Nurse-Led Vital Signs Monitoring Can Safely Identify Low-Risk Hematology-Oncology Patients For De-Escalation

Abstract

Purpose: It is routine practice for patients to be on vital signs monitoring (VSM) once every 4 hours, which is laborious and disruptive. VSM de-escalation has been demonstrated to be safe in low-risk (LR) patients, but it has not been well studied in the hematology-oncology setting.

Methods: A quality improvement project was conducted in 3 hematology-oncology inpatient wards within a comprehensive cancer center, from March 2017 to July 2017 (pilot phase) and from October 2017 to Sept 2018 (maintenance phase). Root causes for frequent VSM identified via problem analysis include (1) perception of VSM, (2) lack of concise clinical guidelines, and (3) lack of nurse empowerment. Consensus criteria to define suitable LR patients and a nurse-led VSM de-escalation protocol were formulated.

Results: Of 1,065 patients who underwent nurse-led VSM de-escalation, there was a 50% reduction in the mean number of nurse encounters (NE) per month (P < .01), with total savings of 2,731.5 NE-minutes per month. VSM re-escalation was required by 10.1% of patients; all were deemed unpreventable with more frequent VSM and none resulted in severe adverse outcomes. With additional interventions such as spot audits and retraining, recruitment for de-escalation improved from 51.7% of LR admissions in the pilot phase to 93.8% in the maintenance phase (P < .01). The time saved was used to enhance other aspects of patient care, such as patient education. One hundred thirty-nine of 169 doctors and nurses surveyed after implementation (96.5%) supported continuing this protocol.

Conclusion: A well-defined protocol allows safe nurse-led de-escalation of VSM for LR patients without adverse outcomes and was shown to be sustainable in this cohort of hematology-oncology patients.