Comparison On Difference In Manual And Electronic Recording Of Vital Signs In Patients Asmitted In Ctvs Icu And Ccu .

http://doi.org/10.33698/NRF0177- Meenakshi S Chand, Sunita Sharma, Rana S Singh, Srinivas Reddy

Abstract: The comparative study was conducted on difference in manual and electronic recording of vital signs in patients admitted in CTVS-ICU and CCU of Advanced Cardiac Centre at PGIMER, Chandigarh. The study was conducted on purposively selected 50 samples admitted in CTVS-ICU and CCU, PGI, Chandigarh. For each subject electronic and manual readings of vital signs were recorded after every 30 minutes for four times. Readings of manual and electronic vital signs were recorded simultaneously. Data included the recordings of temperature, pulse rate, respiratory rate and blood pressure (systolic and diastolic). The recordings were compared to know the difference between manual and electronic readings. The study findings revealed that statistically there was highly significant difference between the manual and electronic readings of temperature, (p<.001) pulse rate, (p<.001) systolic BP and diastolic BP (p<.001), While the difference in respiratory rate was not significant between both methods. Though the difference in temp, pulse and respiratory rate was clinically not significant.

Keywords

Vital signs, Manual and Electronic of Vital signs.

Correspondence at

Meenakshi S. Chand

Lecturer

Desh Bhagat University School of Nursing, Amloh Road, Mandigobindgarh.

Introduction

Vital signs are called the sign of life. All of these vital signs can be observed, measured and monitored. This will enable the assessment of the level at which an individual is functioning. Normal range of measurement of vital signs change with age and medical condition. 1 Patient’ s observations are an important part of nursing care in that they allow the patient’s progress to be monitored and also to ensure prompt detection of adverse events or delayed recovery.2

Vital signs are a quick and efficient way of monitoring a client’s condition and evaluating the client’s response to intervention.3 The term vital signs suggests measurement of vital or critical physiological functions. There is only limited information regarding the frequency with which observation should be undertaken and much of this is based on survey of nurses, clinical practice reports and expert opinion. Surveys of nurses have shown that many of them admit to carrying out frequent vital sign measurements on patients believing to be a routine procedure unrelated to perceived individual patients needs.2

When and how often to assess a specific client’s vital signs are chiefly nursing judgment, depending on the client’s health status. These signs, which should be looked at in total are checked to monitor the functions of the body. The signs reflect changes in function that otherwise might not be observed.4 The purpose of recording vital signs is to establish a baseline on admission to a hospital or clinic. Vital signs may be recorded by a nurse, physician, physician’s assistant, or other health care professional. The health care professional has the responsibility of interpreting data and identifying any abnormalities from a person’s normal state, and of establishing if current treatment or medications are having the desired effect.1

The monitoring of patients is an essential task in the adequate care of critical ill patients. Coronary care units, intensive care units and operating rooms are the specialized units where monitoring of vital sign is the basic task. Monitoring of vital signs is carried out to know the pathophysiological condition of the patient. Vital signs are monitored manually and with the introduction of monitoring information to monitor the patient in any location and situation. The evolution of the monitoring equipment has been an enormous impetus in improving the quality of healthcare.5

Specialized units, such as coronary care units (CCUs), intensive care units (ICUs), operating rooms and anesthesia wards, needs the continuous observation of the patient. Monitoring of Vital signs helps the physician respond to any event that may be life threatening, and implement the actions required to return the patient to a favorable condition. While obtaining the vital signs, a nurse need to understand and interpret the values, communicate findings appropriately and begin interventions as needed. Careful measurements techniques ensure accurate findings. There is need to analyze the vital signs to interpret their significance.2

The ability of the nurse is to integrate information into a meaningful evaluation of the patient’s status can provide valuable information to the physician for instituting therapy and ultimately helping the patient. Knowledge of the baseline level of vital signs is helpful in determining appropriate goals and individualized treatment plans for p a t i e n t s b o t h w i t h a n d w i t h o u t cardiopulmonary diseases.2

Nurses have ultimate responsibility for accuracy. Temperature, Pulse, Respirations, Blood Pressure are assessed and interpreted together. Nurses must consider patient’s normal pattern in relation to standard values/range.6 There are not enough medical workers to go around, especially in intensive care units. When a patient must have continuous monitoring, a stay in the intensive care unit is necessary. Using a monitor on a patient continuously gives an immediate objective reading on all measurements. Visual monitoring or periodic monitoring can be affected by small swings in readings. With constant readings, a visual representation is available to place these small movements into perspective. There is no need for subjective observations of the patient’s condition.7

Continuous e l ectronic patient monitoring is beneficial when abnormal physiology is rapidly recognized by the clinician and it alarms them that the patient’s condition is deteriorating. Early recognition of deteriorating condition is only of value if the treatment is delivered quickly.8 Monitoring is used extensively in critical care units. Besides, critical care areas ‘vital sign’ measurement traditionally involves manual recording of pulse rate, respiratory rate, temperature and blood pressure. Now medical electronics makes continuous non-invasive measurement and display of some or all of the physiological variables. Patients are at risk in the intensive care units, most often when they are unattended. Because someone cannot always be at the bedside, monitors and alarms must be used to alert the staff to dramatic changes.9

Young and Griffiths tried to undertake a systematic review of primary studies of the effect of electronic, automated, non- invasive, vital sign monitoring on high risk surgical and medical patients in acute care wards. They failed to find any studies comparing any form of continuous electronic vital sign monitoring with intermittent manual vital signs recording on adult patients in acute wards.8

An electronic device continually monitors up to five vital signs (heart rate, respiration rate, skin temperature, oxygen saturation, and blood pressure), and display data on the monitor all times. Nursing staff regularly and continuously review vital signs and the patient status index to identify patients who experience distress and they attempt to stabilize the patient. Studies suggest that the system enables nurses to identify quickly and get help for patients, whose condition is deteriorating, leading to fewer unplanned intensive care unit admissions and out-of-intensive care unit cardiac arrests and significant cost savings.10 Continuous electronic monitoring is an adjunct to patient care when periodic vital sign monitoring does not provide frequent enough assessment and/or by providing an alert when the patient’s vital signs have deviated outside an identified acceptable range.11

The conventional, manual methods require a considerable amount of nursing time. There is effect on staffing when even one member of nursing staff must take a patient’s blood pressure every 15 minutes. It was therefore hypothesized that if vital signs were obtained by the electronic monitoring, nurses would have more time for patient care. A glance at the monitor’s reading would provide a quick assessment of vital functioning. With electronic equipment, it is possible to measure pulse, temperature, and blood pressure during point of time- but the readings will not necessarily be comparable with those we might get if we took manually.12 Imani et al compared the two body temperature measurements by mercury and digital thermometer and found that there is no statistical significant difference between the measurements by mercury and digital thermometer.13 There is only limited research relating to monitoring respiratory rate, and these studies focused on issues such as the inaccuracy of respiratory rate measurement as a marker for respiratory dysfunction. Inaccuracies in respiratory measurement have been reported in the literature. There has been very little research evaluating the measurement of pulse rates.2

Fabian et al. studied that the results obtained by the modern automatic blood pressure (BP) monitors using oscillometric method are highly dependent on conditions from cardiovascular diseases (e.g. atherosclerosis) the resulting values differ significantly from those measured by the traditional auscultation method.14 A research study signifies that occasionally, an individual Non Invasive Blood Pressure determination value will vary by as much as 37 mm Hg from the direct arterial value. There are some other factors that can prevent accurate measurement of blood pressure with NIBP devices. Irregular or rapid cardiac rhythms hinders in determining blood pressure using NIBP devices because of their great beat to beat variability. Other conditions like excessive patient’s movement may interfere with detection of cardiac oscillations by the NIBP monitor. This can l ead to error i n b l ood pressure measurements.15

There are suggestions that vital sign monitoring has become a routine procedure, but little useful information was identified in regards to the optimal frequency of vital sign measurement. It was noted that many of the important issues related to vital sign measurement have not been investigated through research.16 The measurement of temperature, pulse, blood pressure and respiration has never been easier. Hundreds of automated device exist that not accurately reproduce the functions measured, but now provide digitized data that can easily be sent over the internet, telephony or wireless communication systems.17

In intensive care units like CTVS-ICU and CCU patients are on continuous monitoring. So it’s the responsibility of the health care professionals to be vigilant while monitoring the physiological parameters as electronic monitoring of vital signs may differ from the manual monitoring of the vital signs. It is important to obtain valid and reliable measurements in order to develop an accurate assessment. Understanding the rationale and methods for vital signs assessment will aid in obtaining valid and reliable measurements and assist in the provision of optimal health care in a variety of patient care setting.3

Objective

To find out the difference in manual and electronic recording of vital signs.

Materials and Methods

CCU and CTVS-ICU of Advanced Cardiac Centre were selected as critical units equipped with electronic monitors to observe the patient physiological parameters continuously. These monitors were installed by same company with same working manual.

A written permission for conducting the study was obtained from Head of Department, of the CTVS-ICU, and CCU of Advanced Cardiac Centre, PGIMER, Chandigarh. The tools used for data collection includes a Demographic Performa containing name of patient, age, sex, C.R no, bed no., ward and diagnosis, Record Performa for Electronic and manual recording of vital signs and Protocol to measure vital signs manual as well by electronic monitors. The tools and protocols were developed and got validated by the experts from medical and nursing field.

Patients on electronic monitoring for continuous assessment of physiological parameters admitted at CTVS-ICU and CCU of Advanced Cardiac Centre, were enrolled in the study. The samples were purposively selected from the target population, provided that they met the inclusion and exclusion criteria of the study. With the purposive sampling technique, 50 subjects were enrolled for the study meeting the inclusion criteria i.e. patients admitted in Advanced Cardiac Centre and on electronic monitoring of vital signs and exclusion criteria i.e. patients on ventilators, pacemakers, patients with irregular heartbeats, obese and children. Four measurements of vital signs temperature, pulse, respiration, blood pressure (systolic and diastolic each) were monitored and recorded. Four readings for each parameter were recorded after 30 minutes interval consecutively. Readings of each parameter for manual and electronic were recorded simultaneously. The data was analyzed using descriptive and inferential statistics with the help of SPSS version 16.

Results

50 subjects were enrolled for the study from CCU and CTVS-ICU with different cardiac conditions. 29(58%) subjects were taken from CCU and 21(42%) subjects were derived from CTVS-ICU. The subjects were in the age group of 21-80. Out of total 50 subjects, 42(84%) were males and 8(16%) were females. Mean age of the males was 57.12 years with the range 30-80 years and mean age of the females was 49.25 years with the range 25-58 years.

Table 1 shows the mean difference of vital parameters like temperature, pulse, respiration, systolic blood pressure and diastolic blood pressure between manual and electronic measurements. Total 200 readings were recorded manually and as well as electronically. Paired t-test was applied to find the significant difference between manual and electronic measurements within the group. Results showed that the mean difference in temperature readings were0.10±.20 and p value showed that there was highly significant difference between the manual and electronic readings of temperature, (p<.001). The mean difference in pulse rate was 1.0±3.80 and it was highly significant (p<.001). The mean difference in systolic BP and diastolic BP was found 0.015±1.16 and 13.14±7.60 and it was highly significant(p<.001), While mean difference in respiratory rate was 0.015±1.16 which is not significant between manual and electronic measurements, (p=0.883)

Coefficient of variation for two methods (manual and electronic measurements) of different variables:

Table 3 presents the coefficient of variation for two methods (manual and electronic measurements) of different parameters like temperature, pulse, respiration, systolic blood pressure and diastolic blood pressure. Coefficient of variation quantifies the variation in measurements and compares the variability of different samples. Results showed that variations in temperature both methods manual & by electronic methods were found (CV %) 1.51 and 1.57 respectively. The Pulse rate (CV %) was 21.29 and 20.82. Respiratory rate was having (CV %) 26.25 and 25.48. The Systolic BP (CV %) was 15.23 and 14.36 and Diastolic BP (CV %) was 14.39 and14.69. These results showed that variations in both methods were found similar of manual and electronic measurements of vital signs.

Table 1: Mean difference of vital parameters between manual and electronic measurements

N=200

Vital Parameters	Manual Measurement		Electronic Measurement		Mean Difference in manual and electronic measurements	t 199 p value
	Mean	SD	Mean	SD
Temperature	36.54	0.55	36.43	0.57	0.10±.20	7.285 < .001
Pulse rate	82.50	17.56	83.57	17.01	1.0±3.80	3.981 < .001
Respiration rate	22.07	5.79	22.05	5.61	0.015±1.16	.182 .883
Systolic BP	133.60	20.34	120.46	17.30	13.14±7.60	24.432 < .001
Diastolic BP	87.08	12.52	73.54	10.80	13.53±7.85	24.383 < .001

Table 3: Coefficient of variation for two methods (manual and electronic measurements) of different variables

Variables	Manual			Electronic
	MEAN	SD	CV(%)	MEAN	SD	CV(%)
Temperature	36.54	0.55	1.51	36.43	0.57	1.57
Pulse Rate	82.50	17.56	21.29	83.57	17.39	20.82
Respiration Rate	22.07	5.79	26.25	22.05	5.61	25.48
Systolic BP	133.60	20.34	15.23	120.60	17.30	14.36
Diastolic BP	87.08	12.52	14.39	73.54	10.80	14.69

Discussion

Vital signs are called the sign of life. Vital signs are observed and monitored to assess the level of individual functioning. Measurement of vital signs determines the client’s level of health and response to physical and psychological stress as well as medical, surgical and nursing therapy. Any alteration is indicative of deviation of health from normal. Vital signs are an important component of patient care. They provide critical information needed to make life-saving decisions, and confirm feedback on treatments performed. Therefore, vital signs should be accurately documented. Abundant research indicates that vital signs aren’t consistently assessed, recorded, or interpreted. Monitoring a patient’s vital sign should be a thoughtful and scientific assessment. In intensive care units a nurse needs to measure vital sign correctly and to interpret the values in order to obtain accurate assessment. The present study compares the difference in manual and electronic recording of vital signs. The study conducted on 50 samples with electronic monitoring of vital signs admitted at CTVS- ICU and CCU of Advanced Cardiac Centre at PGIMER, Chandigarh.The sample was purposively selected from the target population. Readings were recorded manually and electronically. Electronic monitoring saves time as compared to manual monitoring of vital signs. Study by Holmes shows that a glance at the monitor readings would provide a quick assessment of vital functioning. But the readings will not necessarily be comparable with those we might get if we took manually.12 Young and Griffiths tried to undertake a systematic review of primary studies of the effect of electronic, automated, non-invasive, vital sign monitoring on high risk surgical and medical patients in acute care wards. They failed to find any studies comparing any form of continuous electronic vital sign monitoring with intermittent manual vital signs.8

The present study showed that the temperature by manual method showed a mean difference of 0.10±0.20, from the electronic method, which was statistically significant. In most cases manual temperature readings were higher than electronic readings. In contradiction to the result of this study, another study by Imani et al compared the two body temperature measurements by mercury and digital thermometer and found that there is no statistically significant difference between the measurements by mercury and digital thermometer.13 In the present study the mean difference of 0.10±0.20 is not a clinically significant one. The little change in variation of temperature by this range is unlikely to change a clinical decision. So, this result showed that the electronic thermometry is as accurate as that of the manual thermometry.

The mean difference between the pulse readings by electronic method and the manual method was 1.0±3.80. In most of the cases the electronic reading was more than the manual reading. This range of difference in the clinical setting is not a significant one. So even the mean difference is statistically significant we can say that the electronic monitors are equally accurate in a clinical setting.

Respiration rate did not show any significant difference between readings of manual and electronic (mean difference 0.01±1.16). This result indicated that electronic method of recording respiration is same as recorded manually. There is limited research relating to monitoring respiratory rate, and these studies focused on issues such as the inaccuracy of respiratory rate measurement as a marker for respiratory dysfunction.2

Present study showed that the systolic and diastolic blood pressure readings by manual method had more values than the electronic method with a mean difference of 13.14±7.60 and 13.53±7.85. These differences were found highly significant statistically. Fabian et al studied that the results obtained by the modern automatic blood pressure (BP) monitors using oscillometric method are highly dependent on conditions of cardiovascular system of the monitored person. Especially, with people who suffer from cardiovascular diseases (e.g. atherosclerosis) the resulting values differ significantly from those measured by the traditional auscultation method.14 The present study was also carried out in the CTVS-ICU and CCU, where patients were admitted with cardiac conditions.

The null hypothesis of this study was that there is no significant difference between the vital signs measurement by manual and electronic methods at 0.05 level of significance. This has been rejected as the study findings revealed that statistically there was highly significant difference between the manual and electronic readings of temperature, (p<.001) pulse rate, (p<.001) systolic BP and diastolic BP (p<.001), While the difference in respiratory rate was not significant between both methods. Results of Coefficient of variation for two methods (manual and electronic measurements) of different parameters like temperature, pulse, respiration, systolic blood pressure and diastolic blood pressure signified that variation in both methods was similar.

The present study revealed that there is statistically significant difference in manual and electronic recordings of temperature, pulse rate, systolic blood pressure and diastolic blood pressure, but the respiratory rate difference is non-significant throughout the study. The difference present in temperature and pulse recordings is not large enough to say it a clinical significant. Systolic and diastolic recordings show more difference which is clinically significant as well. Both methods are found to be consistent as variations in both methods were found similar. Clinicians and nursing personnel should be vigilant enough while recording blood pressure. Another aspect of more difference in blood pressure could be that the study is carried out in Critical Cardiac Units where variations in vital signs are possible as these patients are more prone to be hemodynamically unstable. Hence it is recommended to undertake research in other hospital settings where patients’ physiological parameters are more stable. Basic knowledge of the principles of monitoring equipment and correct interpretation of data is important since failure to do so can result in misdirected therapy.

References

1. Vital [Online]. [cited 2010 March 2 4 ] . A v a i l a b l e f r o m : U R L : h t t p : / / www.surgeryeccyclopedia .com/St-Wr/Vital- Signs.html
2. Best Evidence Based Practice Information Sheets For Health Professionals [Online]. 1999 [cited 2010 Feb 24]; Available f r o m : U R L : h t t p : / / w w w . j o a n n a Briggs.edu.au/pdf /BPISEng_3_3pdf
3. Potter AP, Perry A. Fundamentals of 7th ed. India: Elsevier Publications; 2009. p. 503-43.
4. Berman A, Snyder SJ, Kozier B, Erb Fundamentals of Nursing. Concepts, Process, and Practice. 8th ed. India: Pearson Education; 2008. p. 527-43.
5. Barro S, Presedo J, Felix P, Castro D, Vila New Trends in Patient Monitoring. Disease M a n a g e m e n t & H e a l t h O u t c o m e s . 2002;10(5):291-306.
6. Bruderle Vital signs [Online]. 2003 Feb13[cited2010 March16]; Available from: URL: http://www.homepage.villanova.edu /elizabethbruderle /1103/vitals.htm Zertisky

7. Patient Monitors –Electronic Equipment For Monitoring Patients [Online]. [cited 2011 Jan 16]; Available from: URL: http://ezinearticles.com/?Patient-Monitors— Electronic- Equipment- For- Monitoring- Patients&id=3780296
8. Young D, Griffiths Clinical trials of monitoring in Anesthesia, critical care and acute ward care. Br. J. Anaesth 2006;97(1):39- 45.
9. Pilbeam SP, Cairo JM. Mechanical Physiology and Clinical Application. 4th ed. India: Elsevier Publications; 2007.p. 161-3.
10. Votruba Real-Time Vital Sign Monitoring Ensures Timely Care for At-Risk Patients, leading to Fewer Unplanned Intensive Care Unit Admission and Out-of –Intensive Care Unit Cardiac Arrest [Online]. 2008 [cited 2010 Dec]: Available from: URL: http://www. innovations. ahrq.gov
11. Continuous Electronic [Online] 1999[cited 2011Jan 2 ]: Available from: URL: on-and-learning/Nursing-http://www.sickkids. ca/Nursing/Education-and-learning/Nursing StudentOrientation /module-two-clinical-care/ electronicmonitoring/index.html

12. George JH. Electronic Monitoring of Vital AJN [serial online] 1965 Feb [cited 2010 Feb 26];65(2):68-71.
13. Imani Salehi S, Habibian R , Sadeghi B, Hatamipour K. Comparative Study of Measuring Body Temperature by Mercury and Digital Thermometer. IJN 2009;21(56):9-16
14. Fabian V, Janouch N, Novacova L, Stepancova Comparative study of non- invasive blood pressure measurement methods in elderly people . Engineering in Medicine and Biology Society. [serial Online] 2007 [cited 2011Jan2]: 612-5. Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed/18 002030
15. Dobbin RK. Noninvasive Blood Pressure Critical Care Nurse 2002;22(2): 123-4.
16. Evans D, Hodgkinson B, Berry Vital Signs.The Joanna Briggs Institute for Evidence Based Nursing and Midwifery [online]. 1999 [cited on 2011Feb] :8-9. Available from: URL : http://www.lesionadomedular.com/archivos/al macen/signos%20vitales.pdf
17. Bayne Vital Signs: Are We Monitoring the Right Parameters? Nursing Management 1997 May; 28(5):74-6