Vital Signs The ultimate tradition An EBP Journey of discovery

1. 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

2. Literature synthesis to establish an evidence-based policy on routine vital sign frequency Have things really changed?

3. Ways of Knowing =Sources of Knowledge • Tradition • Authority • Experience (trial and error)

4. 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)

5. 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)

6. 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

7. 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

8. 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)

9. 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).

10. A hierarchy of evidence

11. 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.

12. 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

13. 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

14. There has been little evaluation of the optimal frequency of patient observations

15. 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)

16. 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)

17. 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)

18. 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

19. 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)

20. 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

21. 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)

22. Going further back in the medical literature…

23. 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

24. 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

25. 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

26. 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)

27. 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

28. …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?

29. 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)

30. 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

31. 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

32. 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)

33. 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)

34. 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

35. "Vigilance: The Essence of Nursing" To encompass The Work of nurses requires redesigning, transforming reconceptualizing care concepts

36. 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)

37. 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

38. “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?

39. 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

40. 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

41. 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

42. 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

43. 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!

44. 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).

45. 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)

46. 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

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