Re:Triage Vital Signs
I agree with Jim's comments that BP is a screen and has poor specificity, especially in the ED setting. My concern about an inclusion/exclusion list, from a human factors standpoint, is that they are often too complex to remember-as Jim illustrates in attempting to create a list from memory. In my experience, most triage nurses don't have their triage protocols in front of them either, unless they are built into an EHR. In defense of Jim's position though, there is support for an inclusion/exclusion list: The Nat'l High Blood Pressure Group recommends "all children with any chronic medical condition(s) and/or being treated with meds known to raise BP have their BP measured at least once during every healthcare encounter" (http://www.guideline.gov/summary/summary.aspx?doc_id=14293). They also site an AAP recommendation that children "over 3" have a BP done at least once a year and that an "abnormal" BP reading obtained with a mechanical device is repeated manually. This is becoming increasingly difficult as what I am seeing is that many EDs don't even have manual BP cuffs, especially in all the kid sizes. Also, adolescents have been described to have white coat syndrome just like adults, so perhaps another question to ask is "what is the value of one BP in the ED setting for kids" (see Jim's comment about chasing false positives)?
As for references/sources, our Pediatric ESI triage study group was unable to find a standard, evidence based set of normal/abnormal vital signs in the ED setting. To illustrate this we published an article based on a comparison of pediatric emergency courses and texts, including differences in vital sign parameters (Hohenhaus SM, Travers D, Mecham N. Pediatric triage: a review of emergency education literature. J Emerg Nurs. 2008 Aug;34(4):308-13). So what's normal and what's abnormal and how do we know?!
We also found in the pediatric ESI triage study that ED nurses who cared for children on a regular basis were much more likely to do hands on assessments and were comfortable taking vital signs including BPs without adding much additional time to the intake. Though we did not specifially measure time, these nurses tended to be doing information gathering- interviews, tactile assessment- while obtaining the BPs so not an "additional" step, so I expect that if we were to actually measure time it wouldn't be a significant amount- would make an interesting study that could impact both patient safety as well as throughput.
The consensus document-AAP Guidelines on Care of Children in the ED- states in its "checklist" that vital signs, including BPs, should be obtained on ALL children and infants. (http://webcast.hrsa.gov/archives/mchb/dcafh/20100223/Checklist.pdf). Again, from a human factors standpoint, repetition and practice adds to proficiency. If we continue to take a full set of vital signs, including BPs, only on a select group of kids, we miss an opportunity to become more competent at the skill and thus may miss that one kid who could benefit from the expertise.
Susan M Hohenhaus MA, RN, FAEN
President, Hohenhaus & Associates, Inc.
Editor, Pediatric Update, ENA Connection
Section Editor, Clinical Nurse Forum, Journal of Emergency Nursing
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