Authors' objectives: The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Provide an evidence-based approach to creating monitoring protocols based on a patient’s risk of deterioration and link these to nursing workload and economic impact. The frequency that patients in hospital should have their vital signs (e.g. blood pressure, pulse, oxygen saturations) measured is currently unknown. Current monitoring protocols (from NHS England) are based on expert opinion supported by little empirical evidence. The challenge is to find the balance between insufficient monitoring of patients (which risks missing early signs of deterioration and delays in treatment) and over-observation of stable patients (which wastes resources needed in other aspects of patient care). Guidance suggests monitoring frequency should be determined by a patient’s severity of illness – often measured using risk scores. One such score is the National Early Warning Score (NEWS), which provides a simple integer value showing how much a patient’s vital signs are outside normal ranges. A high NEWS score means the patient is at high risk of deterioration, prompting a range of responses from increasing observations to review by a doctor and changes to treatment. While there is evidence that NEWS can predict patient risk of adverse outcomes [such as death or transfer to the intensive care unit (ICU)], there is no evidence to suggest the appropriate monitoring frequency based on that risk. With so much discussion about pressures on NHS resources, especially workforce issues, this is an important topic. This study aimed to fill the evidence gap and guide development of future monitoring protocols taking into account the risk of deterioration and the impact on nursing workload and associated cost. We addressed the following research questions: What is the current practice for recording a patient’s vital signs? Who typically takes vital sign observations? How long does it take to record a set of vital signs required to calculate a NEWS score? And how do nursing staff fit observation in alongside other clinical work? Can we predict a patient’s risk of deterioration over time based on their NEWS score? Can we use these risk predictions to identify acceptable monitoring frequencies for each NEWS value? Can we estimate the economic impact and cost-effectiveness of new monitoring protocols to identify whether these are feasible for use in practice?

Authors' results and conclusions: Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a ‘round’, including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. We explored several different scenarios with our stakeholders (clinicians and patients), based on how ‘risk’ could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient’s risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients’ National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse–patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. Observational study Across the four hospitals we studied, we found a variety of practices, with two hospitals having RNs take the majority of vital sign observations, while the other two hospitals favoured HCAs or student nurses. However, whoever took the observations spent roughly the same length of time. The average of 5:01 minutes per observation over a ‘round’ included the preparation time associated with locating and preparing the equipment and travelling to the patient’s area. An average of 3:45 was spent at each patient’s bedside (excluding interruptions not related to the vital sign taking), rising to 4:24 at the bedside with all interruptions included. Interruptions included jobs needing to be done at a set time of day, jobs convenient to do at the same time as vital sign observations, communication with other health professionals, emergencies, work prompted by the proximity to the patient, and absence or unavailability of patient. Other clinical work seemed to take priority during core time (9 a.m.–5 p.m.) but staff made up for this by scheduling the main rounds of observations around the main shift-change times (early morning and early evening) when there were fewer competing tasks. Any future protocol reducing the frequency of observations might support timely recording during core times, though they would probably still be prioritised below fixed-time activities. Any change to existing protocols might have knock-on effects on proximity-related care. For example, reducing the frequency of observations would reduce the opportunities for the patient to ask a question or benefit from other interaction with the nurse. Correspondingly, increasing the frequency could improve the quality of care provided. Our stakeholders proposed that ‘social interaction’ could be separated from vital sign observations, with a short ‘check-in’ approach adopted for lower-risk patients. In conclusion, while individual components of observation work are quite small, when aggregated over many patients and multiple observations per patient per day, they add up to a substantial amount of daily nursing workload that has to be integrated, prioritised and resourced. We developed a framework using clinical data to propose new observation protocols and a way of evaluating them both clinically (in terms of patient outcome) and economically (possible cost-effectiveness). Our work supports the approach of the current monitoring protocol, whereby patients’ NEWS2 scores guide observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse–patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on scheduling vital sign observations, but our retrospective design did not allow us to take into account all factors impacting monitoring frequency. Ultimately, it is for relevant professionals to collectively decide how our work should be used: nationally this could be the Royal College of Physicians reviewing NEWS; locally, it could be clinicians/managers determining local practice.

Authors' methods: Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time it takes to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions to explore the relationships between NEWS and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Observational study We observed nursing staff on 16 randomly selected adult general wards at 4 acute general NHS hospitals. All wards included in this study used NEWS2, the 2017 update to NEWS. Three hospitals used electronic systems to record vital signs and automate NEWS2 calculation. In one hospital, vital signs were recorded on paper charts at the patient’s bedside and NEWS2 was calculated manually. We observed each ward for a total of 8 hours, spread across four sessions, with a total of 715 sets of vital sign measurements observed. Data were collected in real time by non-participating observers using bespoke software on a tablet computer. They also collected contextual data, including the total number of patients on the ward and the numbers of registered nurses (RNs), healthcare assistants (HCAs) and student nurses on shift during the observation session. Further, they recorded factors influencing the measurement and recording of vital signs, including reasons for, and the nature of, interruptions. After each observation session, data were uploaded onto a server managed by the raters’ institution. We did not store any personal data. We quantified the time it took to record a set of vital signs using three different estimates: (1) length of the round per number of vital signs observation sets, (2) time at the patient’s bedside and (3) variants of (1) and (2) removing interruptions. We used an iterative approach and thematic coding to group the different activities that delayed or interrupted vital sign observations.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/17/05/03

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/HYTR4612

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/HYTR4612

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk