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The nurse response to abnormal vital sign recording in the emergency department

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  • Kimberly D Johnson
  • Lindsey Mueller
  • Chris Winkelman

Abstract

Aims and objectives To examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow‐up for abnormal vital signs. Background Monitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses’ roles. Abnormal vital signs have been associated with poor patient outcomes and require follow‐up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care. Design Observational, retrospective chart review. Methods Modified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score. Results About 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation. Conclusions It is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow‐up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow‐up is not being documented. Relevance to clinical practice To ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required.

Suggested Citation

  • Kimberly D Johnson & Lindsey Mueller & Chris Winkelman, 2017. "The nurse response to abnormal vital sign recording in the emergency department," Journal of Clinical Nursing, John Wiley & Sons, vol. 26(1-2), pages 148-156, January.
  • Handle: RePEc:wly:jocnur:v:26:y:2017:i:1-2:p:148-156
    DOI: 10.1111/jocn.13425
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    Cited by:

    1. Jørghild Karlotte Jensen & Randi Skår & Bodil Tveit, 2019. "Hospital nurses' professional accountability while using the National Early Warning Score: A qualitative study with a hermeneutic design," Journal of Clinical Nursing, John Wiley & Sons, vol. 28(23-24), pages 4389-4399, December.
    2. Tracey Stone & Jon Banks & Heather Brant & Joanna Kesten & Emma Redfern & Ann Remmers & Sabi Redwood, 2020. "The introduction of a safety checklist in two UK hospital emergency departments: A qualitative study of implementation and staff use," Journal of Clinical Nursing, John Wiley & Sons, vol. 29(7-8), pages 1267-1275, April.
    3. Martin Spångfors & Gitte Bunkenborg & Mats Molt & Karin Samuelson, 2019. "The National Early Warning Score predicts mortality in hospital ward patients with deviating vital signs: A retrospective medical record review study," Journal of Clinical Nursing, John Wiley & Sons, vol. 28(7-8), pages 1216-1222, April.
    4. Valentina Nino & David Claudio & Christie Schiel & Brendan Bellows, 2020. "Coupling Wearable Devices and Decision Theory in the United States Emergency Department Triage Process: A Narrative Review," IJERPH, MDPI, vol. 17(24), pages 1-23, December.

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