Vital Signs The ultimate tradition An EBP Journey of discovery

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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

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Literature synthesis to establish an
evidence-based policy on routine vital sign
frequency
Have things really changed?
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Ways of Knowing Sources of Knowledge

• Tradition
• Authority
• Experience
• (trial and error)

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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)

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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)
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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

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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

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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)

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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).

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A hierarchy of evidence
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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
  36433-650
• 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.

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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

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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

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• There has been little evaluation of the optimal
  frequency of patient observations

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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)

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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)

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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)

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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

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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)

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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

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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)

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Going further back in the medical literature
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Cost-ineffective nursing care? 1978

• Orders written by MEDICAL RESIDENTS
• VS frequency did not correlate with subsequent
  critical events
• Such orders wasteful of nursing resourcesother
  skilled observations may be neglected!
• Resulted in a
• significant time-consuming
• cost-ineffective
• nursing care
• Vautrain Griner, 1978

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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

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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

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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)

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Radical redefinition of whats 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

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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?

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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)

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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 nursings job!
• We need to individualize assessment of V/S
  measurement - for more efficient allocation of
  hospital resources

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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

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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)

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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)

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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

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 "Vigilance The Essence of Nursing"

• To encompass The Work of nurses
• requires redesigning, transforming
  reconceptualizing care concepts

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Nightingales 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)

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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

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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?

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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

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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
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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

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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

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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!
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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 2131
• 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).

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References (cont)

• 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 (105109)
• 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 (11971200)

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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 (272279)
• Zeitz, K. (2005). Nursing observations during the
  first 24 hours after a surgical procedure what
  do we do? Journal of Clinical Nursing, 14, 334343

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Thanks to

• Magnet project listserv members for their
  responses to the query
• General Medical Unit Frequency of Vital Signs