Vital signs and early warning scores.Canberra: ACT Health; 2011
Vital signs and early warning scores procedure.Canberra: ACT Health; 2018
Recognising and responding to acute deterioration. National Safety and Quality Health Care Standards, 2nd edn. Sydney: ACSQHC; 2017
Alexis O. Providing best practice in manual pulse measurement. Br J Nurs. 2010; 19:(4)228-234 https://doi.org/10.12968/bjon.2010.19.4.46784
Bleyer AJ, Vidya S, Russell GB, Jones CM, Sujata L, Daeihagh P, Hire D. Longitudinal analysis of one million vital signs in patients in an academic medical center. Resuscitation. 2011; 82:(11)1387-1392 https://doi.org/10.1016/j.resuscitation.2011.06.033
Bunkenborg G, Poulsen I, Samuelson K, Ladelund S, Akeson J. Bedside vital parameters that indicate early deterioration. Int J Health Care Qual Assur. 2019; 32:(1)262-272 https://doi.org/10.1108/IJHCQA-10-2017-0206
Burchill C, Anderson B, O'Connor PC. Exploration of nurse practices and attitudes related to postoperative vital signs. Medsurg Nurs. 2015; 24:(4)249-255
Cahill H, Jones A, Herkes R Introduction of a new observation chart and education programme is associated with higher rates of vital-sign ascertainment in hospital wards. BMJ Qual Saf. 2011; 20:(9)791-796 https://doi.org/10.1136/bmjqs.2010.045096
Casey G. Pulse oximetry—what are we really measuring?. Nurs N Z. 2011; 17:(3)24-29
Chan ED, Chan MM, Chan MM. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013; 107:(6)789-799 https://doi.org/10.1016/j.rmed.2013.02.004
Chester JG, Rudolph JL. Vital signs in older patients: age-related changes. J Am Med Dir Assoc. 2011; 12:(5)337-343 https://doi.org/10.1016/j.jamda.2010.04.009
Churpek MM, Adhikari R, Edelson DP. The value of vital sign trends for detecting clinical deterioration on the wards. Resuscitation. 2016; 102:1-5 https://doi.org/10.1016/j.resuscitation.2016.02.005
Churpek MM, Yuen TC, Winslow C, Robicsek AA, Meltzer DO, Gibbons RD, Edelson DP. Multicenter development and validation of a risk stratification tool for ward patients. Am J Respir Crit Care Med. 2014; 190:(6)649-655 https://doi.org/10.1164/rccm.201406-1022OC
Clifton DA, Clifton L, Sandu DM, Smith GB, Tarassenko L, Vollam SA, Watkinson PJ. ‘Errors’ and omissions in paper-based early warning scores: the association with changes in vital signs—a database analysis. BMJ Open. 2015; 5:(7) https://doi.org/10.1136/bmjopen-2014-007376
Clinical Excellence Commission. Between the flags: standard calling criteria. 2021. https://www.cec.health.nsw.gov.au/keep-patients-safe/deteriorating-patient-program/between-the-flags/standard-calling-criteria (accessed 19 August 2021)
Coogan N, Marra A, Lomonaco EA. Assessing accurate BP measurement. Nursing. 2015; 45:(4)16-18 https://doi.org/10.1097/01.NURSE.0000461838.55540.6e
Cooper S, Cant R, Sparkes L. Respiratory rate records: the repeated rate?. J Clin Nurs. 2014; 23:(9-10)1236-1238 https://doi.org/10.1111/jocn.12234
Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, Westbrook J, Braithwaite J, Hillman K. Vital signs monitoring and nurse–patient interaction: a qualitative observational study of hospital practice. Int J Nurs Stud. 2016; 56:9-16 https://doi.org/10.1016/j.ijnurstu.2015.12.007
DeVita MA, Smith GB, Adam SK ‘Identifying the hospitalised patient in crisis’—a consensus conference on the afferent limb of Rapid Response Systems. Resuscitation. 2010; 81:(4)375-382 https://doi.org/10.1016/j.resuscitation.2009.12.008
Respiratory rate 6: the benefits of continuous monitoring. 2018. http://tinyurl.com/edmrp3zj (accessed 13 August 2021)
, 9th edn. In: Dougherty L, Lister S, West-Oram A (eds). Chichester: Wiley; 2015
Elliott M, Coventry A. Critical care: the eight vital signs of patient monitoring. Br J Nurs. 2012; 21:(10)621-625 https://doi.org/10.12968/bjon.2012.21.10.621
Fernandez M, Burns K, Calhoun B, George S, Martin B, Weaver C. Evaluation of a new pulse oximeter sensor. Am J Crit Care. 2007; 16:(2)146-152 https://doi.org/10.4037/ajcc2007.16.2.146
Grainger A. Principles of temperature monitoring. Nurs Stand. 2013; 27:(50)48-55 https://doi.org/10.7748/ns2013.08.27.50.48.e7242
Hands C, Reid E, Meredith P, Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf. 2013; 22:(9)719-726 https://doi.org/10.1136/bmjqs-2013-001954
Hill A, Kelly E, Horswill MS, Watson MO. The effects of awareness and count duration on adult respiratory rate measurements: an experimental study. J Clin Nurs. 2018; 27:(3-4)546-554 https://doi.org/10.1111/jocn.13861
Hogan J. Why don't nurses monitor the respiratory rates of patients?. Br J Nurs. 2006; 15:(9)489-492 https://doi.org/10.12968/bjon.2006.15.9.21087
Measuring body temperature using a tympanic thermometer. 2020. https://www.nursingtimes.net/clinical-archive/assessment-skills/measuring-body-temperature-using-a-tympanic-thermometer-2-14-09-2020/ (accessed 19 August 2021)
Jubran A. Pulse oximetry. Crit Care. 2015; 19:(1) https://doi.org/10.1186/s13054-015-0984-8
Kellet J. The assessment and interpretation of vital signs, 2nd edn. In: DeVita M, Hillman K, Bellomo R (eds). Switzerland: Springer; 2017
Kellett J, Kim A. Validation of an abbreviated Vitalpac™ Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian regional hospital. Resuscitation. 2012; 83:(3)297-302 https://doi.org/10.1016/j.resuscitation.2011.08.022
Kellett J, Sebat F. Make vital signs great again – A call for action. Eur J Intern Med. 2017; 45:13-19 https://doi.org/10.1016/j.ejim.2017.09.018
Respiratory rate 1: why accurate measurement and recording are crucial. 2018. http://tinyurl.com/9dhnhej2 (accessed 13 August 2021)
Principles of monitoring postoperative patients. 2013. http://tinyurl.com/5xmbstjc (accessed 13 August 2021)
Liu C, Zheng D, Griffiths C, Murray A. Comparison of repeatability of blood pressure measurements between oscillometric and auscultatory methods. Comput Cardiol. 2015; 42:1073-1076 https://doi.org/10.1109/CIC.2015.7411100
Ludikhuize J, Borgert M, Binnekade J, Subbe C, Dongelmans D, Goossens A. Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a Rapid Response System: A quasi-experimental study. Resuscitation. 2014; 85:(5)676-682 https://doi.org/10.1016/j.resuscitation.2014.02.009
Ludikhuize J, Smorenburg SM, de Rooij SE, de Jonge E. Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. J Crit Care. 2012; 27:(4)424.e7-424.e13 https://doi.org/10.1016/j.jcrc.2012.01.003
Malgaard R, Larsen P, Hakonsen S. Effectiveness of respiratory rate in determining clinical deterioration: a systematic review protocol. JBI Database Syst Rev Implement Reports. 2016; 14:(7)19-27 https://doi.org/10.11124/JBISRIR-2016-002973
Massey D, Aitken LM, Chaboyer W. The impact of a nurse led rapid response system on adverse, major adverse events and activation of the medical emergency team. Intensive Crit Care Nurs. 2015; 31:(2)83-90 https://doi.org/10.1016/j.iccn.2014.11.005
McGhee TL, Weaver P, Solo S, Hobbs M. Vital signs reassessment frequency recommendation. Nurs Manage. 2016; 47:(9)11-12 https://doi.org/10.1097/01.NUMA.0000491132.98848.22
Mirdamadi A, Etebari M. Comparison of manual versus automated blood pressure measurement in intensive care unit, coronary care unit, and emergency room. ARYA Atheroscler. 2017; 13:(1)29-34
Mok W, Wang W, Cooper S, Ang ENK, Liaw SY. Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses. Int J Qual Health Care. 2015; 27:(3)207-213 https://doi.org/10.1093/intqhc/mzv019
National Institute for Clinical Excellence. Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. 2007. http://tinyurl.com/483wcjvc (accessed 13 August 2021)
Nielsen LG, Folkestad L, Brodersen JB, Brabrand M. Inter-observer agreement in measuring respiratory rate. PLoS One. 2015; 10:(6) https://doi.org/10.1371/journal.pone.0129493
Parkes R. Rate of respiration: the forgotten vital sign. Emerg Nurse. 2011; 19:(2)12-17 https://doi.org/10.7748/en2011.05.19.2.12.c8504
Patient Safety Surveillance Unit. From death we learn 2014. 2014. http://tinyurl.com/ys863dee (accessed 13 August 2021)
Philip K, Richardson R, Cohen M. Staff perceptions of respiratory rate measurement in a general hospital. Br J Nurs. 2013; 22:(10)570-574 https://doi.org/10.12968/bjon.2013.22.10.570
Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005; 111:(5)697-716 https://doi.org/10.1161/01.CIR.0000154900.76284.F6
Pretto JJ, Roebuck T, Beckert L, Hamilton G. Clinical use of pulse oximetry: Official guidelines from the Thoracic Society of Australia and New Zealand. Respirology. 2014; 19:(1)38-46 https://doi.org/10.1111/resp.12204
Resuscitation Council UK. The ABCDE approach. 2021. https://www.resus.org.uk/library/abcde-approach (accessed 13 August 2021)
Rolfe S. The importance of respiratory rate monitoring. Br J Nurs. 2019; 28:(8)504-508 https://doi.org/10.12968/bjon.2019.28.8.504
Rylance J, Baker T, Mushi E, Mashaga D. Use of an early warning score and ability to walk predicts mortality in medical patients admitted to hospitals in Tanzania. Trans R Soc Trop Med Hyg. 2009; 103:(8)790-794 https://doi.org/10.1016/j.trstmh.2009.05.004
Shahbabu B, Dasgupta A, Sarkar K, Sahoo SK. Which is more accurate in measuring blood pressure? A digital or an aneroid sphygmanometer. J Clin Diagn Res. 2016; 10:(3)LC11-LC14 https://doi.org/10.7860/JCDR/2016/14351.7458
Smith JJ, Bland SA, Mullett S. Temperature—the forgotten vital sign. Accid Emerg Nurs. 2005; 13:(4)247-250 https://doi.org/10.1016/j.aaen.2005.08.002
Sund-Levander M, Grodzinsky E. Assessment of body temperature measurement options. Br J Nurs. 2013; 22:(16)942-950 https://doi.org/10.12968/bjon.2013.22.16.942
Tollefson J, Hillman E. Clinical psychom*otor skills: assessment tools for nurses, 7th edn. Melbourne: Cengage; 2019
Vink P, Tulek Z, Gillis K, Jönsson AC, Buhagiar J, Waterhouse C, Poulsen I. Consciousness assessment: A questionnaire of current neuroscience nursing practice in Europe. J Clin Nurs. 2018; 27:(21-22)3913-3919 https://doi.org/10.1111/jocn.14614
Respiratory rate 5: using this vital sign to detect deterioration. 2018. http://tinyurl.com/avueersy (accessed 13 August 2021)
Williams P. deWit's fundamental concepts and skills for nursing, 5th edn. St Louis (MI): Elsevier; 2018
World Health Organization. Pulse oximetry training manual. http://tinyurl.com/3bpjn5b2 (accessed 13 August 2021)
Yeung MS, Lapinsky SE, Granton JT, Doran DM, Cafazzo JA. Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. J Clin Nurs. 2012; 21:(7-8)975-982 https://doi.org/10.1111/j.1365-2702.2011.03937.x
