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Manual observation push to prevent deterioration

Nurses across the country are returning to manual observations following evidence that reducing reliance on technology can dramatically improve care, Nursing Times has learnt.

Trusts are abandoning or planning to reduce their use of automated machines that take blood pressure readings, amid fears that they make it more difficult to monitor vital signs.

They are following in the steps of Salford Royal Foundation Trust, which reduced cardiac arrests by 32 per cent after launching a scheme involving a return to manual blood pressure readings (Click here to see the Nursing Times article).

At Medway Foundation Trust, critical care consultant nurse Catherine Plowright is planning to replace automated machines in a surgical ward with traditional sphygmomanometers for a trial period this summer.

“Standing with the patient and talking to them may well be the thing that makes the difference in picking up vital signs,” she said.

She said the move had attracted “mixed responses” from clinical staff. But monthly observation audits will reveal whether it has helped staff detect signs that patients’ conditions are deteriorating at an earlier stage.

George Elliot Hospital Trust is introducing a system in the next three months whblood ereby all blood pressure readings taken with automated machines will then be checked against manual readings.

Director of nursing, quality and workforce Dawn Wardell said: “We’re using much more machinery now. There’s a whole piece of work that needs to be done to show us whether we should keep [technology] across the board.”

Many nurses were discussing similar moves at their organisations at Nursing Times’ and HSJ’s Patient Safety Congress last week.

She hopes to gather evidence as to whether the two techniques produce different results.

A Nursing Times survey last year found 85 per cent of respondents used automated technology to monitor vital signs. But 42 per cent felt reliance on this equipment could make nurses less likely to identify, or act on, signs of patient deterioration.

Patient observation and the deteriorating patient is one of the central elements of a National Patient Safety Agency drive to increase engagement with nurses.

NPSA head of patient safety (deterioration) Kate Beaumont said there needed to be a debate as to whether there should be a wholesale return to manual observations, particularly for blood pressure readings.

She said: “It seems to be more accurate when someone has an abnormal blood pressure, particularly when it’s low.

“But more importantly, it encourages and promotes an improved patient assessment by nurses because it encourages nurses to touch, feel and press.

“You can feel whether someone’s clammy, or hot, or cold. It promotes that compassionate relationship between the nurse and patient because you spend more time with them and talk to them.

“By using a Dynamap, my hunch is that you spend less time on observations.”

North Tees and Hartlepool Foundation Trust executive director of nursing and patient safety Sue Smith said she was “very interested” in phasing in manual observations for blood pressure readings across “most areas” of the organisation.

This is because it would improve monitoring of vital signs and prevent technology from “deskilling” nurses.

However, it may not be practical for patients requiring very frequent observations, she added.

Walsalls Hospital Trust resuscitation officer and clinical skills lead Phil Jevon has published a comparison of different blood pressure measurements that found the mercury sphygmomanometer was still the “gold standard”.

He said it was important for nurses to understand the limitations of automated devices, particularly for critically ill patients. They could be inaccurate if wrongly calibrated or in certain circumstances such as cardiac arrhythmia. However, there was insufficient evidence to support a universal “back to basics” approach.

Readers' comments (17)

  • As a student nurse, I feel that there is more of a need for manual observation.
    There is no opportunities for nurses to take vital signs such as blood pressure using a sphygmomanometer, and as a result not only are patients health being put at risk, but we are losing our skills.
    We cant just rely on technology to do everything for us. Nurses need to carry out more thorough assessment on patients, even if does take more time, it will have greater benefits for the patient in the long term.

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  • This is excellent news, but I don't think it will happen for practical reasons.

    1. Time, there just is not enough staff to perform every observation manually. Student Nurses are already used to 'do all the obs' (I know I was!)

    2. Training and availability of equipment, throughout my training the vast majority of wards did not even have a manual sphig, it was only when I reached A&E that I was finally shown. They didn't even teach it in the ridiculously limited skills labs at uni!

    If these are sorted, then I thing this will be a fantastic move forward. Technology is a great tool, but it can never replace real skill.

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  • I agree as a student nurse it was often the only quality time you had to talk to patinets during observation rounds.
    Taking observation is a skill you need to look and listen to what the patient does or in many case does not telling you. Watching nurses stand behind a Dynamap, introduces barriers to quality care. We must not always rely on machines nursing is about touch, looking, listentning and providing quality care that has a heart and empathy.

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  • I was surprised to find that automated blood pressure cuffs are the only ones available on most units. As an instructor, I insist that students use a manual cuff only. Reliance on automated machines is POOR practice. I had a student caring for a patient whose heart rate increased dramatically from a medication reaction, the blood pressure was rapidly declining and she was unable to effectively use a manual cuff. It was embarrassing for her and grossly unsafe for the patient. In critical situations, the nurse must be able to accurately assess vital signs and an automated cuff won't cut it.

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  • Good heavens, wherever did you get the notion that nurses are able to spare the time to talk to patients and undertake to do manual observations. If you actualy spent time on an averagely busy ward, you would soon see the amount of extra forms that have been generated recently, in my trust in any case. Not taking into account the ridiculously time wasting morning bed meetings which nobody I have spoken serves any purpose other than to save managers time going to the wards and speaking to nurses on an individual basis. Manager who now are facing wholesale redundancy, heeheeheehee, makes you wonder why they were put in post in the first place if after two years in post they are 'surplus to requirements'. In my trust 300 nursing jobs are being cut. I recently found out that night sisters who provide clinical support to nurses on the wards at night are also surplus to requirements and are being redeployed. Wait for it, they have been replaced by 'Bed Co-ordinators' whose job it is to be a pain in the arse to nurses by continualy asking, 'why isn't this patient gone yet, how many beds have you got, anybody going later'. You get the picture. If trusts have to save money, get rid of nurses and employ more managers. nothing changes. And no I haven't forgotten the original point, where do you think we are going to get the extra time to sit and talk to patients. I doubt very much you have any real grasp of what it's like on wards these days.

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  • As I do not work at ward level in my present post I read the above comments with interest. One of the reasons that hospitals moved over to the automated system - which also includes digital read out thermometers was to remove the risk of mercury spillage from ward areas. Has this factor been discussed prior to introducing mannual sphygs again. Personally I do prefer the manual type as I have always found them much more accurate.

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  • I am a student nurse, and at our university we are taught how to do manual observations, because the tutors feel it is vital we learn this way before going out on placement. I agree that manual observations are skills that are being taken over by automated machines, and that there can be too much reliance on them, although they are useful. The skills of manual observations are an important part of patient care, and being able to touch, feel and observe whist doing them are important skills if we are to observe and detect signs in the deteriorating patient. Those few minutes we spend with the patient, no matter how busy the ward, are vital in developing that rappore with the patient. I realise that wards can be very busy, but this is no excuse for rushing observations that are important. Even patients that appear stable can deteriorate and observations are often omitted during busy periods, and just taken on the more ill patients. I have taken observations on stable patients and detected changes which I reported and were acted upon, the patient not being as stable as thought to be. If signs of deterioration are detected and acted upon, then we are doing our job and saving ourselves extra work, by preventing and treating what could have been a whole lot of extra work if not acted upon, even an unecessary death or near one, cardiac arrest, haemorrhage for example.
    I have recently been on a placement on an acute medical ward and observations were taken seriously and staff had a postive attitude to following the local and nationals protocols on Track and Trigger and similar systems. We need to help develop a postive attitude to observations in those places where they are not and realise how important they are. Although taken with an automated machine on the ward, they were taken manually if needed. I much prefer taking observations manually and always took the pulse and respirations, despite the patients commenting that I was the only one who took their pulse this way, but pulse oximeters are not always accurate. I was really interested in the importance of observations and how they can become ritualistic even today, so I completed a reflective piece on their importance. Our university encourages us to have a positive and realistic attitude to our practice and encourages the importance of reflection and critical analysis to help change our practice and improve our skills and learning, which should improve patient care.

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  • I think whilst the automated machines are a great tool where appropriate, they're taking away the relationship between the patient and nurse. I'm an HCA and on occasion I've taken a step back and really watched and thought about what it looks like at obs time and it's quite surreal. You get both nurses and HCAs walking up to patients, most of the time the patients know what's coming so very few words actually get said between the two, the obs are taken and then they move on. I think it's a very cold way to interact with patents and I've often thought it reminds me of some kind of factory line.

    I don't think this is particularly the fault of nursing staff but rather the fact that the whole environment doesn't lend itself to taking the time to take manual obs and spend time with the patient. If you can get as many done as fast as you can and then get back to what you were doing before, then why bother?

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  • in places such as australia and america and even ireland only trained nursed do the obs. i have now taken it upon myself to do at least 1 set of obs during my shift when on duty, however busy i may be. we currently use automated machines and i cant wait for the manual sphygs to return. when i was a student we were taught to do manual blood pressure and i agree with above comments that you need to look feel and listen not just watch the machine

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  • Since when does using a Dynamap stop you interacting with the patient and observing them? I find that statement quite worrying! It doesn`t! In my experience nurses will always default to using a manual sphyg if there is a need to anyway eg. if the BP wont record on the dynamap as it is too low. There is definately a place for both!

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  • Does anyone know if there is a health and safety issue (gone mad) with the traditional Sphygs having mercury in them and being hazardous if they are dropped and broken?

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  • Mercury has not been totally banned by any official directive yet but some trusts have discontinued the use of Mercury sphygmos anyway. If a ward has a Mercury spill kit and uses it according to the guidelines, that is acceptable.
    The Britsh Hypertension Society have produced a list of approved manual measuring devices, these can be used instead of Mercury ones, if desired. They have also produced guidelines for the use of Mercury Sphygmos. I am concerned that the use of Aneroid devices will increase. Bear in mind that Aneroid devices lose thier accuracy quite quickly and should be checked regularly.
    I am involved in teaching undergraduate student nurses and time and time again they tell me that there are very few manual devices in hospital wards so they don't get the chance to practice.I wonder how an exceptionally low or high reading is checked?
    I also worked for over 20 years as a Treatment room nurse in a very busy health centre and always used a Mercury sphygmo, still considered by many cardiologists to be the Gold standard.

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  • There is no doubt that the manual observations is the best practice. but in a situation where you have to attend to so many patients the machine should be used.Most wards are understaffed and you can not afford to spend so much time with patient taking blood pressure. As a student I attend to about thirty patients using the machine three times a day, and it is quite a task. Doing it manually will take much time.

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  • I work mainly nights on a very busy medical ward and would not have the time to use a manual sphyg. However I feel I spend enough time with each patient as I need to observe their general condition. After all medication is being administered at the same time which gives me ample time to ask how they are feeling, etc.

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  • It is fantastic news that the limitation of machines for basic clinical assessment is being widely acknowledged.

    As RO/Clinical skills trainer I have long advocated the use of manual clinical assessment tools - the best assessment tool being your 'eyes' a start

    Physical manual assessment facilitates
    patient contact

    Tactile skin assessment - we often note problems by 'default', ie if they skin is clammy, dry etc the observer identifies ad reports this

    A machhine merely records the rae of the pulse, not the rhythm, regularity or if weak, thready etc

    Respirations are so much more than the rate, both visual and audible assessments are also required for accurate assesment.

    EWS charts are an excellent supporting tool, but all too often they are universally applied, with no provision for the 'norm' for the patient, hence triggered inappropriately.

    I teach this regularly during my contact with transitional student nurses, non registered staff with NVQ level 3 and senior medical students and am constantly remninded that this knowledge is just not being widely taught.

    Lets hope that this report will begin to change this...

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  • i totally agree with afew articles above such as Anonymous 5-Jun-2010 0:40 am & James. the automated machines certainly save time and in general are less subjective. lets not blame poor nursing skills or competencies on machines. i am very competent at using the sphyg but for instance when someone is awaiting social input for days, what are you going to benefit from using manual Vs automated? if there is no clinical indication to check rate or rhythm of pulse manually, then what do you expect to learn from that?

    some nurses for instance sit at nursing station when completing documentation, when you can spare those mins to document while sat at patient's bedside. healthcare assistants & students do obs on my ward but i try if i can spare some time, then i do them myself inorder to get closer to my patients.

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  • I work in the community and we have always peformed manual observation. It clearly states in the NICE hypertension guidelines that electronic sphygs are not recommended due to their inaccuracy. We all have mercury free manual sphygs. I have always been appalled to find nurses and GP's using electronic means to record obs on ill patients. You need to take a pulse manually to pick up on abnormalities. Surely this is obvious. Peoples conditions change, even when they appear well. Isn't health care about prevention these days? Well it is on the community.

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