Recognising deterioration: nurses’documentation of vital signs–a systematic literature review

Abstract: Introduction: Research show that patients frequently display abnormal vital signs as much as 48h before a serious adverse event occur, such as cardiac arrest or unplanned intensive care unit admission. Therefore, early recognition of these changes trough vital sign examination is essential in the prevention of deterioration. However, deterioration is often missed.Aim: The aim was to investigate to what extent nurses in the general ward are documenting vital signs prior to patient deterioration. Methods: A systematic literature review was done usingthe databases PubMed and CINAHL. Inclusion criteria: general ward and publication 2010-2020, exclusion criteria:emergency department, acute admission ward, paediatric ward, psychiatric ward, interventions and continuousmonitoring. Critical appraisalusingtools from Joanna Briggs Institute. PRISMA statement for reporting of systematic reviews.Results: Nine studies were included. It was seen that the fraction of cases who had vital signs documented prior to deterioration was diverse, although never complete. Some studies showed an acceptable fraction of patients who weremonitoredin the hours prior to deterioration, but it was seen that the monitoring did not always escalate as the patient got worse. The vital signs most frequently documentedwereheart rate and pulse, thoughstill missing in a large fraction of charts. Respiratory rate was documented less than the other vital signs.Conclusions: This study suggests that documentation of vital signs prior to deterioration is diverse but often incomplete. Further research is needed to understand what can be done to improve vital sign documentation on general wards.