Vital Signs The ultimate tradition An EBP Journey of discovery

Vital Signs
The ultimate tradition
An EBP 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 evidencebased policy on routine
vital sign frequency
Have things really changed?
Ways of Knowing =
Sources of Knowledge
 Tradition
 Authority
 Experience
(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 Error
 One
method of doing something is tried
 Does 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
time/expense for a nursing activity
 NEED: Prospective studies to accurately
identify day time risk factors to predict need
for night time monitoring
 Sharda, Carter, Wingard, & Mehta (2001)
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 inaccurate
Toms 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
Implications for practice
 With a growing emphasis
preventing adverse events
 The vital role of nurses

not just data collectors
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
Patients who received high surveillance
= 157 falls
 Patients who received low or no
surveillance = 324 falls
 Cost avoidance for one fall = $17,483

Findings: High surveillance
cost $191/ hospitalization
The essence of surveillance = mundane, not dramatic
Make sure nothing happens (at least, nothing bad)
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!
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,138. 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