If you asked any health care provider if they would ever send a patient home from the hospital with unstable vital signs, you would be met with a guffaw, and an expression of bewilderment that anyone could ask so silly a question. The answer is a resounding "NO” and this is known by every caregiver doctor, nurse, PA and advanced care provider. Common sense, right?
I recently came across an article entitled, Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes, (1) which piqued my interest. Published last month by researchers from, UT Southwestern Medical Center Texas, it describes the increased 30 day readmissions and mortality associated with the discharge of patients with unstable vital signs.
My immediate reaction was how a paper could be written on such a silly subject. No one discharges a patient with unstable vital signs. Having studied medical errors for decades, I should not have been so naive. The data revealed is staggering.
The study was well designed and covered 6 different institutions, adult patients and excluded hospice. After looking at 32,835 individuals they found that 18.7% were discharged with one or more unstable vitals. Almost one in five patients leaves an acute care facility not having vitals which are stable. Multiple other studies have identified global adverse event rates over 30% for hospitalized patients but the magnitude of the problem with a measure as simple as vital signs is incomprehensible.
I continued to struggle saying the study must have been flawed. Maybe it was the definition of unstable vitals,
Definition of Vital Sign Instability Vital sign instabilities were considered present at discharge if the most abnormal value for a particular vital sign met any of the following criteria within 24 hours of discharge
- temperature ≥37.8 °C,
- heart rate ≥100 beats per minute,
- respiratory rate >24 breaths per minute, systolic blood pressure ≤90 mmHg, or
- oxygen saturation <90 %.
These cutoffs for vital sign instability were based on clinical face validity and previously published studies.5,17
The definition is simple, accurate and validated. Finally I concluded that these patients must be the sickest of the sick with extensive chronic comorbid conditions and vital signs which were abnormal for the patient at baseline. Fortunately the researchers controlled for potential prognostic and other cofounders and found that
“rates of postdischarge adverse outcomes did not differ by whether the instability was also present on admission.”
After the reluctant acceptance of the reality of the data presented, I was further jolted by the reference to the previous studies from the 1980s and 1990s that showed identical results
Our findings confirm and extend the landmark studies by RAND and Halm et al., which assessed the effect of more broadly defined clinical instabilities on discharge in groups with selected conditions in the 1980s and 1990s, respectively.4,5 Overall, these studies found that 15–19 % of hospitalized patients had at least one instability on discharge, and that having any instability was associated with significantly increased risk of 30-day mortality and readmission.
The medical community has been aware of these results for over 30 years and to this day 1 in 5 patients is still sent home with unstable vitals?! It is frequently quoted by experts in implementation science that the adoption of new practices in the medicine takes on average of 16 years. Maybe these facts and simple suggestions to insure stable vital signs, while known, have never been seriously acted upon.
With the extensive recent press about the high rate of medical errors and that medical errors constitute the third leading cause of death in the US, we can only once again identify a basic failure of the health care system to put the simplest safeguards in place to protect patients. Now that this error has been identified, hopefully the medical system will moving forward address the issue but it is difficult to be sanguine knowing the data has been published for over 30 years. While there have been some modest successes in decreasing iatrogenic harm, the problem remains prodigious. There are myriad articles showing the absence of the practice of evidence based medicine, and plethora of literature on gray medicine and low value care. We must redouble efforts to effectuate change.
Are there solutions, yes, technology must be brought to bear through the electronic medical record: caregivers being notified of unstable vitals in the prior 24 hours. More broadly ...
- Central policy makers must further scrutinize hospital practice.
- The industry must adopt standards of safe care.
- Direct notification of the patient should be adopted
- Requirements to practice evidence based medicine should be started
- Patient engagement and joint decision making must be encouraged
The authors do simply state what is common sense
Assessing the stability of a patient’s vital signs in the 24 hours prior to discharge is a simple, objective, and clinically sensible way of determining safety for discharge.
The gigantic chasm between education/knowledge and action once again is manifest. Using neurocognitively aware interventions, we must institute change. While notifications and warnings do not change human behavior, I am hoping the knowledge of this research will impact all those who learn of this study to act.
Make a difference.
(1) J Gen Intern Med. 2016 Aug 8. [Epub ahead of print]
(2) Halm EA, Fine MJ, Kapoor WN, Singer DE, Marrie TJ, Siu AL. Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia. Arch Intern Med. 2002;162(11):1278–1284. 6
Nicolas Argy, MD, JD
Copyright © 2016 Nicolas Argy