0 - 90.3) NPV (%;95%CI) 84.4 (74.7 - 90.9) 90.3 (81.3 - 95.2)
Items / Color Zone Draft NEWS Finalized version of NEWS Retraction Mild
Moderate Abdominal Distension
Mild Moderate
Temperature (°C) 35-35.9 <35
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Discussion
The NEWS chart with action pathway and reference range of significant clinical signs
Facilitate early identification of infants at risk of clinical deterioration and take appropriate interventions promptly
Enhance effective team communication especially inexperienced nurses on the recognition of the unwell infant in SCBU
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Discussion
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The NEWS chart is only a set of observations, but the subsequent full clinical evaluation of the infant is needed.
The other elements of assessment is also significant.
For respiratory assessment, chest retraction is one of clinical signs for respiratory distress. The observation of respiratory pattern, SpO2 and O2 requirement are also very important for infants.
The chest retraction scale is simply defined as mild or severe in new version instead of mild and moderate or marked.
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Discussion
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For abdominal distension assessment, it is associated with feeding tolerance, nature and frequency of stool in daily intake and output chart, and soft or tense in abdominal palpation.
The abdominal distension scale is simply defined as mild or severe in new version instead of mild and moderate or marked.
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Discussion
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Hypothermia is common in newborn infants despite measures to prevent hypothermia <36°C immediate after birth, resuscitation, and warm transportation.
Neonatal hypothermia is associated with increased morbidity and mortality especially among sick newborn infants who need medical attention in SCBU.
Nurses have to step up appropriate supportive intervention, and notify concerned parties.
The temperature scale is kept status quo in new version.
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Clinical Practice
A new version of the NEWS chart is developed and will be implemented in 2017 when available.
The NEWS chart is only one component of our assessment for early identifying newborn infants at risk of clinical deterioration in SCBU.
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NEWS can facilitate early identification of infant’s clinical deterioration in SCBU and provide guidance for nurses to initiate appropriate intervention for improving patient outcome.
Conclusion