Derby Kelly M, Hartung Natalie A, Wolf Sherry L, Zak Heather L, Evenson Laura K
Author Affiliations: Clinical Nurse Specialist (Mss Derby, Wolf, and Zak), Nursing Quality Specialist (Ms Hartung), and Nurse Administrator (Ms Evenson), Department of Nursing, Mayo Clinic, Mantorville, Minnesota.
Clin Nurse Spec. 2017 Nov/Dec;31(6):343-348. doi: 10.1097/NUR.0000000000000330.
The purpose of this project was to standardize vital sign (VS) monitoring throughout a patient's stay in the hospital, including at admission, following transitions to different levels of care, reassessment of abnormal VS results, daily monitoring, and before dismissal. The population of focus was adult general and progressive care patients.
Standards for VS monitoring, documentation, and provider notification were established. Unit routines, nursing procedural guidelines, and order sets were updated with the new standards. Nursing staff received Web-based education. Compliance with the new standards was monitored monthly, and data were shared with nursing leadership. Leadership reviewed the data with nursing staff to identify opportunities and recognize achievements.
Overall, improvement in VS documentation was achieved. Continued opportunities exist for monitoring and reassessment of a full set of VSs after an abnormal result.
Establishing a minimum standard of VS frequency and documentation allows for all healthcare providers to trend and monitor a patient's clinical status. Variability in patient care can be diminished by establishing minimum standards of VS monitoring.
本项目的目的是在患者住院期间规范生命体征（VS）监测，包括入院时、转至不同护理级别后、对异常VS结果进行重新评估、日常监测以及出院前。重点人群为成年普通和进阶护理患者。
制定了VS监测、记录及向医护人员通报的标准。根据新标准更新了科室常规、护理操作指南及医嘱集。护理人员接受了在线教育。每月监测新标准的遵守情况，并与护理管理层共享数据。管理层与护理人员一起审查数据，以发现机会并认可成绩。
总体而言，VS记录得到了改善。在出现异常结果后，仍有持续的机会对全套VS进行监测和重新评估。
确立VS监测频率和记录的最低标准，可使所有医疗服务提供者追踪和监测患者的临床状态。通过确立VS监测的最低标准，可减少患者护理的差异。
