Background and Clinical Pearls
Vital signs provide objective patient condition data, contributing to the diagnosis, treatment and transport decisions, and triage. Measuring and documenting at least two sets allows trending of the patient's condition and provides medical-legal evidence that you were monitoring the patient for changes. Finally, reporting vital signs to the ED helps them appropriately triage the patient. Respiratory rate and oxygen saturation are important vital signs that deserve special mention because they are often neglected or inaccurately measured. Pulse oximetry is an indispensable tool sometimes met with skepticism in EMS. While undeniably useful, do we know when it is accurate, and are we aware of its pitfalls? Poor perfusion, hypothermia, patient movement, carbon monoxide, and cyanide poisoning (e.g., smoke inhalation) can all prevent accurate assessment of proper oxygenation.
Additionally, pulse ox lag or latency refers to the delay between actual blood oxygen levels and pulse oximetry readings. This delay can be 30 seconds to a few minutes. This can lead to continuing intubations attempts when the patient is more hypoxic than indicated by the pulse oximeter, extubating when the patient is properly intubated, and overly aggressive bag ventilation. The respiratory rate is notoriously estimated or not assessed. Yet changes in respiratory rate are often the earliest indicator of shock, sepsis, respiratory insufficiency, and other severe conditions. It is the most critical predictor of subsequent cardiac arrest. So, is your patient’s respiratory rate 16?
Performance Improvement and Best Practices
Obtain and document at least one set of vitals on all patient contacts, even if it does not result in a transport. If a patient is transported, a minimum of two sets should be obtained to show continuous monitoring. Vital signs should be obtained and documented in intervals appropriate for the patient’s clinical presentation. (I.e., Critical Every 5 Minutes, Routine Every 15 Minutes)
When documenting the GCS or Peds GCS Scale, document the best response for each section. Break down per section; for example, 4-4-5. Pulse rate, rhythm, and quality should be noted when assessing the “pulse.” When assessing Respiratory rate, rhythm and quality should also be considered; assess the patient's respiratory effectiveness through the above-stated measures. Consider using ETCO2 SiteStream(Nasal Cannula) or Inline(CPAP/Advanced Airway) monitoring for accurate respiratory rate. Titrate ventilation to an appropriate ETCO2 Range of 35mmHg-45mmHg. Some conditions may require deviation from these values. Refer to local protocols. Systolic Blood Pressure is not always accurately displayed on cardiac monitors when using the NIBP cuff. Consider obtaining a manual blood pressure (auscultated or palpated) to better trend the patient’s systolic and diastolic blood pressure. Ensure that the appropriately sized cuff is used for the patient’s size. A too-small cuff can give a false high reading; inversely, a too-large cuff can give a false low reading. A consistent waveform must be present for an SpO2 reading to be considered accurate. Some factors such as low blood pressure, hypothermia, and fingernail polish can affect the waveform and accuracy of the reading. If possible, these issues should be corrected to obtain a better waveform and more accurate reading. SpO2 waveform should be correlated to a pulse. Conditions such as carbon monoxide poisoning can present with an SpO2 within normal ranges. This is because SpO2 only measures the percentage of saturated hemoglobin, not what it is saturated with. Titrate oxygen saturation to an accurate SpO2 reading of 92%-99%.Other Relevant Data and Educational Resources
EMS programs should be familiar with all current guidance on field triage about the care of patients suffering from traumatic injuries. Numerous informational resources are available from the State of North Dakota’s Trauma System via their website. GCS capture remains a critical element of EMS’s evaluation and management of trauma patients. https://www.ems1.com/ems-products/medical-monitoring/articles/patient-vital-signs-5-tips-for-emts-paramedics-ppfyyuFnCZKWxTsV/
Rural EMS Counts Vital Sign Measures
The six Vitals Sign reports are for all patient contacts. All Vital Signs must be documented in the Vital Signs sections. The Vitals Reports exclude the following disposition values: 1) Cancelled (No Patient Contact), 2) Cancelled (Prior to Arrival at Scene), 3) Cancelled on Scene/No Patient Found, 4) Standby - No Service or Support Provided, 5) Patient Dead on Scene - No Resuscitation Attempted (With Transport), 6) Patient Dead on Scene - No Resuscitation Attempted (Without Transport), 7) Patient Dead on Scene - Resuscitation Attempted (With Transport), 8) Patient Dead on Scene - Resuscitation Attempted (Without Transport), 9) Transport Non-Patient, Organs, etc., and 10) Wheelchair Transport.
Vitals- Glasgow Coma Scale Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one Glasgow Coma Scale score gathered and documented in the appropriate discrete data field.
Vitals- Pulse Rate Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one pulse rate gathered and documented in the appropriate discrete data field.
Vitals- Respiratory Rate Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one respiratory rate gathered and documented in the appropriate discrete data field.
Vitals- Set of Vital Signs Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one set of vital signs gathered and documented in the appropriate discrete data fields. For this measure, a set of vital signs consists of: Glasgow Coma Scale score, pulse rate, respiratory rate, systolic blood pressure, and pulse oximetry.
Vital- SpO2 Documented Description: Assessing and monitoring vital signs is critical for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one pulse oximetry reading gathered and documented in the appropriate discrete data field.
Vitals- Systolic Blood Pressure Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one systolic blood pressure reading gathered and documented in the appropriate discrete data field.
Click here to see a deep dive of North Dakota Vital Sign documentation.