Prognosis and OutcomesIdentification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score☆
Introduction
Most critically ill patients who are admitted to the intensive care unit (ICU) or have a cardiopulmonary arrest show clear and detectable signs of deteriorating in the hours preceding these events. More than 80% of these patients could be identified in the 24 hours before these severe adverse events (AEs) [1], [2], [3], [4]. In 1 study, the quality of care in the hours preceding these AEs has been deemed substandard because of a lack of knowledge and skills, inadequate appreciation of clinical urgency, and failure to seek advice [5].
Current clinical practice regarding the systematic measurement of vital signs in patients on general hospital wards is largely unknown, although data exist that completeness of general observations after major surgery in the first 3 postoperative days was only 17% [6]. The ability to recognize a deteriorating patient is the paramount feature of rapid response systems that aim at the reduction of severe AEs [7]. To aid in this detection of deteriorating patients on the general wards, track and trigger (TT) systems have been developed. These systems rely on the measurement of readily available vital signs. Two types are in use: single-parameter systems are based on the deviation of a single parameter from normality, whereas the multiple TTs rely on the calculation of a score based on a multitude of parameters [8]. Diagnostic performance of TTs varies widely [9], [10]. Although TTs, including the Modified Early Warning Score (MEWS), have been widely adopted throughout the world [11], [12], the workings of these systems in clinical practice have not been fully elucidated. Predictive capabilities vary between different studies [8], [9], and little is known regarding common practice concerning measurement of vital signs on nursing wards [13], [14].
The primary aim of this study was to describe the current practice of nurses in a university hospital in the Netherlands regarding the measurement of vital signs. Secondarily, we analyzed the possible usefulness of the MEWS in the early recognition of medical and surgical patients who subsequently died or experienced serious AEs.
Section snippets
Hospital setting
This study was conducted in the Academic Medical Center in Amsterdam, the Netherlands, which is a 1000-bed teaching university hospital. For this research, all medical and surgical wards participated including 8 medium care beds equally divided between specialties.
Study design and definitions
This was a retrospective study on all admitted patients in 2007 who endured one of the following AEs: (1) cardiopulmonary arrest, (2) unplanned ICU admission, (3) unexpected death, or (4) emergency surgery. The first 3 AEs were
Demographics
In Table 1, the demographics of the 204 included patients are shown. Twenty-seven (13%) had a cardiopulmonary arrest, 29 (14%) underwent emergency surgery, 50 (25%) died unexpectedly, and 98 (48%) underwent an unplanned ICU admission. One hundred twelve patients came from the medical wards (55%), and 88 (43%) came from the surgical wards. Emergency surgeries were predominantly performed on surgical patients, whereas unexpected deaths, cardiopulmonary arrests, and unplanned ICU admissions were
Discussion
The results of this study show an important lack of measurement and documentation of vital signs in patients in the 48 hours preceding severe life-threatening AEs. Pulse rate and blood pressure were recorded most often, whereas urine production and level of consciousness were seldom recorded. Respiratory rate was documented in only 23% of the cases. As expected, the number of vital sign measurements increased when an MEWS of 3 or more was present, but even then, respiratory rate was not
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No conflict of interest declared.