The clinical neglect of vital signs’ assessment: an emerging patient safety issue?

Abstract

Objectives: Vital signs assessment is a critical component of acute clinical care. Despite this, research has consistently found that the assessment of these signs is often neglected in clinical practice. This paper highlights three recent cases reported in the media where the neglect of vital signs assessment resulted in patient mortality.

Results: Recent media reports highlighted the potentially devastating consequences of vital signs not being rigorously assessed, including avoidable death. The public needs to be confident they will receive safe, quality health care when they are admitted to hospital.

Conclusion: The neglect of vital signs assessment places patients at risk of poor outcomes. Early detection of clinical deterioration via the assessment of vital signs facilitates prompt medical intervention. Factors contributing to the neglect of vital signs assessment need to be identified and corrective action is taken to improve the safety of clinical care.

Keywords:

• assessment
• safety
• quality
• vital signs

Vital signs are regarded as an essential part of patient monitoring as early detection of preventable outcomes is key to timely intervention (Brekke et al., 2019). Vital signs represent the afferent limb of rapid response systems and are thus critical in detecting patient deterioration and facilitating early medical intervention (Difonzo, 2019). Despite the importance of these signs, research has consistently found that vital signs’ assessment is often neglected in clinical practice (Kamio et al., 2018; Weenk et al., 2019). Recent media reports have also highlighted the potentially devastating consequences of vital signs’ assessment being neglected (e.g. Milligan, 2019). This editorial highlights the importance of early detection of deterioration via the assessment of vital signs and the need to understand factors contributing to the neglect of vital signs’ assessment to improve the safety of clinical care.

Vital signs are the simplest and probably the most important data gathered on hospitalised patients (Kellett, 2017). Measuring vital signs is fundamental to clinical assessment, risk evaluation and for preventing patient deterioration (Smith et al., 2017). It also only takes about five minutes to assess a patient’s vital signs (Dall’Ora et al., 2021). Despite this, research has found vital signs’ assessment is often sparse, respiratory rate is often not recorded or is simply estimated, vital signs are poorly documented, and abnormal vital signs are not being acted upon (Badawy et al., 2017; Chapman et al., 2019; Kamio et al., 2018; Saab et al., 2021; van Graan et al., 2020).

The causes of this neglect are not clear as most studies to date have focussed on highlighting the problem rather than exploring the underlying reasons. However, factors found to contribute to the neglect of vital signs’ assessment include: how experienced the nurse is; postgraduate qualifications; the perceived importance of patients’ sleep; the perception that vital signs’ assessment is unnecessary in low-risk patients; nurse staffing levels; and an absence of formal guidelines (Hope et al., 2018; Lambe et al., 2017; Redfern et al., 2019; Stevenson et al., 2018). The neglect of vital signs’ assessment is now so widespread and problematic that it has recently been reported in the Australian media. Three recent cases highlighted the importance of vital signs’ assessment and, most importantly, the potential tragic outcome if this monitoring is not performed.

Media reports

In the first case, a 63-year-old resident of an aged care institution fell out of his wheelchair while trying to open a bedside locker (Cunningham, 2019). This resulted in his head becoming trapped in the locker draw. He was trapped for 45 min until paramedics arrived. During this time, nursing staff attempted to move him but were unable to do so. When paramedics arrived, they were shocked to find he was deceased (Cunningham, 2019). The coroner identified numerous deficiencies in the resident’s care, including a lack of vital signs’ assessment and the failure to convey the urgency of the situation during an emergency call. The coroner deemed the death preventable (Cunningham, 2019).

The second case appeared in a report about the quality of health care in regional and rural Australia (Milligan, 2019). It involved an 18-year-old male who presented to the emergency department of a base hospital with a painful, swollen knee. Staff initially assumed it was a sporting injury. His vital signs were not assessed, and he was sent home (Milligan, 2019). He returned to the emergency department five hours later for an ultrasound. As the department was busy, he was told to come back later for the result.

He returned 12 h later and was told to come back in 2 weeks if the pain did not improve; again his vital signs were not assessed during this presentation. The next morning, he was unable to walk and his pain was excruciating. He was therefore driven to the hospital by his father. This time his vital signs were assessed, approximately 33 h after his first presentation (Milligan, 2019). At that point, the patient was deteriorating. He was delirious, clammy and mottled so a rapid medical response call was made. At this point it was recognised the patient had an infected toenail and was in septic shock. Realising he was critically unwell, staff arranged to transfer him to a tertiary referral hospital in a major city hospital; this took 13 h. Shortly after arriving at the referral hospital, the patient went into cardiac arrest and died (Milligan, 2019).

The third case involved an 18-year-old male who presented to the hospital with a suspected diagnosis of pneumonia (Bavas, 2019). According to his parents, his vital signs reached critical levels multiple times during his admission. This should have prompted an emergency response but did not (Bavas, 2019). During the initial hours of his admission, his oxygen saturation kept dropping which triggered a bedside monitor’s alarm. Staff responded by adjusting the monitor’s alarm limits so that it would alarm less frequently. Eighteen hours after he presented to hospital, a rapid response call was made just prior to the patient having a cardiac arrest. He died two weeks later in hospital (Bavas, 2019).

Despite the importance of vital signs’ assessment, the clinical neglect of these signs is widespread and unfortunately not a new clinical problem. For many years, research has highlighted that vital signs are not assessed as rigorously as they should be (e.g. Harrison et al., 2005; Hogan, 2006). This may be because nurses’ attitudes towards vital signs’ assessment are often poor (Alshehry et al., 2021; Dall’Ora et al., 2019). The failure to assess vital signs rigorously represents a missed opportunity to detect clinical deterioration, as these signs are an essential component of early warning systems (Bartzak, 2022; Eddahchouri et al., 2021).

The extent of this clinical problem is now so severe it is receiving media attention, perhaps years later than it should have. Recent cases in the media and research findings raise critical questions such as why vital signs’ assessment is neglected; whether nurses actually appreciate the clinical importance of vital signs; what can be done to improve the clinical assessment of vital signs; and whether the public can be confident that when they present to hospital their vital signs will be accurately assessed. Research needs to further explore the underlying reasons for the neglect of vital signs’ assessment and most importantly, develop evidence-based strategies to ensure these signs are assessed appropriately.

Vital signs’ assessment is a standard and crucial component of clinical nursing care. When a patient is admitted to hospital, they need to be confident they will receive safe, quality care. Failure to assess these signs puts patients at risk, as their clinical deterioration might not be detected or is recognised far too late for medical intervention to be effective. This creates the risk of adverse outcomes, which is a particular concern for patients with an excellent prognosis. More needs to be known about why vitals signs’ assessment is neglected and, most importantly, what action can be taken to ensure these signs are rigorously assessed.

Disclosure statement

No potential conflict of interest was reported by the author(s).