Abstract:
Background: Measurement and correct interpretation of vital signs is part of routine
clinical care. Repeated measurement enhances early recognition of deterioration, may
help prevent morbidity and mortality and is a standard of care in most countries.
Objective: To examine documentation of vital signs by clinicians for admissions to
paediatric wards in Kenyan hospitals, to describe monitoring frequency by nurses and
explore factors influencing frequency.
Methods: Vital signs information (temperature, respiratory and pulse rate) for the first 48
hours of admission was collected from case records of children admitted with nonsurgical conditions to 13 Kenyan county hospitals between September 2013 and April
2016. A mixed effect negative binomial regression model was used to explore whether
the severity of illness (indicated by danger signs or severe diagnostic episodes) is
associated with increased vital signs observation frequency.
Results: We examined 54 800 admission episodes with an overall mortality 6.1%. Nurse
to bed ratios were very low (1:10 to 1:41 across hospitals). Admitting clinicians
documented all or no vital signs in 57.0% and 8.4% cases respectively. For respiratory
and pulse rates there was pronounced even end-digit preference (an indicator of incorrect
information) and high frequency recording of specific values (P < 0.001) suggesting
approximation. Monitoring frequency was explored in 41 738 children. Those with
inpatient stays ≥48 hours were expected to have a vital signs count of 18, hospitals varied
but most did not achieve this benchmark (median 9, range 2-30). There were clinically
small but significant associations between vital signs count and presence of multiple
severe illnesses or presence of severe pallor (adjusted relative risk ratio = 1.04, P < 0.01,
95% confidence interval CI = 1.02-1.06 and 1.05, P = 0.02, 95% CI = 1.01-1.09,
respectively).
Conclusions: Data suggest accurate admission measures are sometimes missing
especially for pulse and respiratory rates, possibly linked to manual measurement.
Monitoring frequency is often low in the high risk population studied probably indicating
how quality of nursing care is undermined by considerable human resource shortages.