The Factors that Affect the Frequency of Vital Sign Monitoring in the Emergency Department

Vital signs monitoring in Australasian emergency departments: Development of a consensus statement from ACEM and CENA

BACKGROUND

Emergency Department (ED) care is provided for a diverse range of patients, clinical acuity and conditions. This diversity often calls for different vital signs monitoring requirements. Requirements often change depending on the circumstances that patients experience during episodes of ED care.

AIM

To describe expert consensus on vital signs monitoring during ED care in the Australasian setting to inform the content of a joint Australasian College for Emergency Medicine (ACEM) and College of Emergency Nursing Australasia (CENA) position statement on vital signs monitoring in the ED.

METHOD

A 4-hour online nominal group technique workshop with follow up surveys.

RESULTS

Twelve expert ED nurses and doctors from adult, paediatric and mixed metropolitan and regional ED and research facilities spanning four Australian states participated in the workshop and follow up surveys. Consensus building generated 14 statements about vital signs monitoring in ED. Good consensus was reached on whether vital signs should be assessed for 15 of 19 circumstances that patients may experience.

CONCLUSION

This study informed the creation of a joint position statement on vital signs monitoring in the Australasian ED setting, endorsed by CENA and ACEM. Empirical evidence is needed for optimal, safe and achievable policy on this fundamental practice.

Development and Comparative Performance of Physiologic Monitoring Strategies in the Emergency Department

IMPORTANCE

Accurate and timely documentation of vital signs affects all aspects of triage, diagnosis, and management. The adequacy of current patient monitoring practices and the potential to improve on them are poorly understood.

OBJECTIVE

To develop measures of fit between documented and actual patient vital signs throughout the visit, as determined from continuous physiologic monitoring, and to compare the performance of actual practice with alternative patient monitoring strategies.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated 25 751 adult visits to continuously monitored emergency department (ED) beds between August 1, 2020, and December 31, 2021. A series of monitoring strategies for the documentation of vital signs (heart rate [HR], respiratory rate [RR], oxygen saturation by pulse oximetry [Spo2], mean arterial pressure [MAP]) was developed and the strategies' ability to capture physiologic trends and vital sign abnormalities simulated. Strategies included equal spacing of charting events, charting at variable intervals depending on the last observed values, and discrete optimization of charting events.

MAIN OUTCOMES AND MEASURES

Coverage was defined as the proportion of monitor-derived vital sign measurements (at 1-minute resolution) that fall within the bounds of nursing-charted values over the course of an ED visit (HR ± 5 beats/min, RR ± 3 breaths/min, Spo2 ± 2%, and MAP ± 6 mm Hg). Capture was defined as the documentation of a vital sign abnormality detected by bedside monitor (tachycardia [HR >100 beats/min], bradycardia [HR <60 beats/min], hypotension [MAP <65 mm Hg], and hypoxia [Spo2 <95%]).

RESULTS

Median patient age was 60 years (IQR, 43-75 years), and 13 329 visits (51.8%) were by women. Monitored visits had a median of 4 (IQR, 2-5) vital sign charting events per visit. Compared with actual practice, a simple rule, which observes vital signs more frequently if the last observation fell outside the bounds of the previous values, and using the same number of observations as actual practice, produced relative coverage improvements of 31.5% (95% CI, 30.5%-32.5%) for HR, 31.0% (95% CI, 30.0%-32.0%) for MAP, 16.8% (95% CI, 16.0%-17.6%) for RR, and 7.8% (95% CI, 7.3%-8.3%) for Spo2. The same strategy improved capture of abnormalities by 38.9% (95% CI, 26.8%-52.2%) for tachycardia, 38.1% (95% CI, 29.0%-47.9%) for bradycardia, 39.0% (95% CI, 24.2%-55.7%) for hypotension, and 123.1% (95% CI, 110.7%-136.3%) for hypoxia. Analysis of optimal coverage suggested an additional scope for improvement through more sophisticated strategies.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, actual documentation of ED vital signs was variable and incomplete, missing important trends and abnormalities. Alternative monitoring strategies may improve on current practice without increasing the overall frequency of patient monitoring.

Utility and Impact Analysis of Inpatient Pediatric Physiologic Monitoring

This study aimed to study the practice and effect of monitoring hospitalized pediatric patients in terms the length of stay (LOS). We have performed a prospective, observational study of pediatric patients in the general ward from October to December 2016. We have recorded the use of cardiac monitor, pulse oximeter, or both, and as per physician order at patient admission. We have studied the proportions of monitoring in different patient groups. We have applied a linear regression model to investigate the relationship between LOS and cardiopulmonary monitoring, orders, and medical complexity. Among 399 patients, patients with cardiac and pulse oximeter monitoring with orders were 68 and 82%, respectively. The pulmonary group had more monitoring than the neurology group of patients. LOS was shorter in patients without monitoring; the median difference for the cardiac monitoring was one day (interquartile range [IQR] = 1), and the pulse oximeter was 0.5 days (IQR = 1). Cardiac monitoring order increased LOS by 22% (95% confidence interval [CI]: 0.5, 48%) and complex past medical history increased it by 25% (95% CI: 4, 51%). Our study highlights the variable practice in using monitors, emphasizing a standardized approach. The judicious use of monitoring may reduce prolonged hospitalization. Selective use of physiologic monitoring of ill-appearing or at risk of hypoxemia or cardiac dysrhythmia will reduce overuse.

Association between Shock Index and Emergency Department Cardiac Arrest

Background

In the emergency department (ED), early identification of patients at risk of cardiac arrest is paramount, especially in the context of overcrowding. The shock index (SI) is defined as the ratio of heart rate to systolic blood pressure. It is a tool used for predicting the prognosis of critically ill and injured patients. In this study, we have discussed the relationship between SI and cardiac arrest in the ED.

Methods

Patients who experienced cardiac arrest in the ED were classified into two groups, SI ≥ 0.9 and < 0.9, according to their triage vital signs. The association between SI ≥ 0.9 and in-hospital mortality was analyzed in five different etiologies of cardiac arrest, including hypoxia, cardiac cause, bleeding, sepsis, and other metabolic problems.

Results

In total, 3,313 patients experienced cardiac arrest in the ED. Among them, 1,909 (57.6%) had a SI of ≥0.9. The incidence of SI ≥ 0.9 in the five etiologies was 43.5% (hypoxia), 58.1% (cardiac cause), 56.1% (bleeding), 58.0% (sepsis), and 65.5% (other metabolic problems). SI was associated with in-hospital mortality (adjusted odds ratio (aOR), 1.6; 95% confidence interval (CI), 1.5–1.8). The aOR (CI) in the five etiologies was 1.3 (1.1–1.6) for hypoxia, 1.8 (1.6–2.1) for cardiac cause, 1.3 (0.98–1.7) for bleeding, 1.3 (1.03–1.6) for sepsis, and 1.9 (1.5–2.1) for other metabolic problems.

Conclusion

More than half of the patients who experienced cardiac arrest in the ED had a SI ≥ 0.9. The SI was also associated with in-hospital mortality after cardiac arrest in the ED. SI maybe used as a screening tool to identify patients at risk of cardiac arrest in the ED and a predictor of mortality in those experiencing cardiac arrest in the ED.

Quality of care, resource use and patient outcome by use of emergency response team compared with standard care for critically ill medical patients in the emergency department: a retrospective single-centre cohort study from Norway

OBJECTIVE

The study aimed to investigate quality of care, resource use and patient outcome in management by an emergency response team versus standard care for critically ill medical patients in the emergency department (ED). The emergency response team was multidisciplinary and had eight members, with a registrar in internal medicine as team leader.

DESIGN

Register-based retrospective cohort study.

SETTING

Tertiary hospital in Norway.

PARTICIPANTS

The study included 1120 patients with National Early Warning Score 2 (NEWS2) 5-10 points from 2015 and 2016. Patients missing ≥3 NEWS2 part scores, <18 years and with orders 'Not for ICU' or 'Not for resuscitation' were excluded.

OUTCOME MEASURES

Quality of care: pain assessment documented, analgesics given within 20 min, complete set of vital signs documented and antibiotics within 60 min if sepsis. Resource use: >3 diagnostic interventions, critical care in the ED and ED length of stay (LOS) <180 min. Patient outcome: intensive care unit (ICU) admission, ICU LOS <66 hours, hospital LOS <194 hours and mortality.

RESULTS

The median age was 66 years, 53.5% were male, 44.3% were admitted to the ICU and the mortality rate was 10.6%. Altogether 691 patients received team management and 429 standard care. Team management had a positive association with 'complete set of vital signs documented' (OR 1.720, CI 1.254 to 2.360), 'analgesics given within 20 minutes' (OR 3.268, CI 1.375 to 7.767) and 'antibiotics within 60 minutes if sepsis' (OR 7.880, CI 3.322 to 18.691), but a negative association with ' pain assessment documented' (OR 0.068, CI 0.037 to 0.128). Team management was also associated with 'critical care in the ED' (OR 9.900, CI 7.127 to 13.751), 'ED LOS <180 min' (OR 2.944, CI 2.070 to 4.187), 'ICU admission' (OR 2.763, CI 1.962 to 3.891) and 'mortality' (OR 1.882, CI 1.142 to 3.102).

CONCLUSIONS

Team management showed positive results for quality of care and resource use. The results for later outcomes such as mortality, ICU LOS and hospital LOS were more ambiguous.

Systems for recognition and response to deteriorating emergency department patients: a scoping review

Background

Assessing and managing the risk of clinical deterioration is a cornerstone of emergency care, commencing at triage and continuing throughout the emergency department (ED) care. The aim of this scoping review was to assess the extent, range and nature of published research related to formal systems for recognising and responding to clinical deterioration in emergency department (ED) patients.

Materials and methods

We conducted a scoping review according to PRISMA-ScR guidelines. MEDLINE complete, CINAHL and Embase were searched on 07 April 2021 from their dates of inception. Human studies evaluating formal systems for recognising and responding to clinical deterioration occurring after triage that were published in English were included. Formal systems for recognising and responding to clinical deterioration were defined as: i) predefined patient assessment criteria for clinical deterioration (single trigger or aggregate score), and, or ii) a predefined, expected response should a patient fulfil the criteria for clinical deterioration. Studies of short stay units and observation wards; deterioration during the triage process; system or score development or validation; and systems requiring pathology test results were excluded. The following characteristics of each study were extracted: author(s), year, design, country, aims, population, system tested, outcomes examined, and major findings.

Results

After removal of duplicates, there were 2696 publications. Of these 33 studies representing 109,066 patients were included: all were observational studies. Twenty-two aggregate scoring systems were evaluated in 29 studies and three single trigger systems were evaluated in four studies. There were three major findings: i) few studies reported the use of systems for recognising and responding to clinical deterioration to improve care of patients whilst in the ED; ii) the systems for recognising clinical deterioration in ED patients were highly variable and iii) few studies reported on the ED response to patients identified as deteriorating.

Conclusion

There is a need to re-focus the research related to use of systems for recognition and response to deteriorating patients from predicting various post-ED events to their real-time use to improve patient safety during ED care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00882-6.

Impact of the coronavirus pandemic on the patterns of vital signs recording and staff compliance with expected monitoring schedules on general wards

Introduction

Coronavirus disease 2019 (COVID-19) placed increased burdens on National Health Service hospitals and necessitated significant adjustments to their structures and processes. This research investigated if and how these changes affected the patterns of vital sign recording and staff compliance with expected monitoring schedules on general wards.

Methods

We compared the pattern of vital signs and early warning score (EWS) data collected from admissions to a single hospital during the initial phase of the COVID-19 pandemic with those in three control periods from 2018, 2019 and 2020. Main outcome measures were weekly and monthly hospital admissions; daily and hourly patterns of recorded vital signs and EWS values; time to next observation and; proportions of ‘on time’, ‘late’ and ‘missed’ vital signs observations sets.

Results

There were large falls in admissions at the beginning of the COVID-19 era. Admissions were older, more unwell on admission and throughout their stay, more often required supplementary oxygen, spent longer in hospital and had a higher in-hospital mortality compared to one or more of the control periods. More daily observation sets were performed during the COVID-19 era than in the control periods. However, there was no clear evidence that COVID-19 affected the pattern of vital signs collection across the 24-h period or the week.

Conclusions

The increased burdens of the COVID-19 pandemic, and the alterations in healthcare structures and processes necessary to respond to it, did not adversely affect the hospitals’ ability to monitor patients under its care and to comply with expected monitoring schedules.

Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department

INTRODUCTION

Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department.

METHOD

A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed.

RESULTS

Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved.

DISCUSSION

Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.

Predicting cardiac arrest in the emergency department

In-hospital cardiac arrest remains a leading cause of death: roughly 300,000 in-hospital cardiac arrests occur each year in the United States, ≈10% of which occur in the emergency department. ED-based cardiac arrest may represent a subset of in-hospital cardiac arrest with a higher proportion of reversible etiologies and a higher potential for neurologically intact survival. Patients presenting to the ED have become increasingly complex, have a high burden of critical illness, and face crowded departments with thinly stretched resources. As a result, patients in the ED are vulnerable to unrecognized clinical deterioration that may lead to ED-based cardiac arrest. Efforts to identify patients who may progress to ED-based cardiac arrest have traditionally been approached through identification of critically ill patients at triage and the identification of patients who unexpectedly deteriorate during their stay in the ED. Interventions to facilitate appropriate triage and resource allocation, as well as earlier identification of patients at risk of deterioration in the ED, could potentially allow for both prevention of cardiac arrest and optimization of outcomes from ED-based cardiac arrest. This review will discuss the epidemiology of ED-based cardiac arrest, as well as commonly used approaches to predict ED-based cardiac arrest and highlight areas that require further research to improve outcomes for this population.

Association of blood pressure documentation with adverse outcomes in an emergency department in Brazil

OBJECTIVE

To associate blood pressure (BP) documentation with adverse outcomes in an emergency department (ED).

METHODS

This is a retrospective observational study, and 642 records of patients admitted to the ED of a tertiary hospital in Brazil were used. We included medical records of patients of both sexes aged over 18 years, who were allocated in general wards in the period December 2015-June 2016. Association between BP measurements with length of stay (LOS), worsening of clinical presentation, unplanned patient transfer, readmission, stroke or transient ischemic attack, cardiorespiratory arrest, and death were investigated.

RESULTS

Association was observed between worsening of clinical presentation and systolic (p = 0.003) or diastolic (p = 0.001) BP values. The association between LOS and worsening of clinical presentation with the number of BP measurements or mean time between BP measurements was statistically significant (p < 0.001). Unplanned patient transfer was associated with an increase in the number of BP measurements (p < 0.001). The mean time between BP measurements was higher among patients who returned to the ED within 48-72 h (p = 0.030).

CONCLUSIONS

The results of this study showed association between BP documentation with adverse outcomes in the ED, reinforcing the need to develop educational strategies regarding nursing records and monitoring of vital signs.

Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study

BACKGROUND

More than one in five patients presenting to the emergency department (ED) with (suspected) infection or sepsis deteriorate within 72 h from admission. Surprisingly little is known about vital signs in relation to deterioration, especially in the ED. The aim of our study was to determine whether repeated vital sign measurements in the ED can differentiate between patients who will deteriorate within 72 h and patients who will not deteriorate.

METHODS

We performed a prospective observational study in patients presenting with (suspected) infection or sepsis to the ED of our tertiary care teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), respiratory rate and body temperature) were measured in 30-min intervals during the first 3 h in the ED. Primary outcome was patient deterioration within 72 h from admission, defined as the development of acute kidney injury, liver failure, respiratory failure, intensive care unit admission or in-hospital mortality. We performed a logistic regression analysis using a base model including age, gender and comorbidities. Thereafter, we performed separate logistic regression analyses for each vital sign using the value at admission, the change over time and its variability. For each analysis, the odds ratios (OR) and area under the receiver operator curve (AUC) were calculated.

RESULTS

In total 106 (29.5%) of the 359 patients deteriorated within 72 h from admission. Within this timeframe, 18.3% of the patients with infection and 32.9% of the patients with sepsis at ED presentation deteriorated. Associated with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well as the variability of the MAP (OR: 1.06). Repeated measurements of heart rate and body temperature were not associated with deterioration.

CONCLUSIONS

Repeated vital sign measurements in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single vital sign measurements at ED admission.

The association between abnormal vital sign groups and undesirable patient outcomes

Introduction:

To determine the association between both abnormal individual vital signs and abnormal vital sign groups in the emergency department, and undesirable patient outcomes: hospital admission, medical emergency team calls and death.

Method:

We undertook a prospective cohort study in a tertiary referral emergency department (February–May 2015). Vital signs were collected prospectively in the emergency department and undesirable outcomes from the medical records. The primary outcomes were undesirable outcomes for individual vital signs (multivariate logistic regression) and vital sign groups (univariate analyses).

Results:

Data from 1438 patients were analysed. Admission was associated with tachycardia, tachypnoea, fever, ≥1 abnormal vital sign on admission to the emergency department, ≥1 abnormal vital sign at any time in the emergency department, a persistently abnormal vital sign, and vital signs consistent with both sepsis (tachycardia/hypotension/abnormal temperature) and pneumonia (tachypnoea/fever) (p < 0.05). Medical emergency team calls were associated with tachycardia, tachypnoea, ≥1 abnormal vital sign on admission (odds ratio: 2.3, 95% confidence interval: 1.4–3.8), ≥2 abnormal vital signs at any time (odds ratio: 2.4, 95% confidence interval: 1.2–4.7), and a persistently abnormal vital sign (odds ratio: 2.7, 95% confidence interval: 1.6–4.6). Death was associated with Glasgow Coma Score ≤13 (odds ratio: 6.3, 95% confidence interval: 2.5–16.0), ≥1 abnormal vital sign on admission (odds ratio: 2.6, 95% confidence interval: 1.2–5.6), ≥2 abnormal vital signs at any time (odds ratio: 6.4, 95% confidence interval: 1.4–29.5), a persistently abnormal vital sign (odds ratio: 4.3, 95% confidence interval: 2.0–9.0), and vital signs consistent with pneumonia (odds ratio: 5.3, 95% confidence interval: 1.9–14.8).

Conclusion:

Abnormal vital sign groups are generally superior to individual vital signs in predicting undesirable outcomes. They could inform best practice management, emergency department disposition, and communication with the patient and family.

Blood pressure documentation in the emergency department

Objective

To analyze the frequency of blood pressure documentation performed by nursing professionals in an emergency department.

Methods

This is a cross-sectional, observational, descriptive, and analytical study, which included medical records of adult patients admitted to the observation ward of an emergency department, between March and May 2014. Data were obtained through a collection instrument divided into three parts: patient identification, triage data, and blood pressure documentation. For statistical analysis, Pearson’s correlation coefficient was used, with a significance level of α<0.05.

Results

One hundred fifty-seven records and 430 blood pressure measurements were analyzed with an average of three measurements per patient. Of these measures, 46.5% were abnormal. The mean time from admission to documentation of the first blood pressure measurement was 2.5 minutes, with 42 minutes between subsequent measures. There is no correlation between the systolic blood pressure values and the mean time interval between blood pressure documentations: 0.173 (p=0.031).

Conclusion

The present study found no correlation between frequency of blood pressure documentation and blood pressure values. The frequency of blood pressure documentation increased according to the severity of the patient and decreased during the length of stay in the emergency department.

The effectiveness of physiologically based early warning or track and trigger systems after triage in adult patients presenting to emergency departments: a systematic review

BACKGROUND

Changes to physiological parameters precede deterioration of ill patients. Early warning and track and trigger systems (TTS) use routine physiological measurements with pre-specified thresholds to identify deteriorating patients and trigger appropriate and timely escalation of care. Patients presenting to the emergency department (ED) are undiagnosed, undifferentiated and of varying acuity, yet the effectiveness and cost-effectiveness of using early warning systems and TTS in this setting is unclear. We aimed to systematically review the evidence on the use, development/validation, clinical effectiveness and cost-effectiveness of physiologically based early warning systems and TTS for the detection of deterioration in adult patients presenting to EDs.

METHODS

We searched for any study design in scientific databases and grey literature resources up to March 2016. Two reviewers independently screened results and conducted quality assessment. One reviewer extracted data with independent verification of 50% by a second reviewer. Only information available in English was included. Due to the heterogeneity of reporting across studies, results were synthesised narratively and in evidence tables.

RESULTS

We identified 6397 citations of which 47 studies and 1 clinical trial registration were included. Although early warning systems are increasingly used in EDs, compliance varies. One non-randomised controlled trial found that using an early warning system in the ED may lead to a change in patient management but may not reduce adverse events; however, this is uncertain, considering the very low quality of evidence. Twenty-eight different early warning systems were developed/validated in 36 studies. There is relatively good evidence on the predictive ability of certain early warning systems on mortality and ICU/hospital admission. No health economic data were identified.

CONCLUSIONS

Early warning systems seem to predict adverse outcomes in adult patients of varying acuity presenting to the ED but there is a lack of high quality comparative studies to examine the effect of using early warning systems on patient outcomes. Such studies should include health economics assessments.

Explaining transgression in respiratory rate observation methods in the emergency department: A classic grounded theory analysis

BACKGROUND

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often inaccurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs.

OBJECTIVE

To develop a substantive theory explaining ED registered nurses' reasoning when they miss or misreport respiratory rate observations.

DESIGN

This research project employed a classic grounded theory analysis of qualitative data.

PARTICIPANTS

Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed responses from individual interviews and open-ended responses from an online questionnaire.

METHODS

Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were employed to code data. This approach facilitated the identification of the main concern of the participants and aided in the generation of theory explaining how the participants processed this issue.

RESULTS

The main concern identified is that ED registered nurses do not believe that collecting an accurate respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational requirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The theory 'Rationalising Transgression', explains how participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing strategies that adjust the significance of the organisational requirement. These strategies include; Compensating, when nurses believe they are compensating for errant behaviour by enhancing the patient's outcome; Minimalizing, when nurses believe that the patient's outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy that sanctions negligent behaviour and occurs when nurses 'cut corners' to get the job done. Nurses' use these strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising transgression CONCLUSION: This research reveals that despite continuing education regarding gold standard guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses' understanding of acceptable practice methods. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes.

Factors related to monitoring during admission of acute patients

Understanding the use of patient monitoring systems in emergency and acute facilities may help to identify reasons for failure to identify risk patients in these settings. Hence, we investigate factors related to the utilization of automated monitoring for patients admitted to an acute admission unit by introducing monitor load as the proportion between monitored time and length of stay. A cohort study of patients admitted and registered to patient monitors in the period from 10/10/2013 to 1/10/2014 at the acute admission unit of Odense University Hospital in Denmark. Admissions with at least one measurement were analyzed using quantile regression by looking at the impact of distance from nursing office, number of concurrent patients, wing type (medical/surgical), age, sex, comorbidities, and severity conditioned on how much patients were monitored during their admissions. We registered 11,848 admissions, of which we were able to link patient monitor readings to 3149 (26.6 %) with 50 % being monitored <1.4 % of total admission time. Distance from nursing office had little influence on patients monitored <10 % of their admission time. But for other patients, being positioned further away from the office reduced the level of monitoring. Higher levels of severity were related to higher degrees of monitoring, but being admitted to the surgical wing reduce how much patients were monitored, and periods with many concurrent patients lead to a small increase in monitoring. We found a significant variation concerning how much patients were monitored during admission to an acute admission unit. Our results point to potential patient safety improvements in clinical procedures, and advocate an awareness of how patient monitoring systems are utilized.

The nurse response to abnormal vital sign recording in the emergency department

AIMS AND OBJECTIVES

To examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow-up for abnormal vital signs.

BACKGROUND

Monitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses' roles. Abnormal vital signs have been associated with poor patient outcomes and require follow-up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care.

DESIGN

Observational, retrospective chart review.

METHODS

Modified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score.

RESULTS

About 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation.

CONCLUSIONS

It is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow-up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow-up is not being documented.

RELEVANCE TO CLINICAL PRACTICE

To ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required.

An introduction to the Emergency Department Adult Clinical Escalation protocol: ED-ACE

PURPOSE OF THE STUDY

This study demonstrates how a participatory action research approach was used to address the challenge of the early and effective detection of the deteriorating patient in the ED setting. The approach enabled a systematic approach to patient monitoring and escalation of care to be developed to address the wide-ranging spectrum of undifferentiated presentations and the phases of ED care from triage to patient admission. This paper presents a longitudinal patient monitoring system, which aims to provide monitoring and escalation of care, where necessary, of adult patients from triage to admission to hospital in a manner that is feasible in the unique ED environment.

METHODS

An action research approach was taken to designing a longitudinal patient monitoring system appropriate for the ED. While the first draft protocol for post-triage monitoring and escalation was designed by a core research group, six clinical sites were included in iterative cycles of planning, action, reviewing and further planning. Reasons for refining the system at each site were collated and the protocol was adjusted accordingly before commencing the process at the next site.

RESULTS

The ED Adult Clinical Escalation longitudinal patient monitoring system (ED-ACE) evolved through iterative cycles of design and testing to include: (1) a monitoring chart for adult patients; (2) a standardised approach to the monitoring and reassessment of patients after triage until they are assessed by a clinician; (3) the ISBAR (I=Identify, S=Situation, B=Background, A=Assessment, R=Recommendation) tool for interprofessional communication relating to clinical escalation; (4) a template for prescribing a patient-specific monitoring plan to be used by treating clinicians to guide patient monitoring from the time the patient is assessed until when they leave the ED and (5) a protocol for clinical escalation prompted by single physiological triggers and clinical concern.

CONCLUSIONS

This tool offers a link in the 'Chain of Prevention' between the Manchester Triage System and ward-based early warning scores taking account of the importance of standardisation, while being sufficiently adaptable for the unique working environment and patient population in the ED.