1. Improving Vital Sign Documentation at Triage: An Emergency Department Quality
Improvement Project
Introduction:
The triage clinic is conventional in local health centers due to the boost in patient load. The
rationale of the triage clinic is primary measurement and to catalog patients according to the
need to keep away from holdup in the treatment of significant cases. Vital signs assessment and
records by the triage nurses (temperature, heart rate, blood pressure, respiratory rate and oxygen
saturation as looked-for is necessary to prioritize the importance of the cases according to most
triage systems international including the Manchester Triage System, Emergency Severity Index
(ESI).
It is imperative to compute and manuscript the vital signs of the patients triaged for preliminary
consideration. Previous studies designate that vital signs assessment is used as one of the tools to
make a decision prioritize the patients and stream them to the right character. They were often
used as a decision-making tool in the prioritization of patients and moving towards the right
Outlook.
The feedback of patients and the initial encounter with clinical staff is where the patient journey
begins has its own significance. Clinical main concern is determined by the presenting symptoms
and vital signs. This is a base of clinical quality.

2. Background:
The Vital Signs standards were formerly developed and in print in 2010 through a enterprise
between the Royal College of Emergency Medicine, the Royal College of Nursing, the Faculty
of Emergency Nursing and the Emergency Nurse Consultants Association.
Since the standards were introduced, there has been a mounting problem of crowding in EDs
with unfavorable effects on clinical outcomes. RCEM published a toolkit to assist EDs with
managing in a crowded department. The early and repeated measurement of vital signs, and the
consequential early warning scores, plays an increasingly imperative role in prioritizing patients
in need of vital attention and identifying those whose clinical state has deteriorated.
Literature Review:
The effectiveness of communicating these parameters is significant to the success of Critical
Care Response Teams who are assembled to help identify and manage critically ill patients as
well as bring critical care expertise, support and earlier intervention to all in-hospital patients
(Hillman 2005, Galhotra et al. 2006). A fundamental importance to the clinical outcomes of a
patient begin with the documentation, acknowledgment and ultimate action on changes in a
patient’s vital signs (Gao et al. 2007, Cooper & Buist 2008). Vital signs (commonly defined as
blood pressure, temperature, heart rate, and respiration rate and oxygen saturation) are key
indicator of a patient’s perspicacity and physiological status. In recent years, it has been revealed

3. that vital signs are vital to objectively identify at-risk ward patients (Buist et al. 1999). Patients
who undergo cardio-respiratory arrests, death or surprising admission to intensive care units, in
acute-care hospitals, often exhibit identifiable vital sign deteriorations prior to these failure-to-
rescue events (Goldhill et al. 1999, Hodgetts et al. 2002, Kause et al. 2004, DeVita 2005, DeVita
et al. 2006, Galhotra et al. 2007). Timely vital signs information and effective patient care
coordination are more important than ever, as communication delays to critical data can limit the
detection of patient deterioration leading to adverse events (DeVita et al. 2006). The role of
nursing in adverse event prediction and prevention is critical and underpins many patient care
decisions (Considine & Botti 2004). Understanding current nursing workflows and nurses’ view
of clinical and documentation processes can help optimise recording of pointof-care vital signs
documentation. Identifying the gaps in healthcare technology, clinical workflows and
environment can inform the design of more effective technology. Clinical workflow analysis is
also critical for the implementation and adoption of technology in healthcare. However, the
research surrounding vital signs and the workflow in general internal medicine environments
associated with the documentation of vital signs has received very little attention. Background,
There are very few reported best practice guidelines for conducting vital sign measurements and
recordings. In the limited examples, the guidelines are more directed towards the clinical practice
and do not include detailed documentation practice standards, but refer to other general
guidelines for record keeping (Royal College of Nursing 2007). However, these hospital-specific
guidelines are often vague and the timeliness of the documentation is non-specific. The Joanna
Briggs Institute (1999) published a systematic review examining vital signs clinical practices but
was limited by the small number of research studies and also did not address the documentation
practices for vital signs. We have found only one study that evaluated patient care technicians as

4. they conducted routine vital signs assessment in the clinical environment. Wager et al. (2010)
found that data entry on tablet computers affixed to vital signs monitors significantly improved
the timeliness of vital signs. This recent study involved patient care technicians who are
assistants to healthcare professionals and have a different role in the clinical environment and
workflow compared with nurses who are involved in more complex tasks. Patient care
technicians are not available in many countries, and conducting vital signs assessment and
documentation remains the responsibility of a registered nurse. The lack of evidencebased
knowledge regarding the nursing workflow, including the amount of time it takes nurses to
collect and document vital signs information into the patient records amidst their other current
clinical tasks, makes it difficult to compare any new process or technology systems to current
processes and technologies. Human factors engineering techniques have been used in attempts to
improve patient safety and quality of care (Potter et al. 2004), and ethnographic analysis can
offer improvements to health care delivery by evaluating the organizational systems and
introducing system design improvements (Wolf et al. 2006). The objective of conducting an
ethnographic study was to better understand nursing activities and delineate the workflow
surrounding vital signs collection and documentation. The data collected from this study provide
an evidence-based understanding of nurses practising in general internal medicine environments.
The time-motion study will measure and compare the timeliness of vital signs assessment and
documentation tasks conducted at various hospital environments. Unified Modeling Language
(UML) activity diagrams were developed from the gathered data to represent clinical nurse
workflow. UMLbased approaches have previously been implemented in health care modelling
and can be used to represent the actual state of the system to identify weak points and target
areas for development (Garde et al. 2003, Pelayo et al. 2009). This research will be the

5. foundation for the identification of potential barriers and opportunities that will be used to guide
the design and development of future processes and systems to enhance the nurses’ ability to
detect deteriorating patients, alert critical care response teams and ultimately increase patient
safety outcome.
Objective
The aim of this study is two-fold. Initially to investigate the factors affecting vital sign data
quality during measurement and documentation. In the end, to provide recommendations on,
how to improve vital sign data quality in emergency care
POPULATION AND SAMPLING
According to Brink (2006:123) a population is the entire group of persons or objects that is of
interest to the researcher, in other words, that meets the criteria which the researcher is interested
in studying. The total population is 12 registered nurses working in emergency department.
DATA COLLECTION
The target population is twelve registered nurses working at university of Lahore, Punjab
Pakistan are given a questionnaire. The respondents’ are requested to complete the
questionnaire and the completed questionnaires are collected.
Data analysis and interpretation
The data of the study is analysis with SPSS computer data from the respondents. The data is
presented in the form of agree and disagree, neutral responses from the respondents in the form

6. of percentage. A number of improvements were made to the final project based on feedback
from the pilot sites
Results
Conclusion:
Teamwork and implementation of quality could improve vital signs documentation at triage.
Nursing compliance of vital signs documentation has improved through education and training
Recommendations:
1. Departments stressed to meet the challenge of measuring a complete set of vital signs within
15 minutes of arrival should evaluation their processes and reflect on how they can learn from
higher performing Trusts
2. Departments are buoyant to use the QI platform to support their QI activities
3. Departments not achieving repeat vital signs within 60 minutes, should review their results
and consider how to effect improvement.
References:
Yeung, M. S., Lapinsky, S. E., Granton, J. T., Doran, D. M., & Cafazzo, J. A. (2012). Examining
nursing vital signs documentation workflow: barriers and opportunities in general internal
medicine units. Journal of clinical nursing, 21(7‐8), 975-982.
Schellein O, Ludwig-Pistor F, Bremerich DH. Manchester Triage System: Process Optimization
in the Interdisciplinary Emergency Department. Anesthetist 2008; 58:163–170

7. Royal College of Emergency Medicine. Vital signs in majors. 2011.
RCEM. Tracking Emergency Department Crowding.
Vital signs Procedures Checklist
Age:_____________________________year & experience
section:____________date:___________
Sr
.N
o Questions Agree
Disagre
e Neutral
Remarks if
any

8. 1
Does the hospital policy state on
documentation of patients’ vital
signs?
2
Is essential to Identify the client
properly and explain what you are
going to do, why it is necessary, and
how he can cooperate?
3
Does t follow hand washing and
other appropriate infection control
procedure necessary?
4
Is necessary to Provide privacy to
client?
5
Does it require Placing the client in
the appropriate position?
7
If a nurse has documented his/her
nursing care in the system, is there
security measure to ensure that
nobody else can erase or modify the

9. entry without being identified?
8
Day and time of arrival or triage
(whichever is earlier) is necessary to
mention?
9
Was vital signs taken at the time of
admission?
10
Does monitor vital signs every hour
for every patient?
11
Does vital signs must monitor on the
basis of priority care?
12
Is there any policy for systematic
documentation?
13
Is there any electronic system of
documentation?