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See Editorial, p 790
1
Emergency Department,
Basingstoke & North Hampshire
Foundation Trust, Basingstoke,
UK; 2 School of Health & Social
Care, Oxford Brookes University,
Oxford, UK; 3 Emergency
Department, Southampton
University Hospital Trust,
Southampton, UK; 4 Public
Health Sciences and Medical
Statistics, CCS Division,
University of Southampton, UK
Correspondence to:
Mr B Armstrong, Department of
Emergency Medicine,
Basingstoke & North Hampshire
Foundation Hospital,
Basingstoke RG24 9NA, UK;
bruce.armstrong@bnhft.nhs.uk
Emerg Med J 2008;25:799–802. doi:10.1136/emj.2007.052951
Recording of vital signs in a district general hospital
emergency department
B Armstrong,1 H Walthall,2 M Clancy, M Mullee,3,4 H Simpson1
ABSTRACT
Aim: To examine and explore factors that may influence
the recording of vital signs in adult patients within the
initial 15 min and again within 60 min of arrival in the
‘‘resuscitation’’ and ‘‘major’’ areas of the emergency
department (ED).
Methods: A retrospective analysis of recording of vital
signs was performed on 400 consecutive sets of notes
from adult patients presenting to the ‘‘major’’ or
‘‘resuscitation’’ areas of a district general hospital ED. The
effect of staffing levels, triage category and attendances
on the recording of vital signs was examined using logistic
regression. The main outcome measures were the
proportion of patients with all vital signs recorded within
15 min of arrival, the proportion of patients with all vital
signs repeated within 60 min of arrival and the outcomes
of logistic regression analysis.
Results: Only 223/387 patients (58%) had all vital signs
recorded within 15 min of arrival and only 29/387 (7%)
had all vital signs repeated at 60 min. There was a
significant relationship between the failure to record vital
signs and lower triage categories. There was no evidence
that staffing levels or number of attendances predicted
the recording of vital signs within 15 min of arrival.
Conclusion: Recording of vital signs was poor and
unrelated to staffing levels or numbers of patients
attending the ED. Failure to record patients’ vital signs
undermines strategies to detect and manage ill patients.
Measuring vital signs is generally viewed as a
‘‘mundane’’ task.1 However, the recording of these
vital signs is important for the early detection of any
deterioration in the patient’s condition.2 McQuillan
et al3 found that frequent and comprehensive
monitoring of vital signs and improved care in the
preceding hours and days could have prevented half
of the admissions to intensive therapy units.
McGloin et al,4 Buist et al5 and Subbe et al6 showed
that patients had adverse vital signs in the hours
before respiratory or cardiac arrest, and in some cases
the recording of vital signs had not even been
completed for some of the sickest patients.7
New emergency department (ED) attendances
for England in 2005–6 were 18.8 million.8 The
study site sees 41 000 new attendances per year. Of
these, 18–20% arrive at the ‘‘majors’’/‘‘resuscita-
tion’’ side of the department; 17% of patients who
attended were ‘‘majors’’ and ‘‘resuscitation’’
patients who were admitted to the hospital.
METHODS
No nationally agreed published standards for the
recording of vital signs were found after compre-
hensive literature searching. The consultant team
(doctors and nurses) therefore agreed a local
Original article
standard for vital signs recording in our ED. This
was used as the standard for the audit (box 1).
The following patients were excluded: planned
returns (for example, for procedural sedation) and
patients who were in respiratory and/or cardiac
arrest (active cardiopulmonary resuscitation in
progress) on arrival in the ED.
Power calculation
The power calculation was based on a pilot study.
With data for 400 patients, the true proportion of
vital signs recorded can be estimated to within a
width of ¡4.8% to ¡3.2 with 95% confidence.
Data collection
Demographic variables were collected for day of
arrival, time of arrival and discharge (home or
admitted to hospital), patient location on arrival
(resuscitation room or major area) and triage
category with details of vital signs recording.
The reception manager was asked to identify 400
consecutive sets of ED notes that met the entry
criteria of the study. Data were collected over a 21-
day period. Only ED clinical records were audited.
This period of time was considered typical in that
the numbers were not significantly different from
the yearly average. In addition, this was not a time
when there had been a new influx of staff.
The auditor (BA) entered the data. Before
embarking on data analysis the quality of the data
was checked by generating frequency tables for all
variables. These tables were checked to see if the
values entered were within the expected ranges
and missing values were handled correctly. Four
hundred sets of data were entered; 13 cases were
found to have been double entered, leaving a
sample of 387.
Factors that affect compliance
In order to explore the relationship between vital
signs and nurse staffing, triage categories and
attendances, each factor needed to be defined
(table 1). Nurse staffing was categorised into three
levels as defined by Rush (personal communica-
tion, September 2006). Triage categories were
defined using the Manchester Triage System.9 For
patient attendances per day, 1SD (16.112 rounded
to 16) either side of the mean (108) defined the
‘‘normal attendance’’ rate; ,1SD below the mean
was defined as a ‘‘quiet day’’ and .1SD above the
mean was defined as a ‘‘busy day’’.
Data analysis
The data were analysed using SPSS for Windows
Version 11. Frequency tables reported whether or
799
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Original article

Recording of vital signs within 60 min of arrival

Box 1 Standard for vital sign recording Of the 387 patients, 42% (n = 161) had no vital signs repeated at
all. Only 29 patients (7%) had all five vital signs repeated within
All adult patients (>18 years of age) attending the ED ‘‘majors’’
60 min of arrival in the ED. Respiratory rate was measured in
or ‘‘resuscitation’’ areas will have their vital signs (respiratory
194 patients (50%), pulse oximetry oxygen saturations in 197
rate, pulse oximetry oxygen saturations (SpaO2), heart rate, blood
(51%), heart rate in 209 (54%), blood pressure in 205 (53%) and
pressure and temperature) recorded within 15 min of arrival and
temperature in 39 (10%).
then repeated again within 60 min of arrival.

Logistic regression analysis

not vital signs were recorded on patients within 15 min of
arrival and again within 60 min of arrival. Logistic regression
was used to identify whether nurse staffing, triage acuity and
patient attendances (as defined in table 1) predicted recording of
vital signs.
RESULTS
Three hundred and eighty-seven patients met the inclusion
criteria. Their mean (SD age was 56 (22.2) years (range 18–100).
Recording of vital signs within 15 min of arrival
Of the 387 patients, only 58% (n = 223) had all five vital signs
recorded within 15 min of arrival (fig 1). For the remainder,
either their vital signs were not measured or they were
measured .15 min after arrival. Vital signs that were measured
after 15 min were documented as ‘‘not recorded within 15 min
of arrival’’. The standard was either met or not. Respiratory rate
was measured in 333 patients (86%), pulse oximetry oxygen
saturations in 348 (90%), heart rate in 352 (91%), blood pressure
in 348 (90%) and temperature in 255 (66%).
Staffing levels (comparing suboptimal with fully funded or
richer staffing) and number of attendances (comparing normal
with quiet or busy) appeared to have little impact on measuring
vital signs within 15 min. There was some evidence that,
compared with suboptimal staffing levels, fully funded staffing
levels led to less recording of heart rate (odds ratio (OR) 0.39
(95% confidence interval (CI) 0.15 to 0.97), p = 0.043) and blood
pressure measurement (OR 0.37 (95% CI 0.15 to 0.93),
p = 0.035) within 60 min.
With regard to triage categories (comparing red/orange with
yellow or green), within 15 min of arrival there was evidence
that vital signs were less likely to be measured in the green
triage acuity group than in the red/orange triage acuity group
for respiratory rate (OR 0.20 (95% CI 0.07 to 0.55), p = 0.002),
oxygen saturation (OR 0.22 (95% CI 0.08 to 0.65), p = 0.006),
heart rate (OR 0.19 (95% CI 0.07 to 0.58), p = 0.003) and blood
pressure (OR 0.18 (95% CI 0.06 to 0.54), p = 0.002).
Interestingly, there was evidence that temperature was more
likely to be measured for yellow triage than for red/orange
triage (OR 2.10 (95% CI 1.34 to 3.29), p = 0.001).

Table 1 Table of definitions

Nurse staffing Triage categories ED attendances
8 9
Fully funded skill mix on a shift Manchester Triage Categories Total attendances at the ED on each day that
Early shift Red: Immediate patients presented in the audit:
6 trained RNs Orange: Very urgent Mean (SD) 107.6 (16.1)
1 ENP Yellow: Urgent Minimum 78
1 HCA Green: Standard Maximum 152
Late shift Normal day overall attendances: 91–123
patients
6 trained RNs
Quiet day attendances: (90 patients
1 trained RN (twilight)
Busy day attendances: >124 patients
1 ENP
1 HCA
Night shift
3 trained RNs
1 trained RN (twilight)
1 HCA

Suboptimal skill mix on a shift

Any shift that has (1 member of
staff at any point

Richer skill mix on a shift

Early shift
7 trained RNs
1 ENP
Late shift
7 trained RNs
1 trained RN (twilight)
1 ENP
Night shift
4 trained RNs
1 trained RN (twilight)
ED, emergency department; ENP, Emergency Nurse Practitioner; HCA, Health Care Assistant; RN, Registered Nurse.

800 Emerg Med J 2008;25:799–802. doi:10.1136/emj.2007.052951

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Figure 1 Vital signs recorded within 15 min and 60 min of arrival in the
emergency department.
Within 60 min of arrival there was also evidence that
respiratory rate (OR 0.17 (95% CI 0.05 to 0.52), oxygen saturation
(OR 0.21 (95% CI 0.07 to 0.62), heart rate (OR 0.15 (95% CI 0.05
to 0.47) and blood pressure (OR 0.15 (95% CI 0.05 to 0.48) were
less likely to be measured in the green triage acuity group than in
the red/orange triage acuity group. The yellow triage category
was also significantly less likely to be recorded in all the same
categories as the green triage category and there was evidence that
temperature was also less likely to be measured. Interestingly,
heart rate (OR 0.39 (95% CI 0.15 to 0.97), p = 0.043) and blood
pressure (OR 0.37 (95% CI 0.15 to 0.93), p = 0.035) were less likely
to be measured during fully funded staffing levels (22 patients
only) than for suboptimal staffing levels.
The number of attendances appeared to have little impact on
measuring vital signs within either 15 min or 60 min of arrival,
with the possible exception that oxygen saturation was more
likely to be measured within 60 min of arrival during quiet
times than during normal times (OR 1.79 (95% CI 1.03 to 3.12),
p = 0.040).
DISCUSSION
Vital signs in this patient sample were poorly recorded on arrival
and very poorly recorded within 60 min of arrival in the ED,
regardless of nurse staffing and attendances. These poor results
are comparable with those reported by Alcock et al2 who studied
the recording of physiological observations of patients admitted
from Accident & Emergency departments. In their study of 739
patients, only 378 (52%) had temperature, heart rate, respira-
tory rate and blood pressure recorded, and 265 (36%) had repeat
observations while waiting for admission.
The lower triage categories of green (except for temperature
within 15 min of arrival) and yellow (for within 60 min) are
associated with poor recording of vital signs, as one would
anticipate. It is not clear why recording temperature within
15 min was more likely to be recorded in the yellow triage
category.
Emerg Med J 2008;25:799–802. doi:10.1136/emj.2007.052951
Original article
Alcock et al2 suggested that there may be an association
between how busy the ED is and the poor recording of vital
signs. In our study no association was found between the
recording of vital signs and staffing levels or attendances
(within 15 min at least), which suggests that factors other
than resources are at play.
Patients with abnormal physiology are more reliably detected
by measurement of vital signs. Failure to measure vital signs is
to deny the deteriorating patient the possibility of early
detection and therefore missing the opportunity for improved
prognosis. Vital sign recording plays a fundamental role in this,
but only if nurses understand the physiological basis of these
vital signs and they are measured, communicated effectively
and acted on by the multidisciplinary team.
Limitations of the study
This was an exploratory study. With regard to the logistic
regression, the smaller numbers of patients in some categories
means that only large differences between groups would have
achieved statistical significance in this sample and that estimates
may be biased. This study also involved multiple statistical testing
(with 60 tests). No statistical adjustment was made to allow for
this. However, the pattern of results (ie, relationship with triage
category) is plausible and would have been anticipated.
In addition, hospital notes were not looked at and it is
possible that vital signs may have been recorded on charts that
went with the patient on admission and were not copied for the
ED notes.
Recommendations
The following recommendations are suggested:
c Nursing and medical staff should be educated as to the
significance of initial and repeat vital sign recording in the ED.
c The vital signs should be documented and communicated
within the multidisciplinary team.
c Clinical action plans should be made for patients who are at
risk of deterioration.
c Audit standards for the measuring and recording of vital
signs in the ED should be agreed from the time a patient
arrives through to discharge or admission to hospital.
Acknowledgements: Katy O’Donnell, Research & Development Manager, Basingstoke
& North Hampshire Foundation Trust, Basingstoke, UK; Christine Bagan, Clinical
Effectiveness Manager, Basingstoke & North Hampshire Foundation Trust, Basingstoke,
UK; Sara Sparks, Operations Manager, Emergency Department, Basingstoke & North
Hampshire Foundation Trust, Basingstoke, UK; Sharon Curtis and Mel Henry, Department
of Emergency Medicine, Basingstoke & North Hampshire Foundation Trust, Basingstoke,
UK; Nursing and Medical staff, Department of Emergency Medicine, Basingstoke & North
Hampshire Foundation Trust, Basingstoke, UK.
Funding: None.
Competing interests: None.
Ethics approval: Ethical approval was granted by Oxford Brookes University research
ethics committee and the hospital’s clinical audit department.
Confidentiality and anonymity was achieved by giving each patient a unique identifying
code.
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802 Emerg Med J 2008;25:799–802. doi:10.1136/emj.2007.052951

 Downloaded from http://emj.bmj.com/ on January 2, 2015 - Published by group.bmj.com

Recording of vital signs in a district general

hospital emergency department
B Armstrong, H Walthall, M Clancy, M Mullee and H Simpson

Emerg Med J 2008 25: 799-802

doi: 10.1136/emj.2007.052951

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