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