Vital Signs Vermont
Content
Vital Signs The ultimate tradition An EBP Journey Journey of discovery
Christine Malmgreen, RN-BC MS MA & Dr Lillie Shortridge-Baggett, EdD RN NP & Maggie Adler, RN-BC BSN Masters Candidate
Literature synthesis to establish an eiden!ebased "oli!y on routine ital sign #re$uen!y
a v e t h i n g s r e a l ly ly changed?
Ways of Knowing = Sources of Knowledge %radition Authority E"erien!e
'trial and error(
Sources of knowledge for practice %radition – Something is done in a specific way because it has al)ays been done that )ay Authority – Something is done in in a certain way because someone in authority has said to do it this way (Policy and procedure)
Definitions of Ways of Knowing
E"erien!e – Trial and Error One method of doing something is tried
Does it work !es " continue
#o – try something else
(Definition of insanity)
Begins with a question…
Start here* +hat hae you )ondered about +hy do )e do things this )ay s there a better )ay
Begin by as.ing a #o!used !lini!al $uestion
PIC P / (Patient$ Population or Problem)% &or hospitali'ed patients – (nterention)% what fre*uency of ital signs C – (+omparison with other treatments$ treatments$ if applicable)% n,a 0 – (Outcomes)% proides the most efficient model without sacrificing patient safety
!istory of nurses taking "ital signs
#o reference to any form of ital
sign monitoring by nurses pre -./0 +oncept of nurses ta.ing ital signs eoled " -./0 to -/12 +odified into nursing te3t of the -/12s
4eit' 5 6c+utcheon (7220)
#r #raditional aditional sources of of practice guides guides 8eiew
6a9or nursing te3tbooks Policies for recommendations
Frequency of recording postoperative vital signs
&re*uency of ital sign collection based on %raditions
#O#E supported by E:DE#+E
4eit' 5 6c+utcheon (7220);
$ hierarchy of e"idence
%inding a syste&atic re"iew +e #ound three%
<oanna =riggs nstitute (-///); :ital Signs; Best Practice Bulletin 0 Bulletin 0 (0)% SS# -07/"-.>
Eans$ D; ?odgkins ?odgkinson$ on$ =; 5 =erry$ <; (722-); :ital signs in hospital patients% a systematic reiew; International Journal of Nursing Studies 0%@A00"@12
Bockwood$ +;$ +onroy"?iller$ T;$ Page$ T; (722A$ December); :ital signs; Systematic 8eiews " <oanna =riggs nstitute$-"0.; 8etrieed Cugu Cugust st -$ 722.$ from Prouest #ursing 5 Cllied ?ealth Source database; (Document D% -A1->/-01-);
Clso published in International Journal of Evidence-Based Healtcare! :ol Healtcare! :ol 7(@)$ <ul 722A; pp; 72>"702 as an update;
'ital Signs( )*** Best Pra!ti!e n#ormation Sheet summary o# !urrent best eiden!e on 12S Vital Signs versus Observations
The measurement of temperature$ pulse$ heart rate and blood pressure is termed both
#either hae been well defined
Limitations C small number of studies% studies% :,S are $uite limited in terms of detecting important physiologic changes Beel : eidence e3pert opinion
Frequency of Vital Signs
Bimited information based on Sureys o# nurses3
+linical practice reports E3pert opinion
Sureys o# nurses - many admit
+arry out fre*uent :,S on patients they t hey belieed did not re*uire them 'ritual (
?ad become FroutineG$ unrelated to perceied indiidual patients needs
%here has been little ealuation o# the o"timal #re$uen!y o# "atient obserations
Systematic Review Review,, 2! Pur"ose* Establish an eidence base for :,S measurement in hos"ital "atients
6easurements that constitute :,S 0"timal #re$uen!y Bimitations of :,S
Method* E3plored systematic reiews$ clinical trials and broader issues surrounding FroutineG :,S )ithin a!ute !are setting
Eans$ ?odgkinson 5 =erry (722-)
Conclusions+
"#uc of current practice of $%S &easure&ent based more on tradition and tradition and e'pert opinion tan on researc(
Re!ommendation* furter researc into te broader issues issues of $%S &easure&ent to ensure
&ost useful para&eters &onitored at an appropriate frequency using accurate tecniques
Eans$ ?odgkinson 5 =erry (722-)
Syste&atic re"iew , -../ 0b4e!tie %o "resent the best aailable in#ormation related to the monitoring o# "atient 12S Purpose of :,S
Bimitations of :,S
0"timal #re$uen!y o# measurements Hhat measures should constitute ital signs
Bockwood$ +onroy"?iller$ 5 Page (722A$ December)
#he e"idence C ariety of measures may be use useful ful additions to the traditional four :,S
6onitoring outcomes% these can change patient care and
pulse o3imetry
smoking status
Eiden!e based* :,S monitoring #re$uen!y #or "atients returning returnin g #rom PAC5 a#ter surgery
%indings *onsidera+le researc on &any aspects of $%S
Fwealth of researchG on ensuring accuracy #OT reflected in practice Still need to ,no.
H?CT parameters to measure 0"timal #re$uen!y
8ole of technology (new)
Conclusions A re-ealuation of the role of :,S %
" it appears tat at ti&es tis practice is underta,en &ore troug routine tan any serious atte&pt to &onitor patient status(
The exact role of vital signs in healthcare institutions needs to be redefined to ensure optimal practice
'ital Signs policy and procedure
F8outine ital signsG " redefined shift I * -7 hr 6ore fre*uent based on nursing 4udgment
Specific guidelines for accurate measurement Jnlicensed personnel assigned tasks nclude as nursing obserations - Pulse o3 measurement$ smoking and mental status
enhances early detection of aderse eents mproe outcomes
Ne't steps. ncorporate steps. ncorporate the patient,family as collaborators in obseration (consistent with E=P)
0oing further 1ack in the &edical literature…
Cost-ineffective nursing care? 1978 Orders written by 6ED+CB 8ESDE#TS K :S fre*uency did not !orrelate with subse*uent critical eents FSuch orders K)aste#ul of nursing resourcesKother s.illed obserations may be neglectedGL
8esulted in a signi#i!ant time-!onsuming & !ost-ine##e!tie
nursing !are
:autrain 5 Mriner$ -/>.
#he e"idence &ounts ,-..) Pre&ise. &re*uent :S monitoring "resumed Pre&ise. &re*uent to be re*uired for safe management of transplant patients$ een at night N=enefits did not outweigh detriments of sleep depriation in fre*uent night monitoring
time2e"ense #or a nursing a!tiity
#EED% Prospectie studies to accurately identify day time risk factors to predict need for night time monitoring
Sharda$ +arter$ Hingard$ 5 6ehta (722-)
$nd &ounts , -..2
Purpose. E aluate aluate benefit of routine :,S monitoring on clinical outcomes in D:T
6ore fre*uent :,S ealuation didin% not result in statistically significant difference
surial
progression of disease
predict of patient disposition
Potti$ Panwalkar$ ?ebert$ Sholes$ Bewis$ 5 ?anley$ 7220
$nd &ounts , -..3
Purpose. Ealuate the benefit from Purpose. Ealuate fre*uent,routine monitoring of :,S on clinically releant outcomes in hospitali'ed patients with +CP as a model
NJrgent need for refinement of common clinical practice of routine (@?) :,S in hospitali'ed patients
6ariani$ Saeed$ Saeed$ Potti$ ?eb ?ebert$ ert$ Sholes$ B Bewis$ ewis$ 5 ?anley (722@)
4adical redefinition of what5s 6"ital7
:ital signs I ital for clin clinical ical decisions
6onitoring is e3pensie and,or inaccurate Toms E; (-//0) #ursing rituals% :ital obserati obserations; ons; Nursing /i&es
Present fre*uency not cost,time"effectie cost,time"effectie
Need* an indiiduali6ed assessment of :,S measurement fre*uency
6ore efficient allocation of resources
ncreased patient priacy and satisfaction
…$nd a1out those frequencies889 One group of physician"researchers indicted what routine :,S fre*uency should N0% be
more #re$uently than $ 7 hrs
#one proided insight into 8o) fre*uently :,S need to be done +ho should determine this fre*uency
On what basis
+hat about the impact of FroutineG monitoring procedures on uncoering and,or warning of coming aderse eents
Maybe there is no answer to these questions? qu estions?
What we do know
He like to say our practice is eidence"based$ howeer$$ Fthe reality is that this is merely howeer rhetoric we hae done little to proide the rigorousas eidence re*uired to inform practiceG
4eit' 5 6c+utcheon$ 7220
Presently FroutineG :,S measurement is inaccurate
+ounterproductie cost ineffectie
6ariani$ Saeed$ Saeed$ Potti$ ?eb ?ebert$ ert$ Sholes$ Bewis$ 5 ?anley (722@)
What we should do C+Q#OHBEDME% C+Q#OHBEDME% +ollecting :,S is one nursing treatment supported more by tradition rather than empirical eidence
Optimal fre*uency of :,S sign measurement has yet to be elucidated –nursings 9obL
He need to indiiduali'e assessment of :,S measurement " for more e##i!ient allocation of hospital resources
%inding and using the e"idence
Criti!ally a""raise eisting eiden!e that
you #ind in your sear!h 5se 9best eiden!e: to guide "ra!ti!e
+hen there is a la!. o# eiden!e* Then what? eyond routine V!S
Beco&ing &ore cost,conscious Spiraling hospital costs " need for critical analyses of practices
Significant attention to the rising cost of hospital care% E!essie '( use o# an!illary seri!es nsu##i!ient em"hasis on
a""ro"riateness of nursing serices effect on oerall health"care costs NN #hat is role of $ursing s%illed observation?
6ariani$ Saeed$ Potti$ Potti$ ?ebert$ Sholes$ Bewis$ Bewis$ 5 ?anley (722@)
Skilled o"servation
PhysiciansL re*uest nurses to use more e##i!ient and a""ro"riate methods o# !lini!al obseration obseration (:autrain 5 Mriner $ -/>.)
obseration, more appropriate for F1isual obseration, more monitoring patient status and progressG (Eans et al;$ 722-)
/e role of visual & # & # en and if tis en could replace vital observation sign &easures0 12oc,ood! et 3l4! 3l4! 5667)
#ursing obserations within 7A hours of surgical procedure (4eit'$ 7221)
4edesigning the work en"iron&ent =egins with nursing ter&inology
E3ternal manifestation of professional thinking
"te dress of our tougts"
6eyer 5 Bain ( 7221)
8nline Journal of Issues in Nursing
"Vigilance: The ssence of !ursing" To encompass %he +or. of nurses re*uires redesigning$ trans#orming reconceptuali'ing care concepts
:ightingale5 :ightingale5ss wisdo&
0bseration is Floo,ing Floo,ing and listening to te su+9ective and o+9ective infor&ation infor&ati on tat te patient provides( provides(
4eit' (7221)
Our primary role% Surveillance
:eit; 1566<)= 6eyer 5 Bain ( 7221)
What is the e"idence9
Present methods of fre*uency of :,S determination does not a##e!t surial out!ome 8isk of clinical deterioration and relationship to increased fre*uency :,S measurement does not !orrelated )ith out!omes Cppropriate utility of nursing nursing serices serices will% will% minimi6e e"ense o# unnecessary tasks unnecessary alleiate the burden to nurses
8edirect resources more imperatie
nursing treatments
“Failure to rescue” Identifying patients at risk of an in,hospital ad"erse e"ent The money *uestion% ?ow do we preent aderse eents$ and what is the relationship to FroutineG ital sign collection
$d"erse e"ent ;$< pre"ention L%ERA%5RE L%ERA% 5RE RE1E+*
8ole of nurses in CE preention from the perspectie of Fphysiologic safetyG
Eiden!e* canges in 28* and altered respiratory rate%function > )arning o# AE
decisions of usual N5RSES "make boundaries in best interestsoutside of patient
+onsidine 5 =otti (722A); International Journal of
Nursing Practice
#m$lications for $ractice
Hith a growing emphasis "reenting aderse eents
%he ital role o# nurses
not 9ust data collectors
nterpreters of multiple and comple3 patient data gathered in conte3t of the whole picture presented by the patient I
enables !a"ture o# im"ending AE AE
Sur"eillance > A ST%&'
N Earlier research identified% factors associated with hospital costs (one I nursing treatments)
Pur"ose o# this study* determine cost of one nursing treatment
ndependent ariable% sureillan!e older hospitali'ed adults at risk for falls
Sheer$ B;$ %itler, M3;$ Qerr$ P; (722.); The effect of high nursing sureillance on hospital cost; Journal of Nursing Scolarsip Scolarsip
Patients
; <=> #alls )ho re!eied high sureillan!e Patients )ho re!eied lo) or no sureillan!e ; ?@ #alls
Cost aoidan!e #or one #all ; <>,7?
Findings: !igh sur"eillance cost ?)*)@ hospitaliAation
%he essen!e o# sureillan!e sureillan!e ; ; mundane, not dramati! Ma.e sure nothing ha""ens 'at least, nothing bad(
# o o y y t t i i l a u $ $ g g o o d e l e e s s ! ! , i i r e " " m d ; o h h e d n n i e a g Ama6ing #a!t* Ma4ority #a!t* Ma4ority o# ! h a r m m a i n n t s s "roto!ols #or Ra"id Res"onse i e e D l i # i# teams loo. #or alterations in 12S 'B2P, "ulse, rarely res"irations( as reasons #or initiating a ra"id res"onse
4eferences
+onsidine <$ =otti 6 6;; (722A); Hho$ when and where dentification of patients at risk of an in"hospital aderse eent% mplications for nursing practice International practice International Journal of Nursing Practice 722AR < % 7-–0Dais$ :ital signs of +lass surgical patients; Hest < #urs 6;<; 8es (-//2); -7% A2"AEans$ D; ?odgkinson$ =; 5 =erry$ =erry$ <; (722-); :ital signs in hospital patients% a systematic reiew; nternational <ournal <ournal of #ursing Studies 0 (722-) @A00"@12 ?irter$ <;$ 5 :an #est$ 8;B; (-//1); :igilance% C concept and a reality; *?N3. /e *linical Foru& for Nurse 3nestetists! 3nestetists! @ (7)$ (7)$ /@"/. Bockwood$ +;$ +onroy"?iller$ T;$ Page$ T; (722A$ December); :ital signs; Systematic 8eiews " <oanna =riggs nstitute$-"0.; 8etrieed Cugust Cugust -$ 722.$ from Prouest #ursing 5 Cllied Cllied ?ealth Source database; (Document D% -A1->/-01-);
4eferences ;con5t
6ariani P$ Saeed 6J$ Potti C$ ?ebert =$ Sholes Q$ Bewis 6<$ ?anley <&;; (722@); neffectieness of the measurement of routine ital signs <& for adult inpatients with with community"ac*uired pneumonia; nternational <ournal of #ursing Practice -7 ((-21–-2/) 21–-2/) 6eyer$$ M;$ Bain$ 6;C; 6eyer 6;C; (<une 70$ 7221 7221); ); :igilance% The Essence of #ursing 8nline Journal of Issues in Nursing ; Cailable% http%,,nursingworld;org,o9in,topic77,tpc77@;htm retrieed from the http%,,nursingworld;org,o9in,topic77,tpc77@;htm retrieed internet$ @,02,21 Potti$ C;$ Panwalkar$C; Panwalkar$C; ?ebert$ =;$ S Sholes$ holes$ Q;$ Bewis$ 6;<;$ 5 ?anley$ <; (7220); neffectieness of 6easuring 8outine :ital Signs in Cdult npatients Hith Deep :enous Thrombosis; +lin Cppl Thrombosis,?emostasis /(7)%-@0"-@@ Schumacher S;= (-//1);; 6 6onitoring onitoring ital signs to identify postoperatie complications; 6ed Surg #urs A% -A7"1 Sharda$ S;$ +arter$ <;$ Hingard$ <8;$ 5 6ehta$ P; P; (722-); #ursing obserations 6onitoring ital signs in a bone marrow transplant unit% are they needed in the middle of the night Bone #arro /ransplantation 7> /ransplantation 7> (-(--/>–-722) />–-722)
4eferences
Sheer$ B;$ Titler$ 6;$ Qerr$ P; (722.); The effect of high nursing sureillance on hospital cost; <ournal of #ursing Scholarship Scholarship A2 (7)%-@-"@/
:autrain 8B 5 resources$ Mriner P& (-/>.); PhysicianUs orders$ use of nursing and subse*uent clinical eents; <ournal Of 6edical Education V< 6ed EducW 10 (7)%-71".; 4eit'$ Q;$ 5 6c+utcheon$ ?; (7220); Eidence"based practice% To be or notofto#ursing be$ this Practice is the *uestion; nternational <ournal / (7>7–7>/) 4eit'$ Q; (7221); #ursing obserations during the first 7A hours after a surgical procedure% what do we do Journal of *linical Nursing $ -A$ 00A–0A0
#hanks to Magnet "ro4e!t listser members #or their res"onses to the $uery*
eneral Medi!al 5nit Fre$uen!y o# 1ital Signs
