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Table 2 Factors affecting vital sign data quality

From: How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments

Themes, categories and example quotes
Theme Main category Subcategory Meaning unit (examples) Quote and type of documentation practice
Care process Standardized process Standardized triage Standardized Triage - Securing Vital Sign measurements “We do triage on all patients arriving at the emergency department. No difference if they are arriving by ambulance or walking in. A short history and vital sign measurements are included in all patients.” PD
   Standardized documentation Standard of documentation improves completeness “I think it has improved a lot (data quality of vital sign). Before the structured workflow was set, respiratory rate was not completed as often as today." DD
   Failure to comply Failure to comply - Individual Clinical Judgement “If a patient has a minor complaint the standard may not be experienced as relevant. In those cases, there may be failure to comply” DD
   Lack of standard Lack of Standard in repeated measurement documentation “A patient was kept close to the nurse desk with automated continuous vital sign measurements for hours. Only two recordings were entered into the EHR.” DD
  Management Quality control Government Control of Care Quality “We received feedback from the National Board of Health and Welfare considering our documentation of vital signs. That has made us change routines on documentation and the way we follow up on compliance with documentation standards” DD
   Change management Resistance to change - switching to digitalized flow [switch to digitalized flow] “It wasn´t completely easy to achieve. At first, the physicians lacked the paper. But nowadays no one wants to switch back.” DD
   Education/training of staff Understanding of documentation importance “You have to educate to increase the understanding why it [documentation] is important. Otherwise, there may be neglect of registrations.” MD
  Competence and knowledge Method and equipment Error sources - temperature, ear wax “When it comes to temperature measurements there may be problems due to simple error sources, like wax in the ear canal.” MD
   Clinical competence Clinical Validity check “You cannot always trust the device. You have to make a clinical validity check. If there is a problem, you may have to recheck or change method.” DD
Information technology Workflow support Mobility Mobile documentation required when switching to digitalized flow “Unless we get access to computers at every room or more mobile ways of working, like iPADs we will likely hold on to the paper triage record” PD
   Overviews Overview of vital sign measurements “We need a good overview of measurements so that they can be followed over time.” PD
   Checklists Process overview and checklist. “What we lack in the EHR is a usable alternative to paper-based triage record. It should provide overviews and checklists to make sure that everything that should be done gets done and that nothing is forgotten” PD
   Calculation support Automatic calculation of triage score “We enter the short history and vital signs in the EHR and with a click, the triage colour will be calculated.” DD
  Documentation support Structured documentation Documentation templates - anxiety about forgetting “It makes sure that everything gets done and that we all do it the same way. It will decrease anxiety about forgetting. “PD
   Logical controls Logical controls - dictation and free text “We use dictation to enter the vital signs into the EHR. It will be entered in free text. There are no built-in logical controls.” MD
   Completeness checks Completeness checks “To complete the triage all vital signs have to be registered. It is a part of the triage process and the system demands a full set.” DD
   Automatic registrations Automatic registrations of measurements to improve completeness “Automatic registration of repeated measurements would really improve documentation. If patients are measured every 15 min, there is no time to manually register all measurements.” DD
  Interoperability Interoperability within system Reuse of information between modules in EHR “We are working in our acute care module. We don’t want to use separate parts of the system making double entries" DD
   Interoperability between system Sharing information with pre-hospital records “Vital signs will be measured in the ambulance. We will manually copy them into our EHR." DD
  1. Footnote: In the table the following abbreviations are used in relation to the quotes; Paper-based documentation (PD), Mixed documentation (MD) and Digital documentation (DD)