Elsevier

Journal of Critical Care

Volume 27, Issue 4, August 2012, Pages 424.e7-424.e13
Journal of Critical Care

Prognosis and Outcomes
Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score

https://doi.org/10.1016/j.jcrc.2012.01.003Get rights and content

Abstract

Background and Purpose

Clear and detectable signs of deterioration have been shown to be present in many patients multiple hours before undergoing a serious life-threatening event. To date, few studies are available describing normal practice and the possible effectiveness of structured tools regarding recognition of deteriorating patients. The aim of this study was to describe the current practice in measurement and documentation of vital signs and the possible usefulness of the Modified Early Warning Score (MEWS) to identify deteriorating patients on hospital wards.

Methods

A retrospective observational study of medical and surgical patients from 2007 with a severe adverse event including cardiopulmonary arrest, unplanned intensive care unit admission, emergency surgery, or unexpected death was performed. We studied all vital parameters that were collected and documented in the 48 hours before these events, and the MEWS was retrospectively calculated.

Results

Two hundred four patients were included. In the 48 hours before the event, a total of 2688 measurements of one or more vital signs were taken. Overall, 81% of the patients had an MEWS value of 3 or more at least once during the 48 hours before their event. Recordings of vital signs were mostly incomplete. Even when the MEWS was 3 or more, respiratory rate, diuresis, and oxygen saturation were documented in only 30% to 66% of assessments.

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.

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