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Table 1 Overview of themes and sub-themes with supporting quotations (by group)

From: Health professionals’ initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

Theme 1: Complying with DETECT e-PEWS
Documenting Vital Signs Group (D-VS) Reviewing and Responding to Vital Signs Group (R-VS)
Initial impressions
I was trained in a hospital where we didn’t have that so I just thought it was quick and easy to carry it in, put it in your pocket, go into the room and you can just do everything in real time rather than writing it on a piece of paper and going out and sometimes you can get distracted … …. I thought that was really effective device to have (D-VS4).
I think I thought that it was quite systematic the way it goes through then different sections of the onset that you have to put in. I just remember thinking that it was a big change and that we were never going to use it and that isn’t true as we do use it just not all the time (D-VS5).
I’m confident in the numbers I’m putting in … at first I was thinking, ‘If I put, like, a wrong digit in, it’s going to start sending … all sorts of alerts and they’ll think the child’s got desperate,’ but it’s worked out absolutely fine (D-VS2).
It takes a little while to get your head round and knowing where everything is and knowing what you need to do …. [but] I don’t find them confusing anymore …. and I think also the more and more we have used it the more we appreciate the advantages of it … …. It’s a lot simpler information wise, [there’s] a bit less messing [finding an available computer] … vital [signs] are getting noted straight away (R-VS2).
I liked it, from the beginning (R-VS4).
It’s all just there in front of you. And you can pick it up as and when you need it (R-VS5).
Clinical utility issues
If everything was on the same device [for entering], so if all the fluids and everything like that were also on there, then I would find it a lot better (D-VS3).
Only the odd time I think I’ve put obs on and they’ve not registered as being done but then I’ve spoke to people in DETECT and got that looked at. It’s not a common thing (D-VS6).
I think maybe once or twice I’ve started on my patient and then I’ve released oh god, that’s not my patient … … you’ve got to double-check (D-VS1).
Sometimes when you have got gloves on you press a number but it gives, say for instance a couple of times I have wanted to put in 24 resps and gone to 4 but the 4 hasn’t linked up (D-VS4).
A couple of times we’ve put in observations and they’ve actually not gone through to Meditech. There’s like a couple of hours missing and stuff and sometimes like if the nurse in charge has spotted that before you, they’ll come over and say ‘Have you done obs for the last such and such hours’ and I’m like ‘Well yes, I have actually’ (D-VS3).
On our ward … it’s fast turnover, so …. if [new admission is] not booked in on the system, you can’t actually get their name up on the device -- so sometimes you have got to wait … (D-VS2).
To be honest, I thought it was extra work … because we have bedside computers in every bed space so for us, it was like having to use an extra device because our PEWS were on Meditech to begin with so we’re logging on every hour to put fluids on there at the moment and before. So it felt like I had to access another device. … ..I still don’t think it’s right for the HDU environment to be honest … … .because we’re accessing the computers to do the fluid anyway so it was easy enough to just put our PEWS in on there during that time while we were putting the fluids in (D-VS3).
[Problems] have been resolved quickly (R-VS1).
Without the DETECT device our job would be harder then, you know, as simple as it is (R-VS5).
I’ll often already have one or two baton bleeps and then you can be caught holding an on-call bleep as well … … so I’d say two to three devices will often be the case, so it does add another one (R-VS7).
I guess the main thing is logging in. If you forget your password, usually that has got to be the main one (R-VS2).
The internet signal [can be a problem] …. If we’re in the stairwell, for instance …. and then we won’t get an alert … and then it takes a while to kick in. That’s unfortunately the build of the hospital not the device (R-VS5).
Our ward manager has very strongly started pushing it and making it very much priority, we use it for vitals, notifying doctors when we are concerned about patients and things like that … (R-VS2).
Our ward manager was very good at just making sure going round saying can we please charge the devices please put them back on charge. We have had a couple of staff who have accidentally taken it home in their pocket and things like that because you know you think is this my phone, a calculator just routinely, I think [manager] put signs on the doors saying ‘Is it in your pocket’? (R-VS2).
It depends on whether those alerts are actually coming to your device, whether they’re pinging or not and whether anybody’s actually looking at it (R-VS6).
I think that idea of a recurrent [alert] alarm could support [DETECT] … a couple of times …. I’ve not heard alarm [in busy area that’s noisy], and because it hasn’t gone off again, I’ve missed it (R-VS4).
It’s systematic, real-time, and it’s got my back
With a paper towel you record your obs and no one was seeing that were they? Only you (D-VS1).
If you’re walking round with bits of paper, you can always lose them, or, like, forget to put them on the system, but if they’re recorded straight away on [DETECT], anyone can see them, and they’re done in, like, real time (D-VS2).
Recording obs in real time and that gives a good time line if a child does deteriorate, because then you can say I did an obs at this time, I was in the room and right there and then rather than I did the obs and then 10 minutes later I documented them and counted up what the score was and contacted the doctor, electronically it’s all done right then and there for you it does scoring (D-VS4).
Being newly qualified and anxious in my job because I am new and you have to build confidence it is good for me to know that I’ve got that as a backup if I am concerned about a patient as I can just click that button and I have done it in the past and there is a phone call straight to the pod and there is a doctor saying I have just had an alert for patient such as such and then they can come and review the patient for you. (D-VS4).
I think the neurological assessment is quite good when you are putting the GCS in as some people don’t remember to do all the steps or know exactly where to place or if you take the device in with you, you can go through it in the room with the patient and it’s also got the sizes of the pupils it doesn’t just say like 2, 3, 4 it’s the size that you can compare it to as well, so that’s quite useful (D-VS5).
I just thought ‘Oh another device and an extra bit of work’, but it actually isn’t, it’s faster (D-VS1).
At first, when I was first putting obs on, it took me for ever, ‘cause I was, like, submit, and then making sure the numbers was right on there, but obviously because I’m used to it now and I know what questions are coming next, I’m quite quick on them, so I know exactly what I’m inputting and, you know (D-VS2).
I think it is good for inputting, like, observations at real time, so if a patient does react, you can then communicate at the right time, and quickly enough, to get in touch with doctors and things like that, to obviously observe the patient and, you know, review them and things (D-VS2).
Yeah, I think it saves on paper as well, having loads of paper and trying to rifle through paper as a student trying to find the relevant stuff that you need even with notes and stuff or obs charts, but here you just do it on the DETECT …. look at the vital signs, get the graph up to look at how their obs have changed in the last 24 hours or last 12 hours … … … you can just find exactly what you want, when you want just through technology (D-VS4).
I suppose you do have to really concentrate on the observations, and you have to read what you writing in not just like, and people don’t do it wrong in that sort of sense, people don’t skip past things because they can’t, because you can’t skip past it, you have to do it. And so you can’t just say, oh, we won’t take the temperature this time, or will just work through the rest time. Because you’re having to write down you’ve not done it so that is true actually the results were getting actually are better (R-VS5).
I think in terms of data input it’s made a massive difference …. I do think because the data entry is quicker, I think information is considered more quickly (R-VS7).
You can access it from anywhere and … see [data] at any point of time and … the notes you used to write on paper used to get lost (R-VS6).
So I was straight in with the patient then and with the doctor. And we were able to bring the child who needed intubating on the ward …… but it was a controlled step up to critical care … …. we were there at the time they needed us (R-VS5).
It helps us to get there [to child] quicker, and it does what it says on the tin, really, truthfully (R-VS4).
I can see improved communication in the hospital … ..where a high PEW has been triggered, I have been alerted and as soon as I have gone a couple minutes later someone from the ACT team has come as well so that’s actually quite reassuring for the nurses as well (R-VS3).
It ties everything together - before everything was very separate - …. It’s pulling it into one place. It’s all accurate and [real] time and all that so all that has benefitted us quite a lot. Now [we do handover using the devices] at the bedside … .. it’s very much easier you don’t have to get access to sit down at a computer. Way quicker, way quicker (R-VS2).
I just thought they were picked up quickly and the few times when I have been concerned the obs have already been on to it so to me that’s working isn’t it? (R-VS1).
I like the idea of them being able to pin tasks and you being able to reply to the task rather than getting bleeped and having to interrupt what you’re doing and not knowing whether your bleep is not that urgent (R-VS7).
I think sometimes, for the medical teams because I work closely with them, the idea of generating a task enables them to prioritise their workload doesn’t it? If you need to prescribe some paracetamol for somebody and you need to do a cannula then you know they can prioritise what they need to do where I think doctors are probably getting bleeped a lot more than what they need to be now for more simple things (R-VS3).
It improves situational awareness
I mean whenever I’ve been in charge it’s really good because you get an automatic alert if a patient scores a high PEW or there’s a sepsis concern so you’re automatically made aware of it … and I can escalate any concerns or contact the medical team and we’re using it for electronic handover (D-VS6).
Quick because if a child’s PEW is a certain amount on the ward the nurse in charge will come straight to you and say I’ve noticed that such a such is 4 why is this? What are your reasons, how are you feeling? (D-VS4).
I jump onto my DETECT thing and I can pull up the PEWs chart and I like the fact that it does it in an old fashioned chart so you can see trends a little bit easier [than Meditech] and also I like to be able to see what the nurse’s handover is as well on it (R-VS3).
Our [ACT] team are able to tag patients that have stepped out of critical care, or acute admissions, and children within 24 hours that come in particularly poorly … so we’ve got a vast view on which patients we need [to review] (R-VS5).
Definitely quicker, we [ACT] pick up alerts and contact the ward straight away.... Before [DETECT] we wouldn’t even know that these kids were PEWing on the wards at all until we walked around the ward (R-VS5).
I think we would rather have a PEW come up and know that its normal for them than not have something come up and miss something completely as that would just be tragedy (R-VS2).
We can see if someone’s [child’s] struggling a little bit.. shows on their PEW, and we can … contact the ward earlier to try and help out (R-VS4).
Yeah, that [nurse concern and parent concern option] really makes a massive difference, I think. Because obviously there’s some kids [underlying condition].. that will always trigger the PEW. But that’s just them; they’re fine like that. You know, there’s nothing—there’s no intervention to be done; nothing needs to happen. So we can ring and say, ‘What’s the matter? Something’s wrong. Is there anything we can help you with? D’you need us to do anything?’ (R-VS4).
I think that it’s created a culture of everyone taking [deterioration] very seriously, not that everyone didn’t take [deterioration] seriously before, everyone’s always taken things seriously, but it’s now a priority to be using [DETECT] and you know engaging with it …. actively … [it’s] putting information to the forefront (R-VS7).
I use the Careflow App on my phone … every day that I’m in hospital and some days I’m not in hospital to keep tabs (R-VS7).
I do feel like they have improved communication … especially handover when they are updating properly … you know what needs to be done next …. it really helps when the doctor comes on the ward as they have got all the vitals already before they even step on the ward. So, yeah, communication wise it definitely has improved (R-VS2).
It can create distance from and support closeness with patients
I think it can limit conversations with parents - they might not want to speak to you … if they see you on a device … ‘cause they might think they’re distracting you (D-VS2).
You could be in a room with a child with a real high score and it is not safe to leave them and you have to be there monitoring them. So on the device it allows you to say are you concerned, yes, are the parents concerned, yes or no, and then do you want to contact someone and you can click yes and that goes through to either a doctor or links up to the nurse in charge so you are able to stay with your patient but also to alert the staff with your concerns without leaving the room which I think is a really good idea (D-VS4).
If you’ve got a baby on CPAP who’s dead agitated for instance … you can [soothe the baby] and do your obs … you don’t have to leave your patient to come away and either go on the computer or like it used to be on paperwork (D-VS1).
[DETECT] is quick, and it gives us real time data and all that kind of stuff. But actually, the process of it feels distant from your nursing care (R-VS5).
I think sometimes your concentration is pulled more towards your device rather than the child (R-VS5).
It accommodates clinical judgement
To be honest again the PEWs we do obviously follow the PEWs system on our ward but it’s a lot different to on the ward because our PEWs are basically anything over 6 because a lot of ours that have a PEW of 4 anyway just because of their oxygen levels and things like that. So we’ve moved ours up to 6 so I yeah, we just kind of know the difference in numbers instead of going with PEWs because a lot of ours will sit at 75 like one SATS above 75 anyway so that’s going to alert as a PEW there because, but that’s normal for that patient. They’ll normally sit in two litres of oxygen but again they’ll PEW one or two for that because they’re needing oxygen but yeah, that’s their normal anyway. So just a lot of these things like so we’ll go up to our nurse in charge and say look, I’ve just PEWed a 6 for this patient but they normally PEW a 4 anyway so they’re actually not, it’s not extreme that we need to ring a consultant or whatever or ring somebody, ring a doctor (D-VS3). They were getting alerts from the DETECT devices and saying like, this child is poorly and this child was poorly, but they know that child and they know that that is normal for that child, so actually what was happening was they were getting bleeped so many times and it was like they were filtering through it all … … whereas when the nurses actually bleep you, not the DETECT devices bleep you, I think it was more accurate that way and I think there is always those patients that have a high PEW score and when you log in, if you know them you can ignore it, if you don’t know them you think, ‘Oh, is that a problem?’ so I think actually as a way of highlighting the people with the worst obs as sick, I haven’t found it useful (R-VS7).
The ward we are on is fantastic there and obviously a lot of the time we will say to the doctors, you know, patient X has PEWed this but obviously we are not having any nursing concerns but we have to tell you (R-VS2).
Theme 2: Circumventing DETECT e-PEWS
It’s easy to fall back to old ways
I use it … Every shift probably multiple times a shift … … I don’t use the computer for anything …. [but] I probably use them at the bedside less than 50% of the time … I still tend to do obs as I used to, write them down on a bit of paper and then fill them in when I come out of the cubicle. It’s just a habit really that I haven’t really changed. … … …… I tend to do it straight away as soon as I come out, but say if I am really busy and have got other things to do, then it might be like 10 minutes and I will do my whole set of 4 obs first and then put them all in on the system (D-VS5). I carry mine all the time [but] the girls on the ward don’t generate tasks specific for me … .because I am ward based and I am walking around the ward all the time, so if there is an issue they will just grab me rather than generate a task (R-VS3).
It’s not reliable in terms of getting a response,
If it was something that they have PEWed high then I do feel more comfortable just bleeping them and speaking to the over the phone. Yeah so you know they have definitely read it and are definitely aware of it, you have heard them talk to you (D-VS5). I think people have been nervous and they haven’t been reassured that it is going to get picked up and they don’t want to leave there patients but they start to get a bit paranoid as a nurse as you start to think I need this patient to be seen (R-VS2).
Because a lot of the medics haven’t been using the task list properly, they’ll see a task but the medics wont complete the task or respond to the task, so the wards will then bleep and they just got out the habit of it, it wasn’t really working because everyone wasn’t on board with it hopefully that’s getting sorted with plans ahead for that (R-VS5).
I think [nurses] probably because their experience I expect has been that when they put a job on Careflow no one does it and they have to bleep them anyway. I think they disengage (R-VS7).
Theme 3: Disregarding DETECT e-PEWS
At the start we were trying to use the way to alert doctors but now we’ve got our own consultants on the ward so we don’t tend to use, we don’t use the detects for that any more. We just go to our own doctors (D-VS3).
Not too sure if they [doctors] take [DETECT] as serious as we [staff nurses] do because they don’t use it as much or they’re not as reliable with it and don’t count on it as much as we do (D-VS6).
The doctors I mean, especially the surgeons, definitely the surgeons don’t use them. The surgical wards definitely don’t bother for that reason. Medical ones were better but I think it’s definitely sort of tailed off really (R-VS5).
I would say another thing that we noticed and struggled with initially was when we put through concerns to the doctors a lot of the time they weren’t getting picked up on the other end so we would have to go on and bleep and do all the things we were doing so it just doubled up on the workload basically (R-VS2).
Alert fatigue (R-VS6).
I think people have been nervous and they haven’t been reassured that it is going to get picked up and they don’t want to leave there patients but they start to get a bit paranoid as a nurse as you start to think I need this patient to be seen (R-VS2).
It’s not massively used at the moment it’s gone a bit by the wayside but we are trying to reintroduce the task and going to give it another push it a bit more hopefully (R-VS5).
I think when they introduced it, they introduced, apart from the bleeps, we had to carry other device, I think that was impractical because then you were carrying your mobile, your bleep, and a third device, I mean, you don’t have so many pockets (R-VS6).
So ultimately, the doctors not using them is then leading to other people not using them (R-VS5).