Monitoring of Vital Signs: A Review of Literature on CCRT, MEWS, Clinical Deterioration, RRT

Monitoring of the vital signs
Name of the student
Name of the university
Author’s note

CHAPTER 2: REVIEW OF LITERATURE
2.1 Introduction
In this chapter, an overview of previous research on CCRT, Modified early
warning score, clinical deterioration will be discussed .It introduces the framework for
the studies that comprises the main focus of the research described in this study. The
literature search methodology will be explained and discussed. The publications year of
all the articles will be adjusted accordingly to ensure enough data is collected to analyze
this topic. Research articles on the advantages and limitations will be explored to get
more information. The most relevant and up to date articles will be reviewed.
2.2 Data Extraction Strategy
The search was initiated through The National Centre for Biotechnology
Information (NCBI) using PubMed, Medscape, Science Direct, Cochrane and Research
Gate, Google Scholar search, CINAHL Nursing Journal Databases and Springer. This
chapter will explain how important of early identification of deteriorating patients with
proper treatment according to patient condition that may help patient in their survival.
The key words that used to search article for this study is Modified early warning score
and Rapid Response team which discovered 18,900 articles.
Besides that, searching was done by using specific words which all related to this study
such as clinical deterioration, unplanned admission to Intensive care Unit, code blue
and mortality shows 4,450 articles.

During the searching of the articles, the researcher found that some of the article that
were published was not a full texted articles but only abstracts. The searching of Articles
for this study was from the year of 1990 till 2018.
Most of the studies on Modified early warning score teaching were linked to
international settings because very limited studies focus from Middle East. This studies
more focus on how to reduce patient’s clinical deterioration, unplanned admission to
Intensive care Unit, code blue and mortality.
2.3 Previous study on clinical deterioration
The past decade of research finding revealed that, there is increased focus on
identifying and act according to patient deteriorating condition in hospitalized patient
(Massey et al, 2017, Australian Commission on Safety and Quality in Health Care
(ACSQHC) 2010, National Institute for Health and Clinical Excellence (NICE), 2007).
Patient deterioration can be identified by simple procedure which calls vital sign
monitoring. Monitoring vital signs is essential to the entire hospitalized patient in acute
care hospitals (Mirela et al, 2016). Traditionally, Vital signs are measurements of the
body's most basic functions and this signs are universally used to monitor patients’
progress. The five main vital signs are routinely been monitored by healthcare workers
especially nurses for all the patients in ward. Those five vital signs are blood pressure
(BP), pulse/heart rate (HR), Respiratory Rate (RR), oxygen saturation (SpO 2) and
temperature .Any changes in their patient’s vital sign trends, it can indicate clinical
deterioration or Adverse Events (AEs).However, Elliott and Coventry (2012) have
opined that monitoring of the five vital signs are not comprehensive for the assessment

of the clinical deterioration. According to Elliott and Coventry (2012), proper
documentation of the clinical deterioration can be achieved via monitoring of five vital
signs along with periodic assessment of pain, the degree of consciousness (Glassglow
Coma Scale or GCS score) and amount of urine output. The study undertaken by Khan
et al. (2016), highlighted that at present, monitoring of the vital signs are done via the
use of automated wearable human vital sensors. This automated sensor has special
sensing mechanisms, sensor fabrication and other data processing requirements which
help to side pass the human errors and thereby helping the healthcare professionals to
fetch accurate results.
According to Massey et al, (2016), ‘’a systematic review of eight studies from the
US, Canada, the UK, Australia and New Zealand, highlights that the median overall
incidence of adverse events was 9.2% and almost half of these events were regarded
as preventable “on the other hand, in 2013, Jha et al conducted a observational studies
and the burden of AEs worldwide was estimated, approximately 43 million AEs occur
every year around the world .This AEs lead to ‘”23 million associated disability‐adjusted
life years, increasing hospital length of stay, poor quality of life and increasing morbidity
and mortality “(Massey et al, 2016).
Almost all the hospitals are facing the same situation where suboptimal care
leading to patient mortality and it is recognized worldwide as a major problem requiring
special attention. A good and timely care for these patients may reduce the dangers
they encounter. Therefore, the ability nurses in early identification of deteriorating
patient and response to it timely manner are very essential in patient’s outcome.
(Purling & King 2012, Massey et al, 2016). According to Mok, Wang and Liaw (2015)

vital signs monitoring are an important nursing assessment. However, the nursing
professionals seem to be performing it as a part of routine regime and thus frequently
overlooking the significance of the parameters of the vital signs to detect patient
deterioration. The study conducted by Hands et al. (2013) highlighted that there is only
partial adherence of the vital signs monitoring protocol. Critically ill patients appear more
likely to have vital signs monitored overnight but their analysis is not followed by
periodic repeated assessment. Mok, Wang and Liaw (2015) have opined that proper
clinical knowledge of the nurses about the vital signs along with increase in awareness
about the responsibility of reporting vital signs will help to prevent adverse events and
clinical deterioration in the ward.
2.4 Previous study on Nurses knowledge and practice on clinical deterioration
AEs is unsafe situation in an inpatient hospital setting (Jha et al, 2013). Studies
have been proved that, most of the ICU admission case are results of poor quality care
in wards (Jeddian et al, 2016) and how acutely unwell patients exhibit abnormal vital
signs which are either not recognized or are treated inappropriately can contribute to
physiological deterioration of patients with major consequences on morbidity, mortality
and requirement for intensive care. According to Massey et al, 2016, there is four way of
recognizing or identify patient is deteriorating which is by assessing the patient by vital
sign monitoring , knowing the patient through ‘gut feelings or a sixth sense’ and
identified this as intuition, The level of education of the nurses who had graduated from
a 4‐year university educational program identified patient deterioration significantly
faster than nurses who had graduated from a 2‐year educational program
(Pantazopoulos et al. 2012) and the last one is equipment, where the nurses are

Unfamiliarity with equipment which cause the nurses fail to patient who are at high risk
of deterioration. In 2016 , Mirela with other researcher conducted a structured surveys
and it shows that ,Nurses were not confident about the accuracy of current equipment
used to measure vital signs and about 52.7% nurses from neurosurgery department
believe that automated observation machine did not give a proper reading. Nurses
knowledge and practice is vital in identify patient who are deteriorating, their Clinical
decision making is fundamental to the daily practice as well but in some condition they
are reluctant to escalate care due to concerns they might be criticized if the patient is
not that unwell and about 23.9% of the nurses agreed that due to time constraints most
of vital sign and the accurate of the vital sign monitoring been neglected (Wenqi Mok
et al. 2015). The study conducted by Yoder et al. (2013) reported that nurses also failed
to understand the urgency of monitoring of the vital signs. Their study highlighted that
overnight vital signs are collected frequently among the patients of the wards
irrespective of their risk of clinical deterioration. Yoder et al. (2013) suggested that
nighttime frequency of vital signs monitoring for the low risk inpatients must be reduced
and such reduction is bound to bring dramatic benefits to the seep of the low risk
patients and thereby reducing their length in the hospital stay. According to Mok et al.
(2015), there is a need for continuous professional development in order to improve the
attitudes of the ward nurses towards vital signs monitoring via prioritizing the workload
planning.
2.5 Previous study on Rapid Response Team (RRT)
As part of IHI’s 100,000 Lives Campaign some 1,500 hospitals are now actively
using and/or implementing RRS. The rate of Cardiac arrest, mortality, and lengths of