“Modern hospitals service patients of increasing complexity and co-morbidity. Despite advances in technology and the best efforts of hospital staff, several studies have demonstrated that 6-17% of all hospital admissions are complicated by serious adverse events. These events are often unrelated to the patient’s underlying medical condition and in approximately 10% of cases they will result in permanent disability and even death” – Jones D, Haase M, Bellomo R from Textbook on Rapid Response Systems
The prevailing standard for inpatient general care is for rounding and vital sign checks to occur every 4-8 hours. More recent data suggests this is simply not enough.
The evolution and availability of medical care means that more patients with chronic conditions are living longer. Diseases such as heart disease, cancer, hypertension, stroke and diabetes – often with complex treatment regimens—are often admitted to hospitals either for an elective procedure, or emergency treatment, and their chronic disease burden adds to their complexity.
Why All Vital Signs
Based on chart reviews of patients who experienced a cardiorespiratory arrest, the clearest signs of distress before the event were tachycardia, bradycardia, tachypnea, oxygen desaturation, low systolic blood pressure, respiratory distress and changes in mental status. That is to say, the highest specificity indicator for patients at risk was a combination of heart rate, respiratory rate, systolic blood pressure and change in mental status.
“Instability is not a static phenomenon. Because a patient’s compensatory mechanisms attempt to correct the physiologic causes of the instability, no single-parameter monitoring systems have proven to be wholly sufficient” – Hravnak M, Schmid A, Ott L et al: from Textbook of rapid response systems
Nurses at the Sharp End of Care
Nurses are the most common hospital personnel assessing patient condition, making decisions, and triggering intervention. Successful interventions depend on the early identification of deterioration in patients, the experience and confidence to seek help, and having that help readily available.
“Lack of access to patient data, such as vital sign trends over a period of time, can lead to delayed recognition of deterioration” – DeVita M, Smith G, Adam S et al. magazine of resuscitation in 2010; 81: 375-382
Nurses Need Early Detection Tools
Nurses on a postoperative general care floor often manage 4-8 patients at a time, making it difficult for them to observe early signs adverse events in their patients. When detection is delayed, there is greater risk of more advanced deterioration that can contribute to higher morbidity and mortality.
“It is now recognized that capturing vital signs as frequently as possible is needed if every patient deterioration is to be assessed and recognized” – Curry J, Jungquist C from Patient Saf Surg
Postoperative Patient Risk
In postoperative surgical patients, adverse clinical events can manifest subtly, or be totally disguised by sleep.
The risk of deterioration is more likely to go undetected in patients where continuous monitoring is an exception, rather than a rule.
“Prolonged hypoxemic episodes are common in post-operative patients” – Sun Z, Sessler D, Dalton J from Anesthesia & Analgesia
It is possible that periods of hypotension and diminished oxygen saturation (Sp02)—whether symptomatic or not—can contribute to a higher risk of myocardial injury after non-cardiac surgery (MINS). MINS patients have a 30-day post-surgical mortality risk 10 times higher than those without MINS
Delays Are Costly
Delays in the discovery of patient deterioration directly impact outcomes and cost. In one study, the authors conclude that hospital mortality increases 3% for each hour an ICU transfer is delayed, and that those patients who are transferred experience a longer length of stay
“Quiet at night”
Sleep is essential to recovery from illness or surgery, yet it is often very difficult to get a good night’s sleep in a hospital. The stress of hospitalization, sleep deprivation, an array of medications, and altered physical activity can result in patients leaving the hospital with risk factors unrelated to their reason for admission.
Cardiac Telemetry Is Not The Answer
The fear of missing life-threatening arrhythmias likely contributes to the overuse of cardiac telemetry. Published study results suggest that using the American Heart Association guidelines for telemetry reduces use by as much as 43%, with no increase in mortality, cardiac arrest, or activation of the rapid response team. These data provide evidence that in patients with no known risk factors, ECG monitoring is not the tool to use to detect deterioration.