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The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward

Chinese Journal of traumatology 2017年第5期20卷 283-287页

作者： Claire M. Keene Victor Y. Kong Damian L. Clarke Petra Brysiewicz Pietermaritzburg Metropolitan trauma Service. Department of Surgery University ofKwaZulu-Natal Durban South Africa Department of Surgery University of the Witwatersrand Johannesburg South Africa School of nursing & Public Health University of KwaZulu-Natal Durban South Africa

Purpose： recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The modified early warning score （MEWS） uses vital signs to categorise the severity of a patient＇s physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Methods： vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator- measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL Results： The details of lgl newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88~; for respiratory rate, 98~; for blood pressure, 92% for temperature and 41~ for GCS. The recorded heart rate was positively correlated with the investigator＇s measurement （Pearson＇s correlation coefficient of 0.76）; while the respiratory rate did not correlate （Pearson＇s correlation coefficient of 0.02）. In 59~ of patients the recorded respiratory rate （RR） was exactly 20 breaths per minute and 27~ had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded （MEWS（R）） and investigator （MEWS（1）） vitals, with the range of MEWS（R） 0-7 and MEWS（1） 0-9. Analysis showed 59% of the MEWS（R） underestimated the physiological derangement （score

关键词： vital signs recording quality modified early warning score nursing acute trauma care

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