Improving Vital Sign Documentation at Triage: An Emergency Department Quality Improvement Project

Background: Improving the quality and safety of patients seen in an emergency department (ED) has become a priority in Italy. The Tuscan Regional Health Ministry has supported quality improvement projects in several Tuscan EDs in cooperation with Harvard Medical International and Harvard Medical School. Objective: To improve the triage process, we assessed the completeness of documenting the vital signs of patients seen at triage in the ED of the University Hospital Santa Chiara, Pisa, Italy. At the University Hospital of Pisa's ED, triage is based on 5 categories, each identified by a color: white (lowest priority), blue, green, yellow, and red (highest priority). For patients triaged as "yellow," blood pressure, heart rate, and oxygen saturation are considered mandatory vital signs and important components of a complete patient record. The aims of this project were as follows: 1) to assess the percentage of patients seen during ED triage in whom vital signs were recorded in the clinical record, 2) to analyze the reasons for missing vital sign data, and 3) to design and implement a strategy to improve the percentage of patients in whom vital signs were recorded. Methods: This project began in November 2005 with the identification of a multidisciplinary ED Quality Team. Faculty from Harvard Medical School provided a 2-day training course on the methods and tools of clinical quality improvement. After the training, the team defined their improvement project. The clinical quality improvement project followed a Plan-Do-Study-Act cycle. Preintervention and postintervention data collection consisted of a retrospective analysis of one-third of all patients triaged in the "yellow" category who were admitted to the ED during 1 month, randomly selected using a computer-generated list. Results: A total of 245 clinical records in the preintervention (March 2006) and 251 (April-May 2007) during the postintervention were included. We found that in 77.9% (191/245) of these records, vital signs were correctly recorded during the preintervention period. Patients with limb trauma and those with abdominal complaints represented the vast majority of patients in whom vital sign data were missing. The postintervention data revealed an improvement in the documentation of mandatory vital signs from 77.9% to 87.9%. Conclusions: Creating a multidisciplinary team and implementing a formal quality improvement project improved vital sign documentation at triage for a group of patients seen during ED triage in 1 Italian hospital.