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Vital Signs Vermont

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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 eiden!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 hae 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   – (nterention)% what fre*uency of ital signs  C – (+omparison with other treatments$ treatments$ if applicable)% n,a  0 – (Outcomes)% proides 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 eoled " -./0 to -/12  +odified into nursing te3t of the -/12s

4eit' 5 6c+utcheon (7220)


#r #raditional aditional sources of of practice guides guides 8eiew  

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/"-.>

Eans$ D; ?odgkins ?odgkinson$ on$ =; 5 =erry$ <; (722-); :ital signs in hospital patients% a systematic reiew; International Journal of Nursing Studies 0%@A00"@12

Bockwood$ +;$ +onroy"?iller$ T;$ Page$ T; (722A$ December); :ital signs; Systematic 8eiews " <oanna =riggs nstitute$-"0.; 8etrieed Cugu Cugust st -$ 722.$ from Prouest #ursing 5 Cllied ?ealth Source database; (Document D% -A1->/-01-); 

 Clso published in International Journal of Evidence-Based Healtcare! :ol Healtcare!  :ol 7(@)$ <ul 722A; pp; 72>"702 as an update;


'ital Signs( )*** Best Pra!ti!e n#ormation Sheet summary o# !urrent best eiden!e on 12S  Vital Signs versus Observations

 

The measurement of temperature$ pulse$ heart rate and blood pressure is termed both

#either hae been well defined

Limitations  C small number of studies% studies% :,S are $uite limited in terms of detecting important physiologic changes Beel : eidence e3pert opinion


Frequency of Vital Signs 

Bimited information based on  Sureys o# nurses3  

+linical practice reports E3pert opinion

Sureys o# nurses - many admit 

+arry out fre*uent :,S on patients they t hey belieed did not re*uire them 'ritual (

?ad become FroutineG$ unrelated to perceied indiidual patients needs


%here has been little ealuation o# the o"timal #re$uen!y o# "atient obserations


Systematic Review Review,, 2! Pur"ose*   Establish an eidence base for :,S measurement in hos"ital "atients   

6easurements that constitute :,S 0"timal #re$uen!y Bimitations of :,S

Method*  E3plored systematic reiews$ clinical trials and broader issues surrounding FroutineG :,S )ithin a!ute !are setting   

Eans$ ?odgkinson 5 =erry (722-)


Conclusions+ 

  "#uc of current practice of $%S &easure&ent based more on tradition and tradition and e'pert opinion tan on researc(

Re!ommendation* furter researc into te broader issues  issues of $%S &easure&ent to ensure   

&ost useful para&eters &onitored  at an appropriate frequency  using accurate tecniques 

Eans$ ?odgkinson 5 =erry (722-)


Syste&atic re"iew , -../ 0b4e!tie  %o "resent the best aailable 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

 Eiden!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-ealuation of the role of :,S % 

" it appears tat at ti&es tis practice is underta,en &ore troug routine tan 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 obserations - Pulse o3 measurement$ smoking and mental status  

enhances early detection of aderse eents mproe outcomes

Ne't steps. ncorporate steps. ncorporate the patient,family as collaborators in obseration (consistent with E=P)


0oing further 1ack in the &edical literature…


Cost-ineffective nursing care? 1978 Orders written by 6ED+CB 8ESDE#TS K  :S fre*uency did not !orrelate  with subse*uent critical eents  FSuch orders K)aste#ul of nursing resourcesKother s.illed obserations may be neglectedGL 

8esulted in a signi#i!ant time-!onsuming   & !ost-ine##e!tie

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$ een at night  N=enefits did not outweigh detriments of sleep depriation in fre*uent night monitoring 

 time2e"ense #or a nursing a!tiity 

#EED% Prospectie 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 ealuation didin% not result in statistically significant difference 


progression of disease

predict of patient disposition 

Potti$ Panwalkar$ ?ebert$ Sholes$ Bewis$ 5 ?anley$ 7220


$nd &ounts , -..3 

Purpose. Ealuate the benefit from Purpose. Ealuate fre*uent,routine monitoring of :,S on clinically releant 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 ([email protected])


4adical redefinition of what5s 6"ital7 

:ital signs I ital for clin clinical ical decisions

6onitoring is e3pensie and,or inaccurate Toms E; (-//0) #ursing rituals% :ital obserati obserations; ons; Nursing /i&es

Present fre*uency not cost,time"effectie cost,time"effectie

Need* an indiiduali6ed assessment of :,S measurement fre*uency 

6ore efficient allocation of resources

ncreased patient priacy 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 proided 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 uncoering and,or warning of coming aderse eents

Maybe there is no answer to these questions?  qu estions? 


What we do know 

He like to say our practice is eidence"based$ howeer$$ Fthe reality is that this is merely howeer rhetoric we hae done little to proide the rigorousas eidence re*uired to inform practiceG 

4eit' 5 6c+utcheon$ 7220

Presently FroutineG :,S measurement is   inaccurate

+ounterproductie  cost ineffectie 

6ariani$ Saeed$ Saeed$ Potti$ ?eb ?ebert$ ert$ Sholes$ Bewis$ 5 ?anley ([email protected])


What we should do  C+Q#OHBEDME%  C+Q#OHBEDME%  +ollecting :,S is one nursing treatment supported more by tradition rather than empirical eidence 

Optimal fre*uency of :,S sign measurement has yet to be elucidated –nursings 9obL

He need to indiiduali'e assessment of :,S measurement " for more e##i!ient allocation of hospital resources


%inding and using the e"idence 

Criti!ally a""raise eisting eiden!e that

you #ind in your sear!h  5se 9best eiden!e: to guide "ra!ti!e 

+hen there is a la!. o# eiden!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!essie '( use o# an!illary seri!es  nsu##i!ient em"hasis on 

a""ro"riateness of nursing serices effect on oerall health"care costs NN #hat is role of $ursing s%illed observation?  

6ariani$ Saeed$ Potti$ Potti$ ?ebert$ Sholes$ Bewis$ Bewis$ 5 ?anley ([email protected])


Skilled o"servation 

PhysiciansL re*uest nurses to use more e##i!ient and a""ro"riate methods o# !lini!al obseration  obseration  (:autrain 5 Mriner $ -/>.)

obseration, more appropriate for F1isual obseration, more monitoring patient status and progressG (Eans et al;$ 722-)

/e role of visual & #  & #  en and if tis en could replace vital observation sign &easures0 12oc,ood! et 3l4! 3l4!   5667) 

#ursing obserations within 7A hours of surgical procedure  (4eit'$ 7221)


4edesigning the work en"iron&ent =egins with nursing ter&inology  

E3ternal manifestation of professional thinking 

"te dress of our tougts" 

6eyer 5 Bain ( 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& 

0bseration is Floo,ing Floo,ing and listening to te su+9ective and o+9ective infor&ation infor&ati on tat te  patient provides(  provides(   

4eit' (7221)

Our primary role% Surveillance 

:eit; 1566<)= 6eyer 5 Bain ( 7221)


What is the e"idence9 

Present methods of fre*uency of :,S determination does not a##e!t surial 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 serices serices will% will%  minimi6e e"ense o#   unnecessary tasks  unnecessary  alleiate the burden  to nurses 


8edirect resources  more imperatie

nursing treatments


“Failure to rescue”  Identifying patients at risk of an in,hospital  ad"erse e"ent  The money *uestion% ?ow do we preent aderse eents$ and what is the relationship to FroutineG ital sign collection


$d"erse e"ent ;$< pre"ention L%ERA%5RE L%ERA% 5RE RE1E+* 

8ole of nurses in CE preention from the perspectie of Fphysiologic safetyG

Eiden!e* canges 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 "reenting aderse eents

%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% sureillan!e older hospitali'ed adults at risk for falls 

Sheer$ B;$ %itler, M3;$ Qerr$ P; (722.); The effect of high nursing sureillance on hospital cost; Journal of Nursing Scolarsip  Scolarsip 



; <=> #alls )ho re!eied high sureillan!e   Patients )ho re!eied lo) or no sureillan!e ; [email protected] #alls 

  Cost aoidan!e #or one #all ; <>,7? 

 Findings: !igh sur"eillance cost ?)*)@ hospitaliAation


%he essen!e o# sureillan!e sureillan!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 aderse eent% mplications for nursing practice International practice  International Journal of Nursing Practice 722AR < % 7-–0Dais$ :ital signs of +lass  surgical patients; Hest < #urs 6;<; 8es (-//2); -7% A2"AEans$ D; ?odgkinson$ =; 5 =erry$ =erry$ <; (722-); :ital signs in hospital patients% a systematic reiew; 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 3nestetists! 3nestetists! @ (7)$ (7)$ /@"/. Bockwood$ +;$ +onroy"?iller$ T;$ Page$ T; (722A$ December); :ital signs; Systematic 8eiews " <oanna =riggs nstitute$-"0.; 8etrieed Cugust Cugust -$ 722.$ from Prouest #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 <&;; ([email protected]); neffectieness 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;$ Bain$ 6;C; 6eyer 6;C; (<une 70$ 7221 7221); ); :igilance% The Essence of #ursing 8nline Journal of Issues in Nursing ; Cailable% http%,,nursingworld;org,o9in,topic77,tpc77@;htm retrieed from the http%,,nursingworld;org,o9in,topic77,tpc77@;htm retrieed internet$ @,02,21 Potti$ C;$ Panwalkar$C; Panwalkar$C; ?ebert$ =;$ S Sholes$ holes$ Q;$ Bewis$ 6;<;$ 5 ?anley$ <; (7220); neffectieness of 6easuring 8outine :ital Signs in Cdult npatients Hith Deep :enous Thrombosis; +lin Cppl Thrombosis,?emostasis /(7)%[email protected]"[email protected]@ Schumacher S;= (-//1);; 6 6onitoring onitoring ital signs to identify postoperatie complications; 6ed Surg #urs A% -A7"1 Sharda$ S;$ +arter$ <;$ Hingard$ <8;$ 5 6ehta$ P; P; (722-); #ursing obserations 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 

Sheer$ B;$ Titler$ 6;$ Qerr$ P; (722.); The effect of high nursing sureillance on hospital cost; <ournal of #ursing Scholarship Scholarship A2 (7)%[email protected]"@/

 :autrain 8B 5 resources$ Mriner P& (-/>.); PhysicianUs orders$ use of nursing and subse*uent clinical eents; <ournal Of 6edical Education V< 6ed EducW 10 (7)%-71".; 4eit'$ Q;$ 5 6c+utcheon$ ?; (7220); Eidence"based practice% To be or notofto#ursing be$ this Practice is the *uestion; nternational <ournal / (7>7–7>/) 4eit'$ Q; (7221); #ursing obserations 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

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