Exploring the frequency of blood pressure documentation in emergency departments

One of the most commonly performed task in the emergency department (ED) is reported as the monitoring of vital signs, yet there are no published standards of care that provide guidelines for the frequency of obtaining vital signs in the ED. The purpose of this exploratory study was to determine the frequency of documentation of vital signs recorded during ED visits across Veterans Health Administration (VHA) facilities.

Deidentified patient level data from the VHA electronic health record (EHR) were abstracted for emergency department visits for 12 randomly selected days in calendar year 2011. The dataset included vital signs data, associated time stamps, facility, length of stay, triage category based on the Emergency Severity Index (ESI), and patient disposition for all patients. Descriptive statistics were used to describe the frequency of the specific vital sign measures, and parametric and nonparametric tests were used to examine study variables by ESI.

The sample consisted of over 43,232 unique patient visits to 94 VHA EDs with a median length of stay of 173.3 min (interquartile range [IQR], 96.1-286.9). The mean number of times that blood pressure (BP) was recorded per visit was 1.23 (SD 1.175). For the entire sample, median time between blood pressure measurements was 139.7 min (IQR, 81.6-230.1). There was a significant difference in median length of stay and median time between blood pressure by ESI category.

In this dataset, median time between documentation of BP in the ED was every 2.3 hr for all patients. While the median time was statistically significant between ESI categories, these times may not be clinically relevant. More important was the inconsistent documentation of vital signs of ED patients in the designated fields in the EHR. Most facilities (84.1%) documented BP for >75% of patient visits. However, eight facilities (9.1%) had BP documented in <50% of patient visits.

It seems unlikely that vital signs are not monitored in the ED; nurses anecdotally report that vital signs are recorded on a paper chart and later scanned as an image into the EHR. However, lack of consistent process in documentation of vital signs may decrease the care team's ability to note early warning signs of physiological instability or deterioration.