DETERIORATING PATIENT

The day is humming along nicely.

Your assigned patients are going about their activities of daily living.

As you enter a room, you sense that there is something not quite right.

One of your patients is pale, sweaty and complaining of feeling unwell.

The last time that their vital signs were recorded they were within the normal range.

Vital signs are

  1. heart rate
  2. respiratory rate
  3. systolic blood pressure
  4. temperature
  5. oxygen saturation
  6. level of consciousness.

Monitoring of respiration includes depth of breathing and pain associated with breathing.

Not much is known about how to manage deteriorating patients.

Clinical deterioration in patients is an independent mortality predictor.

Deteriorating patients are four times more likely to die within 30 days.

Nearly one third of patients admitted with normal vital signs will deteriorate within 24 hours.

Risk factors include old age (85+ years) and do not attempt to resuscitate order.

The most common deterioration in vital signs is pulse rate followed by oxygen saturation.

The importance of vital signs monitoring is undeniable.

Poor monitoring is the most dominant cause of preventable deaths.

One third of preventable deaths was due to poor clinical monitoring.

Vital signs are not consistently assessed, recorded or acted upon.

Respiratory rate is the least frequently measured vital sign.

Only 1 in 6 medical records have complete documentation of vital signs.

Failure to consistently assess and record respiratory rate is a predictor of serious adverse events.

There is a thirteen fold increase in mortality.

Respiratory rate measurement has no automated machine to measure it. 

It is a manual nursing skill that takes time to do properly.

Nurses are less likely to measure the respiratory rate of patients deemed stable.

There is also a lack of training, knowledge, and time constraints that influence the adequate assessment of respiratory rate.

Respiratory rate assessment will:

  1. monitor changes in patient condition
  2. recognise acute changes
  3. indicate signs of deterioration
  4. recognise the need for treatment escalation.

An increase in respiratory rate occurs in hypovolaemia and an early indicator of acidosis.

An abnormal respiratory rate is common prior to cardiac arrest.

The frequency of vital signs monitoring is dependent upon patient acuity, the patient’s chief complaint, hospital policy, nursing judgement and medical orders.

The basic monitoring of vital signs is important to patient survival.

Do it right.

To learn more about deteriorating patients:

Elliott, M. “Why is Respiratory Rate the Neglected Vital Sign? A Narrative Review.” Int Arch Nurs Health Care 2 (2016): 050. https://www.clinmedjournals.org/articles/ianhc/international-archives-of-nursing-and-health-care-ianhc-2-050.pdf

Hands, Chris, et al. “Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol.” BMJ quality & safety22.9 (2013): 719-726. http://qualitysafety.bmj.com/content/22/9/719

Henriksen, Daniel Pilsgaard, Mikkel Brabrand, and Annmarie Touborg Lassen. “Prognosis and risk factors for deterioration in patients admitted to a medical emergency department.” PloS one 9.4 (2014): e94649. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0094649

Hogan, Helen, et al. “Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.” BMJ quality & safety (2012): bmjqs-2012. http://qualitysafety.bmj.com/content/early/2012/07/06/bmjqs-2012-001159.full

Johnson, Kimberly D., et al. “The factors that affect the frequency of vital sign monitoring in the emergency department.” Journal of Emergency Nursing40.1 (2014): 27-35. http://www.jenonline.org/article/S0099-1767(12)00392-3/abstract

Lambe, Katherine, Judy Currey, and Julie Considine. “Frequency of vital sign assessment and clinical deterioration in an Australian emergency department.” Australasian Emergency Nursing Journal 19.4 (2016): 217-222. http://www.aenj.com.au/article/S1574-6267(16)30039-8/abstract