Thank you Kaiser Permanente For Making this possible Special thanks – Cecelia Crawford, RN, MSN Orange County Rescue M

1. Thank you Kaiser Permanente For Making this possible Special thanks – Cecelia Crawford, RN, MSN Orange County Rescue Mission /Casa de Salud Isabel Becerra, CEO Ken Bell, MD, CMO McKesson

2. Vital Signs in the Ambulatory Setting:An Evidence-Based Approach Project Overview In the beginning….

3. Phase I January - December 2009 9 Member Organizations - COCCC Camino Health Centers Central City CHOC Friends of Children Laguna Beach C C Lestonnac Free Clinic Share Our Selves Sierra Health Center St. Jude

4. The Importance of Vital Signs • Assessment - Foundation for • Accuracy– Basis for many clinical decisions • Influences – Patient’s clinical course • Outcome – Impacts patient Therefore, VS should be based on evidence, rather than ritual, routine, & tradition!

5. Educational programs CAN improve HCW’s vital sign measurement techniques

6. Frequency of Vital Signs Trends more important than any single measurement Should NOT be used as a method of ensuring Health Care Worker (HCW) visits Standardize methods of VS measurement

7. Frequency of Vital Signs VS parameters do NOT guarantee normal physiological status Have VS become routine & unrelated to patient needs? Is visual observation more important than routine VS? Couple visual patient observation with VS

8. The Health Care Worker & Vital Signs What happens to VS data after it is collected is as important as the accuracy of the VS themselves! Most influence seen with auscultated Blood Pressure - “White Coat” hypertension May contribute 20% towards misdiagnosis of Stage 1 HTN – (Found mostly in clinical settings) COMMUNICATION – TOUCH – PHYSICAL PRESENCE

9. Vital Sign Technology Electronic thermometers faster results Pulse Oximetry – oxygenated & reduced Hgb Convenient May save time & labor not confirmed by current studies Reduction in measurement errors Standardized & calibrated device vs. many Health Care Worker’s & different techniques Benefits of Electronic Capture of VS: Non-invasive Electronic BP equipment is the most favored method

10. TemperatureInformation Glass Thermometers Associated with adverse events Rectal/oral trauma Mercury exposure Axillary Temps Great variation with no “norm” found

11. TemperatureTechnique Oral Temps Position oral thermometers in left or right sublingual pockets NOT influenced by breathing patterns IS influenced by hot & cold fluids

12. Temperature Tympanic Thermometers Can be affected by Extremes in environmental temps Localized heating/cooling measures Ear tug positively affects accuracy Impacted cerumen adversely influences accuracy

13. TemperatureMore techniques Tympanic Temps - Patient Perceptions Parents prefer for: speed, ease, cleanliness, & safety Peds patients reacted more positively

14. Pulse Count for 60 sec Count for 30 sec and multiply X2 (Shorter time counts = inaccurate data) Apical pulse via stethoscope (Abnormal pulse / Difficult to palpate) Pulse rates via automatic devices not discussed in the literature, but often used in the clinical practice setting

15. Respiratory Rate Count for 60 sec Count for 30 sec and multiply X2 * Shorter time counting can = inaccurate data * • PEDIATRIC PATIENTS • If panting, use stethoscope to count • - Agitation can result in inaccurate RR • If special circumstances needed to assess de-saturation states – • RN & or MD assessment necessary intervention.

16. Blood PressureScience & Education Use a consistent & standardized method to minimize inaccuracies Electronic capture or Auscultation Functional & calibrated equipment Trained to listen for Korotkoff’s sounds Which are heard during auscultation for determination of BP. Produced by vibratory motion of the arterial wall as the artery suddenly distends when compressed by a pneumatic blood pressure cuff, sounds within the blood passing through the vessel or within the wall itself. Properly trained Health Care Worker’s for accurate capture of BP results.

17. Blood PressureTechnique Procedure (Any Method) Upper arm properly supported at  level Proper arm cuff size Patient sitting & at rest for 5 minutes Back supported, legs uncrossed No talking or gestures by patient or HCW Repeat BP’s Minimum 2 minutes apart

18. Blood PressureWhat if’s? BP cannot be obtained? Cuff doesn’t fit? Correct sized cuff isn’t available? HCW should consult with RN or MD for all troubleshooting issues

19. Pulse Oximetry Possible consideration as the 5th VS Use in situations where patient assessment & monitoring is critical

20. Final Thoughts on VS Tempting to view VS as a routine & static piece of data VS are fluid, dynamic, & ever-changing, just like our patients! Crucial Vital Sign Decisions Equipment & Technology Technique & Methods Education & Training Frequency Protocols

21. Final Thoughts Vital Signs In Ambulatory Healthcare Centers HCW Education & Training VS Accuracy & Communication of Data Competencies Annual Review of Skills

22. Vital Signs Conclusions An Evidence Based VS measurement method provides a foundation for: Patient-HCW Relationships Patient Assessment Patient Treatment Quality Patient Outcomes Shift the paradigm from ritual to science!

23. Recommendations – Reference Texts American Academy of Ambulatory Care Nurses (2006): Core Curriculum of Ambulatory Care, 2nd Ed., Elsevier Perry & Potter (2006): Clinical Nursing Skills & Techniques, 6th Ed., Mosby Perry & Potter (2006): Skills Performance Checklists: Clinical Nursing Skills and Techniques, 6th Ed., Mosby

24. Recommendations - Procedure Base Policy & Procedures on AAACN Core Curriculum and Perry & Potter Use AAACN Core Curriculum and Perry & Potter as a daily clinical reference Checklists to instruct and validate clinical competence & skills

25. References American Association of Critical Care Nurses (AACN) (2006). Practice alert: Noninvasive blood pressure monitoring. AACN Newsletter, June 2006, 4-5. Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs: Systematic review. Joanna Briggs Institute Reports, 2, 207-230. Pickering, T.G., Hall, J.E., Appel, L.J., Falkner, B. E., Graves, J., Hill, M. N., Jones, D. W., Kurtz, T., Sheps, S. G., & Roccella, E. J. (2005). Recommendations for blood pressure measurement in humans: A statement for professionals from the subcommittee of professional and public education of the American Heart Association council on high blood pressure research. Hypertension,45, 142-161. Schell, K., Bradley, E., Bucher, L., Seckler, M., Lyons, D., Wakai, S., Bartell, D., Carson, E., Chichester, M., Foraker, T., & Simpson, K. (2006). Clinical comparison of automatic, noninvasive measurements of blood pressure in the forearm and upper arm. American Journal of Critical Care, 14(3), 232-241. Thomas, S. A., Liehr, P., DeKeyser, F., Frazier, L., & Friedmann, E. (2002). A review of nursing research on blood pressure. Journal of Nursing Scholarship, 34, 313-321.

26. For more information of this EBP project CONTACT INFORMATION: Cecelia L. Crawford, RN, MSN Project Manager for Evidence-Based Nursing Practice So. Calif. Nursing Research Program 626-405-5802 Cecelia.L.Crawford@kp.org