Nurses' documentation of physiological observations in three acute care settings

Aims and objectives To explore nurses' documentation of physiological observations in acute care; emergency department, medical and surgical units. Background In Australia, physiological observations include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. There is a clear relationship between abnormal physiological observations and adverse events. Nurses have highest level of responsibility for accurate measurement, interpretation and documentation of physiological observations. Design A descriptive exploratory design was used and the study data were collected using a prospective point prevalence approach between 25 July 2012–22 August 2012. Methods The study was conducted in the emergency department, two 30‐bed medical units and one 30‐bed surgical unit of a 578 bed public health service in Melbourne, Australia. All adult patients aged ≥18 years present during data collection periods were eligible for inclusion. Patients in the emergency department resuscitation area were excluded. Patient characteristics and physiological observations for the preceding 24 hours in ward patients or eight hours in emergency department patients were collected. Results One hundred and seventy‐eight patients were included; 38 emergency department patients, 84 medical patients and 56 surgical patients. The median age was 72·5 years and 43·8% were males. The most frequently documented physiological observations were respiratory rate, oxygen saturation, heart rate and systolic blood pressure. The least frequently recorded physiological observations were temperature and conscious state. One or more abnormal physiological parameters was documented in 79·8% (n = 142) patients; evidence of reporting abnormalities was documented in 19·7% of patients (n = 28/142). When controlled for length of stay, physiological observations were more frequently documented in the emergency department. Conclusions There was variability in the number of parameters documented and frequency of physiological observations documented by nurses. Relevance to clinical practice Physiological abnormalities that do not necessarily fulfil rapid response team activation criteria are common in acute care patients and provide nurses with an opportunity for early recognition of deteriorating patients.