De-escalation of vital signs monitoring (VSM) in hematology-oncology patients using a nurse-led protocol that follows consensus low-risk criteria can maintain quality and safety of care, and allow for time that nurses can use to improve other aspects of patient care. These findings were published in JCO Oncology Practice.
Hospitalized patients routinely undergo VSM once every 4 hours. The task is laborious for nurses and disruptive for patients, especially at night. Although VSM de-escalation has been shown to be safe for low-risk patients, the practice has not been well-studied in hematology-oncology patients, who are often perceived to require more intensive care.
However, not all patients with cancer require frequent monitoring, and patients with terminal cancer admitted for palliative care are not likely to benefit from regular VSM. Therefore, a quality improvement project (QIP) was undertaken at the National University Cancer Institute in Singapore.
Problem analysis identified the top 3 root causes of frequent VSM as perception of VSM, lack of concise clinical guidelines, and lack of nurse empowerment.
The QIP team, consisting of 3 doctors from the Department of Hematology-Oncology and 6 nurses from the Division of Oncology Nursing, established criteria to identify low-risk patients and developed a nurse-led protocol for de-escalation, with the goal of reducing VSM of low-risk hematology-oncology patients by 50% within 4 months.
A pre-implementation survey of 36 doctors and 166 nurses from the hematology-oncology service was conducted to assess support for VSM de-escalation. Responses showed that 97% of the doctors and 75.3% of the nurses supported a QIP to de-escalate VSM. A total of 83.3% of doctors and 89.8% of nurses responded that time savings from de-escalation could be used to improve other aspects of patient care.
Measures tracked monthly to determine effectiveness of the de-escalation protocol were the number of nurse encounters per patient, the number of nurse-encounter minutes per patient, and the proportion of low-risk admissions for which VSM was de-escalated.
Measures tracked to countercheck that de-escalation was performed safely were the proportion of cases that required VSM re-escalation and the proportion of cases with adverse outcomes, defined as potentially avoidable admissions to the intensive care/high dependency unit or unexpected death in patients not receiving palliative care for terminal cancer. QIP team members reviewed cases requiring VSM re-escalation or with adverse outcomes to determine if frequent VSM could have prevented the event.
In the pilot phase (which was conducted from March 2017 to July 2017), a total of 102 patients were identified as low-risk. Ten patients (9.8%) required re-escalation, with the need for re-escalation identified by nurses in 9 of these patients. No adverse outcomes were noted.
However, only 51.7% of eligible low-risk patients admitted underwent VSM de-escalation. The cause was determined to be that nurses were unfamiliar with the criteria and uncomfortable enrolling patients for de-escalation. Strategies that included using senior nurses as mentors, encouraging feedback during daily roll call, and creating a video tutorial for repeat training were implemented to address these barriers. In addition, random audits were conducted to remind nurses to use the protocol.
Formal launch of the protocol occurred from October 2017 through September 2018, referred to as the maintenance phase. After training and audit interventions were implemented, patient recruitment into the protocol increased to 93.8% in the maintenance phase.
Of 1065 patients identified as low-risk, 108 (10.1%) required re-escalation of VSM, with none experiencing unexpected adverse outcomes. The most common reasons for re-escalation included fever (47.2%) and vital sign abnormalities (26.9%); nurses initiated 84.3% of the re-escalations. Review of all the re-escalations determined that none were deemed “not preventable with more frequent VSM.”
A 50% reduction in the mean number of nurse encounters per month was achieved with the nurse-led de-escalation protocol. A savings of 948.4 nurse encounters per month, amounting to a savings of 2731.5 nurse-encounter minutes per month, enabled nurses to provide enhanced psychosocial support, patient education, fall prevention, and ward hygiene.
Postimplementation, the QIP team surveyed 39 doctors and 136 nurses. The doctors reported no perceived difference in patient care, with 100% supporting continuing the de-escalation protocol as routine clinical practice. Most of the nurses (95.6%) reported greater empowerment, confidence, and work satisfaction.
Tham SM, Kasinathan S, Lui PK, et al. Nurse-led vital signs monitoring can safely identify low-risk hematology-oncology patients for de-escalation [published online June 23, 2020]. JCO Oncol Pract. doi: 10.1200/JGP.19.00636