Vital SignsThe ultimate traditionAn EBP Journey of discovery
Christine Malmgreen, RN-BC MS MA&
Dr Lillie Shortridge-Baggett, EdD RN NP&
Maggie Adler, RN-BC BSN Masters Candidate
Have things really changed?
Literature synthesis to establish an evidence-based policy on routine
vital sign frequency
Ways of Knowing =Sources of Knowledge
TraditionAuthorityExperience
(trial and error)
Sources of knowledge for practice
Tradition – Something is done in a specific way because it has always been done that way
Authority – Something is done in a certain way because
someone in authority
has said to do it this way
(Policy and procedure)
Definitions of Ways of Knowing
Experience – Trial and ErrorOne method of doing something is triedDoes it work?Yes - continue No – try something
else
(Definition of insanity)
Begins with a question…
Start here:What have you wondered about?Why do we do things this way? Is there a better way?
Begin by asking
a focused clinical question
PICO
P – (Patient, Population or Problem): For hospitalized patients
I – (Intervention): what frequency of vital signs
C – (Comparison with other treatments, if applicable): n/a
O – (Outcomes): provides the most efficient model without sacrificing patient safety
History of nurses taking vital signs
No reference to any form of vital sign monitoring by nurses pre 1893
Concept of nurses taking vital signs evolved - 1893 to 1950
Codified into nursing text of the 1950s
Zeitz & McCutcheon (2003)
Traditional sources of practice guides
Review Major nursing textbooks Policies for recommendations
Frequency of recording postoperative vital signs
Frequency of vital sign collection based on Traditions
NONE supported by EVIDENCE
Zeitz & McCutcheon (2003).
A hierarchy of evidence
Finding a systematic review
We found three:
Joanna Briggs Institute (1999). Vital Signs. Best Practice Bulletin 3 (3): ISSN 1329-187
Evans, D. Hodgkinson, B. & Berry, J. (2001). Vital signs in hospital patients: a systematic review. International Journal of Nursing Studies 3:6433-650
Lockwood, C., Conroy-Hiller, T., Page, T. (2004, December). Vital signs. Systematic Reviews - Joanna Briggs Institute,1-38. Retrieved August 1, 2008, from ProQuest Nursing & Allied Health Source database. (Document ID: 1451791351).
Also published in International Journal of Evidence-Based Healthcare, Vol 2(6), Jul 2004. pp. 207-230 as an update.
Vital Signs, 1999
Best Practice Information Sheet summary of current best evidence on V/S
Vital Signs versus Observations The measurement of temperature, pulse, heart rate
and blood pressure is termed both Neither have been well defined
Limitations A small number of studies: V/S are quite limited in
terms of detecting important physiologic changes Level IV evidence ~expert opinion
Frequency of Vital Signs
Limited information based on Surveys of nurses* Clinical practice reports Expert opinion
Surveys of nurses - many admit Carry out frequent V/S on patients they
believed did not require them (ritual) Had become “routine”, unrelated to perceived
individual patients needs
There has been little evaluation of the optimal frequency of patient
observations
Systematic Review, 2001
Purpose: Establish an evidence base for V/S measurement in
hospital patients Measurements that constitute V/S Optimal frequency Limitations of V/S
Method: Explored systematic reviews, clinical trials and
broader issues surrounding “routine” V/S within acute care setting
Evans, Hodgkinson & Berry (2001)
Conclusions:
“Much of current practice of V/S measurement based more on tradition and expert opinion than on research”
Recommendation: further research …into the broader issues of V/S measurement to ensure most useful parameters monitored at an appropriate frequency using accurate techniques
Evans, Hodgkinson & Berry (2001)
Systematic review - 2004
Objective
To present the best available information related to the monitoring of patient V/S Purpose of V/S Limitations of V/S Optimal frequency of measurements What measures should constitute vital signs
Lockwood, Conroy-Hiller, & Page (2004, December)
The evidence
A variety of measures may be useful additions to the traditional four V/S
Monitoring these can change patient care and outcomes: pulse oximetry smoking status
Evidence based: V/S monitoring frequency for patients
returning from PACU after surgery
Findings
Considerable research on many aspects of V/S “wealth of research” on ensuring accuracy NOT reflected in practice
Still need to know: WHAT parameters to measure Optimal frequency Role of technology (new)
Conclusions
A re-evaluation of the role of V/S : “ it appears that at times this practice is
undertaken more through routine than any serious attempt to monitor patient status”
The exact role of vital signs in healthcare institutions needs to be redefined to ensure optimal practice
Vital Signs policy and procedure
“Routine vital signs” - redefined Q shift = q 12 hr More frequent based on nursing judgment
Specific guidelines for accurate measurement Unlicensed personnel assigned tasks
Include as nursing observations - Pulse ox measurement, smoking and mental status enhances early detection of adverse events Improve outcomes
Next steps: Incorporate the patient/family as collaborators in observation (consistent with EBP)
Going further back in the medical literature…
Cost-ineffective nursing care? 1978
Orders written by MEDICAL RESIDENTS … VS frequency did not correlate with
subsequent critical events “Such orders …wasteful of nursing
resources…other skilled observations may be neglected”!
Resulted in a significant time-consuming & cost-ineffective nursing care
Vautrain & Griner, 1978
The evidence mounts -2001
Premise: Frequent VS monitoring presumed to be required for safe management of transplant patients, even at night
*Benefits did not outweigh detriments of sleep deprivation in frequent night monitoring
NEED: Prospective studies to accurately identify day time risk factors to predict need for night time monitoring
Sharda, Carter, Wingard, & Mehta (2001)
time/expense for a nursing activity
And mounts - 2003
Purpose: Evaluate benefit of routine V/S monitoring on clinical outcomes in DVT
More frequent V/S evaluation did not result in statistically significant difference in: survival progression of disease predict of patient disposition
Potti, Panwalkar, Hebert,
Sholes, Lewis,
& Hanley, 2003
And mounts - 2006
Purpose: Evaluate the benefit from frequent/routine monitoring of V/S on clinically relevant outcomes in hospitalized patients with CAP as a model
*Urgent need for refinement of common clinical practice of ‘routine’ (Q6H) V/S in hospitalized patients
Mariani, Saeed, Potti, Hebert, Sholes, Lewis, & Hanley (2006)
Radical redefinition of what’s “vital”
Vital signs = ‘vital’ for clinical decisions
Monitoring is expensive and/or inaccurateToms E. (1993) Nursing rituals: Vital observations. Nursing Times
Present frequency not cost/time-effective
Need: an individualized assessment of V/S measurement frequency
More efficient allocation of resources Increased patient privacy and satisfaction
…And about those frequencies..?
One group of physician-researchers indicted what routine V/S frequency should NOT be
more frequently than q 8 hrs
None provided insight into How frequently V/S need to be done Who should determine this frequency
On what basis? What about the impact of “routine” monitoring
procedures on uncovering and/or warning of coming adverse events?
Maybe there is no answer to these questions?
What we do know
We like to say our practice is evidence-based, however, “the reality is that this is merely rhetoric as we have done little to provide the rigorous evidence required to inform practice”
Zeitz & McCutcheon, 2003
Presently “routine” V/S measurement is inaccurate Counterproductive ~ cost ineffective
Mariani, Saeed, Potti, Hebert, Sholes, Lewis, & Hanley (2006)
What we should do
ACKNOWLEDGE: Collecting V/S is one nursing treatment
supported more by tradition rather than empirical evidence
Optimal frequency of V/S sign measurement has yet to be elucidated –nursing’s job!
We need to individualize assessment of V/S measurement - for more efficient allocation of hospital resources
Finding and using the evidence
Critically appraise existing evidence that you find in your search
Use “best evidence” to guide practice
When there is a lack of evidence:Then what?
Beyond routine V/S
Becoming more cost-conscious
Spiraling hospital costs = need for critical analyses of practices
Significant attention to the rising cost of hospital care: Excessive (?) use of ancillary services Insufficient emphasis on
appropriateness of nursing services effect on overall health-care costs ** What is role of Nursing skilled observation?
Mariani, Saeed, Potti, Hebert, Sholes, Lewis, & Hanley (2006)
Skilled observation
Physicians! request nurses to use more efficient and appropriate methods of clinical observation (Vautrain & Griner, 1978)
“Visual observation, more appropriate for monitoring patient status and progress” (Evans et al., 2001)
The role of visual observation – When and if this could replace vital sign measures? (Lockwood, et Al., 2004)
Nursing observations within 24 hours of surgical procedure (Zeitz, 2005)
Redesigning the work environment
Begins with nursing terminology External manifestation of
professional thinking “the dress of our thoughts“
Meyer & Lavin ( 2005) Online Journal of Issues
in Nursing
"Vigilance: The Essence of Nursing"
To encompass The Work of nurses requires redesigning, transforming
reconceptualizing care concepts
Nightingale’s wisdom
Observation is “looking and listening to the subjective and objective information that the patient provides”
Zeitz (2005)
Our primary role: Surveillance
Zeitz (2005); Meyer & Lavin ( 2005)
What is the evidence?
Present methods of frequency of V/S determination does not affect survival outcome
Risk of clinical deterioration and relationship to increased frequency V/S measurement does not correlated with outcomes
Appropriate utility of nursing services will: minimize expense of unnecessary tasks alleviate the burden to nurses Redirect resources ~ more imperative
nursing treatments
“Failure to rescue” Identifying patients
at risk of an in-hospital
adverse event
The money question: How do we prevent adverse events, and what is the relationship to
“routine” vital sign collection?
Adverse event (AE) prevention
LITERATURE REVIEW: Role of nurses in AE prevention from the
perspective of “physiologic safety”
Evidence: changes in LOC and altered respiratory rate/function = warning of AE
NURSES -make decisions outside of usual boundaries in best interests of patient
Considine & Botti (2004). International Journal of Nursing Practice
With a growing emphasispreventing adverse events
The vital role of nurses not just data collectors
Implications for practice
Interpreters of multiple and complex patient data gathered in context of the whole picture
presented by the patient =
enables capture of impending AE
Surveillance ~ A STUDY
* Earlier research identified: factors associated with hospital costs (one = nursing treatments)
Purpose of this study: determine cost of one nursing treatment
Independent variable: surveillance older hospitalized adults at risk for falls
Shever, L., Titler, M*., Kerr, P. (2008). The effect of high nursing surveillance on hospital cost. Journal of Nursing Scholarship
Findings: High surveillance cost $191/ hospitalization
Patients who received high surveillance = 157 falls Patients who received low or no surveillance = 324 falls Cost avoidance for one fall = $17,483
Discharged home, good quality of
life maintained = priceless
Amazing fact: Majority of protocols for Rapid Response teams look for alterations in V/S (B/P, pulse, rarely respirations) as reasons for initiating a rapid response!
The essence of surveillance = mundane, not dramatic
Make sure nothing happens (at least, nothing bad)
References Considine J, Botti M. (2004). Who, when and where?
Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice International Journal of Nursing Practice 2004; 10 : 21–31
Davis, M.J. (1990). Vital signs of Class I surgical patients. West J Nurs Res 12: 40-41
Evans, D. Hodgkinson, B. & Berry, J. (2001). Vital signs in hospital patients: a systematic review. International Journal of Nursing Studies 3 (2001) 6433-650
Hirter, J., & Van Nest, R.L. (1995). Vigilance: A concept and a reality. CRNA: The Clinical Forum for Nurse Anesthetists, 6(2), 96-98
Lockwood, C., Conroy-Hiller, T., Page, T. (2004, December). Vital signs. Systematic Reviews - Joanna Briggs Institute,1-38. Retrieved August 1, 2008, from ProQuest Nursing & Allied Health Source database. (Document ID: 1451791351).
References (con’t) Mariani P, Saeed MU, Potti A, Hebert B, Sholes K, Lewis MJ, Hanley
JF. (2006). Ineffectiveness of the measurement of ‘routine’ vital signs for adult inpatients with community-acquired pneumonia. International Journal of Nursing Practice 12 (105–109)
Meyer, G., Lavin, M.A. (June 23, 2005). "Vigilance: The Essence of Nursing" Online Journal of Issues in Nursing. Available: http://nursingworld.org/ojin/topic22/tpc22_6.htm retrieved from the internet, 6/30/05
Potti, A., Panwalkar,A. Hebert, B., Sholes, K., Lewis, M.J., & Hanley, J. (2003). Ineffectiveness of Measuring Routine Vital Signs in Adult Inpatients With Deep Venous Thrombosis. Clin Appl Thrombosis/Hemostasis 9(2):163-166
Schumacher S.B (1995).. Monitoring vital signs to identify postoperative complications. Med Surg Nurs 4: 142-5
Sharda, S., Carter, J., Wingard, JR., & Mehta, P. (2001). Nursing observations Monitoring vital signs in a bone marrow transplant unit: are they needed in the middle of the night? Bone Marrow Transplantation 27 (1197–1200)
References
Shever, L., Titler, M., Kerr, P. (2008). The effect of high nursing surveillance on hospital cost. Journal of Nursing Scholarship 40 (2):161-69
Vautrain RL & Griner PF (1978). Physician's orders, use of nursing resources, and subsequent clinical events. Journal Of Medical Education [J Med Educ] 53 (2):125-8.
Zeitz, K., & McCutcheon, H. (2003). Evidence-based practice: To be or not to be, this is the question. International Journal of Nursing Practice 9 (272–279)
Zeitz, K. (2005). Nursing observations during the first 24 hours after a surgical procedure: what do we do? Journal of Clinical Nursing, 14, 334–343
Thanks to
Magnet project listserv members for their responses to the query:
General Medical Unit Frequency of Vital Signs