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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 evidence-based policy on routine vital sign frequency.

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vital signs the ultimate tradition an ebp journey of discovery

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

slide2

Literature synthesis to establish an evidence-based policy on routine vital sign frequency

Have things really changed?

ways of knowing sources of knowledge
Ways of Knowing =Sources of Knowledge
  • Tradition
  • Authority
  • Experience

(trial and error)

sources of knowledge for practice
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
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
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

slide7
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
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
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).
finding a systematic review
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
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
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
systematic review 2001
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
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
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
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
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)
conclusions20
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
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)
cost ineffective nursing care 1978
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
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
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
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
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
…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
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
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
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
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
Skilled observation
  • Physicians! request nurses to use more efficient and appropriatemethods 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
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

"Vigilance: The Essence of Nursing"

To encompass The Work of nurses

requires redesigning, transforming reconceptualizing care concepts

nightingale s wisdom
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
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

“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
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
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
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

Findings: High surveillance cost $191/ hospitalization

slide43

The essence of surveillance = mundane, not dramatic

Make sure nothing happens (at least, nothing bad)

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!

references
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
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)
references46
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
Thanks to

Magnet project listserv members for their responses to the query:

  • General Medical Unit Frequency of Vital Signs