Nursing documentation prior to emergency admissions to the intensive care unit

Abstract

Early identification of prodromal signs of acute deterioration of patients is essential in high quality care. Rigorous monitoring of patients is facilitated by risk assessment tools, e.g. the Modified Early Warning Score (MEWS). The purpose of the study was to estimate the accuracy of nursing documentation according to parameters that comprise MEWS in patients prior to emergency admission to the intensive care unit (ICU). The research design was retrospective and descriptive. Data was collected from medical records of in-patients who presented as emergency admission to two ICUs at a university hospital between 1 October and 31 December 2006. Data was collected from 65 patients' records over the 3-month period. Most admissions occurred between the hours of 8 a.m. and 4 p.m. Respiratory failure was the primary reason for admission, followed by septic shock. Respiratory rate was documented for 14% of patients (n = 9) prior to ICU admission, which was the least documented observation. Urine output and fluid balance were documented for 40% of the patients, level of consciousness in 48% of patients (n = 31), temperature for 69% (n = 45) and oxygen saturation for 80% of the patients (n = 53). Respiratory failure was the primary cause of emergency admission of in-patients to the ICUs with respiratory rate the least documented vital sign. Nursing documentation according to the MEWS was insufficient. CONCLUSIONS/RELEVANCE TO CLINICAL PRACTICE: Nurses need to be alerted to the necessity of documenting early signs of deterioration of patients, particularly the respiratory rate. With better monitoring and documentation of physiological parameters, emergency admission to the ICU might be avoided.