Vital sign assessment and nursing interventions in medical and surgical patients with rapid response system triggers
Authors: Considine Julie , Hutchinson Alison M. , Mitchell Imogen , Bohingamu Mudiyanselage Shalika , Mohebbi Mohammadreza , Watts Jennifer J. , Bucknall Tracey 
Published: June 2023

AbstractAim(s)To explore vital sign assessment (both complete and incomplete sets of vital signs), and escalation of care per policy and nursing interventions in response to clinical deterioration.DesignThis cohort study is a secondary analysis of data from the Prioritising Responses of Nurses To deteriorating patient Observations cluster randomised controlled trial of a facilitation intervention on nurses' vital sign measurement and escalation of care for deteriorating patients.MethodsThe study was conducted in 36 wards at four metropolitan hospitals in Victoria, Australia. Medical records of all included patients from the study wards during three randomly selected 24‐h periods within the same week were audited at three time points: pre‐intervention (June 2016), and at 6 (December 2016) and 12 months (June 1017) post‐intervention. Descriptive statistics were used to summarise the study data, and relationships between variables were examined using chi‐square test.ResultsA total of 10,383 audits were conducted. At least one vital sign measurement was documented every 8 h in 91.6% of audits, and a complete set of vital signs was documented every 8 h in 83.1% of audits. There were pre‐Medical Emergency Team, Medical Emergency Team or Cardiac Arrest Team triggers in 25.8% of audits. When triggers were present, a rapid response system call occurred in 26.8% of audits. There were 1350 documented nursing interventions in audits with pre‐Medical Emergency Team (n = 2403) or Medical Emergency Team triggers (n = 273). One or more nursing interventions were documented in 29.5% of audits with pre‐Medical Emergency Team triggers and 63.7% of audits with Medical Emergency Team triggers.ConclusionWhen rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration.Relevance to Clinical PracticeMedical and surgical ward nurses in acute care wards frequently engage in vital sign assessment. Interventions by medical and nurgical nurses may occur prior to, or in parallel with calling the rapid response system. Nursing interventions are a key but under‐recognised element of the organisational response to deteriorating patients.Implications for the profession and/or patient careNurses engage in a range of nursing interventions to manage deteriorating patients, (aside from rapid response system activation) that are not well understood, nor well described in the literature to date.ImpactThis study addresses the gap in the literature regarding nurses' management of deteriorating patients within their scope of practice (aside from RRS activation) in real world settings.When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration.The results of this research are relevant to nurses working on medical and surgical wards.Reporting MethodThe trial was reported according to the Consolidated Standards of Reporting Trials extension for Cluster Trials recommendations, and this paper is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement.Patient or Public ContributionNo Patient or Public Contribution.