RESEARCH

THE FACTORS THAT AFFECT THE FREQUENCY

OF VITAL SIGN MONITORING IN THE
EMERGENCY DEPARTMENT
Authors: Kimberly D. Johnson, PhD, RN, CEN, Chris Winkelman, PhD, RN, Christopher J. Burant, PhD,
Mary Dolansky, PhD, RN, and Vicken Totten, MD, Cleveland, OH

Introduction: Vital signs are an important component of the

nursing assessment and are used as early warning signs of
changes in a patients condition; however, little research has been
conducted to determine how often vital signs are monitored in the
emergency department. Additionally, it has not been determined
what personal, social, and environmental factors affect the
frequency of vital sign monitoring. The purpose of this study was
to examine what factors may influence the time between
recording vital signs in the emergency department.
Methods: We performed a descriptive, retrospective chart
review of 202 randomly selected adult ED patients charts from
representative times to capture a variety of ED levels of
occupancy in an urban, Midwestern, teaching hospital.
Descriptive and hierarchical regression analyses were used.
Results: The strongest predictor of the increased time between

vital signs from the personal health factors was lower patient

Kimberly D. Johnson, Member, Eastern Ohio Chapter ENA, is Postdoctoral

Fellow, VA Quality Scholar Program, Department of Veteran Affairs, Frances
Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
Chris Winkelman is Associate Professor, Frances Payne Bolton School of
Nursing, Case Western Reserve University, Cleveland, OH.
Christopher J. Burant is Assistant Professor, Frances Payne Bolton School of
Nursing, Case Western Reserve University, Cleveland, OH.
Mary Dolansky is Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
Vicken Totten is Director of Research, Emergency Medicine, University Hospitals Case Medical Center, and Assistant Professor, Case Western Reserve
University, Cleveland, OH.
For correspondence, write: Kimberly D. Johnson, RN, PhD, CEN, 5806
Horning Rd, Kent, OH 44240; E-mail: kimj74@gmail.com.
J Emerg Nurs 2014;40:27-35.
Available online 23 October 2012.
0099-1767/$36.00
Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2012.07.023

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VOLUME 40 ISSUE 1

acuity (Emergency Severity Index). This relationship remained

strong even when social factors and environmental factors were
included. Increased length of stay and fewer routes of
medications also had significant relationships to the increased
time between vital sign monitoring.
Discussion: These findings are clinically important
because greater time between vital sign recordings can
lead to errors of omission by not detecting changes in vital
signs that could reveal changes in the patients condition.
The findings of this study provide direction for future
research focusing on determining whether higher frequency
of vital signs surveillance contributes to higher quality care
and linking quality of care to missing vital signs/
inadequate monitoring.
Key words: Vital signs; Emergency department; Monitoring;
Frequency of vital signs; Emergency Severity Index; Crowding

ital signs are simple measurements of physiologic

parameters that represent a set of objective data
used to determine general parameters of a patients
health and viability. These values influence the doctors
and nurses interpretation of a patients overall condition
and affect the course of treatment for each patient individually. Historically, vital signs have been considered as an
integral part of the nursing assessment and as an early
warning sign of patient deterioration.1,2 Vital sign monitoring also may be used as a marker of nursing vigilance
or frequency of direct patient observation to evaluate the
patients condition or responses to interventions.
Vital signs are recorded at least once for every emergency patient and are monitored in the emergency department because changes can herald an imminent adverse
change in the patients condition.3 Although vital sign
monitoring is the most commonly performed task in emergency departments, there is limited information regarding
the optimal frequency with which vital signs should be
monitored. The majority of the literature addressing the

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FIGURE
Model of nursing vigilance in emergency department.

frequency of vital sign monitoring is focused on inpatients

and is inconsistent in nature. Only 4 studies could be
located that addressed vital sign monitoring in the emergency
department.4-7
The frequency of obtaining vital signs depends on hospital policy, nursing judgment, or written physician order
and is commonly based on the patients acuity and chief
complaint. For example, primary stroke centers have guidelines that require vital sign monitoring every 15 minutes
during the acute phases of care, and most intensive care
units require a minimum of hourly recorded vital signs.
A report on rural ED care in the United States suggests that
in trauma admissions, vital sign monitoring should occur
hourly8 and the Trauma Nursing Core Course guidelines
recommend the ongoing assessment of vital signs. However, there are no published standards of care or guidelines
on the recommended frequency of obtaining vital signs for
the general ED population. No research has been published
that examines the frequency of vital sign monitoring by
emergency nurses.
It has been suggested that social factors may affect
variations in patient care. Previous research reports that
female patients wait longer for and receive less pain medications.9 Other studies report that female patients receive
a larger quantity and stronger dose of medication than
their male counterparts.10 Mills et al11 found that nonwhite patients waited longer for and received less medica-

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JOURNAL OF EMERGENCY NURSING

tion than their white counterparts. There are no data

about the impact of insurance (Medicare, Medicaid, private, self-pay) in published reports related to disparate
care in the emergency department.
In addition to gender and race, environmental factors
such as ED crowding have been shown to affect aspects of
care in the emergency department including patient satisfaction levels,12-14 timeliness of medication administration,15,16 and mortality rates.17-19 Furthermore, during
periods of crowding, emergency nurses report perceived
decreases in the quality of care provided to patients.20 However, no studies have been reported that examine how
crowding specifically affects the nursing care provided.
The purpose of this study was to examine the frequency of vital sign monitoring and whether selected factors (age, gender, ethnicity, insurance, number of
comorbidities, number of over-the-counter [OTC] and
prescription drugs, triage category) affect the frequency of
vital sign recording to provide guidance for the development of nursing policy regarding the frequency of vital sign
monitoring. The second purpose was to determine whether
these factors continue to influence the frequency of vital
sign monitoring in the presence of environmental/process
factors (crowding level, family presence, number of
routes of medication administered in the emergency department, length of stay) and to determine whether disparities in care are present. The research questions were as

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follows: (1) What are the personal health factors (number

of prescription medications, number of OTC medications,
comorbidities, age, gender, triage category) that affect the
frequency of vital sign monitoring in the emergency department? (2) What social factors (insurance status, ethnicity) affect the frequency of vital sign monitoring in the
emergency department? (3) Does the effect of personal factors on the frequency of vital sign monitoring in the emergency department change when environmental factors
(family presence, crowding level, length of stay, number of
routes of medications administered in emergency department) are taken into account?

omnibus index. The EDWIN correlated well with nurse

and physician assessments of crowding.12 A score of 1.7
or higher is considered to indicate a crowded emergency
department. The triage category recorded in this study
was determined by use of the Emergency Severity Index,
version 4 (ESI). The ESI has 5 levels to which patients
can be categorized. Level 1 indicates the most urgent category of patients who require immediate care because death
is imminent (ie, cardiac arrest), whereas level 5 is the least
acute category.24 This system of triage is endorsed by the
Emergency Nurses Association and the American College
of Emergency Physicians. The ESI has been recommended
as a valid and reliable triage system.25

Conceptual Model

The model of nursing vigilance in the emergency department that guided this study was based on the social ecologic framework in which personal and environmental
factors contribute to patient outcomes through nursing vigilance (Figure). This model was developed by use of the
model of vigilance of Meyer and Lavin21 to evaluate the effect of social and environmental factors on the relationship
between personal factors and patient monitoring. In this
study, nursing vigilance is measured by the frequency of
monitoring vital signs. Vital signs were used as a proxy
for nursing vigilance because they are an integral part of
the nursing assessment and have been used as a decisionmaking tool that has influenced the course of patient
treatment.22 The effect on patient outcomes was not
measured in this study.
Methods

A descriptive, retrospective chart review was performed

after we obtained approval from the hospitals institutional
review board. A strategic sampling strategy was used to capture a variety of ED occupancies at an urban teaching hospital. The strategy captured 202 adult patients charts,
randomly selected from randomly selected time periods.
The emergency department at the study hospital was
equipped with 23 patient beds and cared for 70,000 patients per year but was designed to care for only 40,000
visits annually. For this study, the frequency of vital sign
monitoring was calculated by dividing the total length of
stay by the number of times vital signs were recorded in
the chart. ED crowding, defined as any time when resources are inadequate to meet patient requirements,23
was measured by use of the Emergency Department Work
Index (EDWIN). The EDWIN is an equation that incorporates important components of the input/throughput/
output model (eg, number of patients, acuity, numbers
of physicians on duty, and bed availability) into a single

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SAMPLE

Crowding levels were calculated at 4-hour intervals during

the study using the EDWIN. We selected 165 charts from
a possible 3,727 subjects from the crowded periods (EDWIN >2) and 60 of a possible 73 subjects from noncrowded periods (EDWIN <2), for a total of 225 reviewed
charts. Although 225 records were requested, a total of
only 212 charts were located for review from 4 one-week
periods (January 11-17, March 8-14, June 14-20, and
October 11-17) to provide a representative snapshot of
seasonal variations in ED occupancy. Of the 212 charts
located, 202 met the inclusion criteria. The inclusion criteria included all the charts of patients assigned to a room
or hallway bed in the emergency department during periods with different crowding levels. Charts were excluded
because the length of stay was less than 3 hours, because
of missing triage assessments, because the patient assigned
a triage category of 4 or 5 (lower acuity patients), or because patients had incomplete baseline triage vital signs.
Because of the shorter length of stay for the critically ill
(eg, ESI 1), most patients with a high acuity were excluded from the study.
POWER/EFFECT SIZE

By use of a power of 0.80 and the probability of a type I

error of 0.05, the expected observable effect size for this
study was 0.95.26
DATA COLLECTION

Demographic variables, arrival information, assessment

data, length of stay, and treatment information were collected for each subject by a single trained researcher. Patient-related factors that potentially affect frequency of
vital sign monitoring were established a priori through discussion with experts (including V.T. and M.D.) and a review
of literature. A pilot study was conducted with 10 charts to
ensure that data points were available in the written records.

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TABLE 1

Characteristics of study sample

Variable

Data

Age [mean (SD) (range)] (y)

Comorbidities [mean (SD) (range)]
Prescription medications [mean (SD) (range)]
OTC medications [mean (SD) (range)]
Length of stay in emergency department [mean (SD) (range)] (min)
Crowding level (EDWIN) [mean (SD) (range)]
No. of routes of medication administered in emergency department [mean (SD) (range)]
Frequency of vital sign monitoring [mean (SD) (range)] (min)
Payment method: Medicaid [No. (%)]
African-American ethnicity [No. (%)]
Family presence [No. (%)]
Admission diagnosis [No. (%)]
Gastrointestinal
Neurologic
Pulmonary
Musculoskeletal
Cardiologic
Female gender [No. (%)]
Triage category
1 (resuscitation) [No. (%)]
2 (emergent) [No. (%)]
3 (urgent) [No. (%)]

47.5
2.52
3.26
0.66
405.1
10.5
1.65
130.8
76
152
79
51
28
26
24
22
144
2.56
1
83
118

(21.5) (18-97)
(1.87) (0-9)
(3.178) (0-14)
(1.037) (0-5)
(205.32) (47-1,407)
(10.0) (1-29)
(1.14) (0-5)
(94.84) (4-807)
(36.9%)
(74%)
(39%)
(24.8%)
(13.6%)
(12.6%)
(11.7%)
(10.7%)
(69.9%)
(SD 0.512)
(<1%)
(41.7%)
(57.3%)

SD, Standard deviation.

TABLE 2

Definitions of statistical terms

Statistical term Definition

Adjusted R2
R2 change
Multicollinearity
P value (P < .01)

The portion of the variance of the outcome that can be explained by the predictor variables
The amount of the variance of the outcome explained when more predictor variables are added
When 2 or more predictor variables have strong correlations to each other
The probability of obtaining the same results by chance (P < .01 means there is less than a 1% chance of this
occurring randomly)

DATA ANALYSIS

Data analysis included descriptive analysis and hierarchic regression. Categorical, non-numeric variables
were recoded into dichotomous dummy variables and incorporated as predictor variables. Three blocks of predictors (ie,
personal health, social, and environmental factors) were
added into the regression 1 step at a time. Data were

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analyzed with SPSS software, version 16.0.27 Data were evaluated for potential violations of the assumptions of regression.
No adjustments were required.
Results

The mean EDWIN score was 2.56. Of the 168 time intervals, 142, or 85%, were crowded. The mean age was 47.5

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TABLE 3

Correlations among social, environmental, and personal health factors

Frequency
of vital
sign
recording

P < .05.
P < .01.
c
P < .001.

0.136a
0.190b
0.253c
0.004
0.252c

0.110
0.021
0.066

Age

0.436c
0.206b

Comorbidities OTC
Triage
medications category

Prescription
medications

Ethnicity Insurance EDWIN

Length
of stay

0.337c

0.217b 0.311c 0.336c

0.107
0.397c

0.215b

0.105
0.003
0.036
0.048
0.046

0.003
0.076
0.175b
0.061
0.000

0.074
0.124a
0.005
0.006
0.023

0.290c
0.066
0.118a
0.095

0.005
0.046
0.020

0.093
0.014

0.005

0.069

0.078

0.107

0.028

0.087

0.054

0.204b

0.223b

0.005

0.361c

0.037
0.055
0.112
0.152a
0.047

0.002
0.091
0.058
0.031
0.057

0.198b 0.031
0.008 0.144a
0.021
0.054
0.057
0.020
0.047 0.044

0.147a

0.004

0.022

Family
presence

0.670c

0.089

0.021

a
b

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Gender
Age
Comorbidities
OTC
medications
Triage
Category
(ESI)
Prescription
medication
Ethnicity
Insurance
EDWIN
Length of stay
Family
presence
No. of
routes of
medications

Gender

RESEARCH/Johnson et al

TABLE 4

Unstandardized and standardized s and significance of social, environmental, and personal health predictor variables for frequency of vital sign monitoring in 3-block hierarchic regression
Predictor variable

Block 1
(se)

Constant
94.20 (44.72)
Gender
18.97 (14.55)
Age
0.22 (0.33)
No. of comorbidities
6.75 (4.93)
Number of OTC medications
10.15 (6.68)
Triage category
28.89 (13.8)
No. of prescription medications 3.78 (2.80)
Ethnicity
Insurance
EDWIN
Length of stay
Family presence
Routes of medication

Standard

0.156a
0.091
0.051
0.133
0.126
0.112

Block 2
(se)

84.82
18.95
0.18
7.16
10.42
29.08
3.62
8.88
2.42

Block 3
Standard

(48.176)
(14.68)
(0.350)
(5.033)
(6.740)
(13.832)
(2.836)
(16.130)
(16.052)

0.091
0.041
0.141
0.115
0.157
0.121
0.040
0.011

(se)

69.24
21.83
0.18
7.71
10.22
33.76
2.80
3.84
0.86
1.47
0.08
11.81
13.73

Standard

(55.00)
(14.226)
(0.339)
(4.884)
(6.541)
(13.581)
(2.759)
(15.756)
(15.552)
(0.630)
(0.031)
(12.559)
(5.594)

0.104
0.041
0.152
0.113
0.183
0.094
0.017
0.004
0.155
0.180
0.062
0.185

P < .05.

years (SD, 21.50 years; range, 17-94 years). Female

patients accounted for 69.9% (n = 144) of the
subjects. Seventy-four percent (n = 152) were African Americans. Most patients reported being single (n = 144, 55.3%).
Characteristics of the sample are available in Table 1.
INFLUENCE OF PERSONAL HEALTH FACTORS ON
FREQUENCY OF VITAL SIGN MONITORING

The variables included in block 1 of the hierarchic regression were (1) number of prescription medications, (2)
number of OTC medications, (3) comorbidities, (4) age,
(5) gender, and (6) triage category (ESI). By use of the
enter method, a significant model emerged (F 6,195 =
4.541, P < .001) with an adjusted R2 = 0.096. (Table 2
shows definitions of statistical terms.) Although significant
correlations were present among predictors (Table 3),
multicollinearity was not indicated. Several of the variables
(number of prescription medications, comorbidities, age,
gender, and triage category) had significant relationships
with the frequency of vital sign monitoring (Table 4).
However, the strongest predictor of the frequency of vital
sign monitoring was the ESI (t = 2.099, P = .037).
INFLUENCE OF SOCIAL FACTORS ON FREQUENCY
OF VITAL SIGN MONITORING

Once the regression was completed on the personal factors,

the social factors of insurance status and ethnicity were

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added in block 2 of the hierarchic regression. The significance of the model remained unchanged with the addition
of the social variables (F8,193 = 3.414, P = .001). However,
the adjusted R 2 decreased insignificantly to 0.088 (R2
change = 0.001, P = .859). There was no evidence of multicollinearity in this model. None of the added social variables correlated with the frequency of vital sign
monitoring (Table 3), and the variables that contributed
significantly to the model were unchanged from the previous regression model, although the regression weights
varied slightly (Table 4).
INFLUENCE OF ENVIRONMENTAL FACTORS ON
FREQUENCY OF VITAL SIGN MONITORING

The third block in the hierarchic regression included environmental factors: (1) family presence, (2) crowding level
(EDWIN), (3) length of stay, and (4) number of routes
of medications administered in the emergency department.
The significance of the model remained unchanged with
the addition of the environmental variables (F 12,189 =
3.915, P < .001). However, the adjusted R2 increased significantly to 0.148 (R2 change = 0.075, P = .002). There
was no evidence of multicollinearity in this model. Several
of the environmental factors had significant contributions
to the variance explained in this model. Triage category (t =
2.486, P = .014) remained a predictor but at a higher significance level. Crowding level (t = 2.332, P = .021), length

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of stay (t = 2.663, P = .008), and number of routes of medications (t = 2.454, P = .015) were also found to have a
significant impact on the model (Table 3).
The length of time between vital signs was increased
by (1) higher (less acute) triage category, (2) increased
crowding (higher EDWIN score), (3) increased length of
stay, and (4) fewer routes of medication administered during the ED stay. Triage category had the greatest impact on
the time between vital signs. Overall, for every increase
of 1 in the triage category (becoming less acute), the time
between vital signs was increased by 34 minutes. Reflecting
acuity, the time between vital signs increased by 5 seconds
for each increase of 1 minute in the length of stay (range,
47-1,407 minutes) and decreased by 14 minutes when the
number of medication routes delivered increased by 1. In
addition, as the EDWIN score increased by 1, the length of
time between vital signs increased by 1.5 minutes.
Discussion

PERSONAL HEALTH FACTORS

Triage category had the greatest impact on the time

between vital sign monitoring. Although the majority
of patients in this study were assigned triage category 2 or
3, the results were consistent with previous studies where
a more acute (lower triage category) patient required more
resources28 as evidenced by more frequent vital signs. Therefore it seems reasonable that triage category (ESI) may be a
good instrument to guide emergency nurses in determining
the frequency of vital sign monitoring required for patients.
SOCIAL FACTORS

This study showed a lack of findings related to disparate

care in relation to social factors. No differences in the
length of time between vital signs were identified based
on age, gender, ethnicity, or type of insurance. However, data were not collected to differentiate nursing
home patients from patients arriving from the community.
Future research to determine whether care is disparate based
on nursing home residency may help in determining the best
methods for caring for this patient population. This project
suggests that vital sign monitoring was not based on common social indicators.
ENVIRONMENTAL FACTORS

Every year, over 120 million patients in the United States

present to an emergency department, and often, that
emergency department is classified as crowded. Although
crowding did not have a significant correlation with the
frequency of vital sign monitoring, it did have a significant impact on the regression model. The time between

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vital sign recordings increased by only 1.5 minutes per

1-point increase in the EDWIN score. The data suggest
that there is a potential cumulative effect of increased
crowding. As crowding levels (EDWIN) increased from
1 to 29, the time between vital sign records could increase
by over 30 minutes. The results have a substantial
impact on the time between vital signs when the whole
range of EDWIN scores is included. This was consistent
with previous research that reported delays in patient care
during ED crowding.20,29,30 The clinical importance of an
increase of 30 minutes between surveillance/recording of vital
signs has not been determined. In patients with hemodynamic instability, 30 minutes may be an sufficient time in
which to have a dangerous alteration in heart rate, blood pressure, or respiratory rate, resulting in a potential failure-to-rescue situation.
One possible explanation for the small change between
each degree of crowding is teamwork among the ED staff.
Previous research has shown that teamwork increases as the
unit becomes more stressful, up to a certain level, and also
decreases the occurrence of missed nursing care.31 Perhaps
the staff may pull together and work as a faster, more efficient team when the emergency department is crowded.
Although the change is incremental and may be significant
over larger variations, it is somewhat reassuring that only
small changes occur with small changes in crowding levels.
ED crowding has been correlated with adverse outcomes such as delayed cardiac intervention and medication
administration, excess mortality rates, and perceived
lower quality of care, 19,20,29,30,32 but its relationship
with nursing care has never been examined. The results
of this study show that the effect of crowding is statistically significant, although the clinical significance needs
to be examined further.
The length of time between vital sign assessments
increased with a longer length of stay. Because of the large
range within the sample, the time between vital sign assessments may be almost 2 hours longer in patients in the emergency department for long periods than for other patients
who are quickly discharged. This finding should not be surprising because often, during the patients stay, the emergency nurse may follow inpatient floor protocol and
obtain vital signs less frequently (eg, every 4 hours) in stabilized patients awaiting inpatient beds. In this study the mean
time between repetitions of recorded vital signs was 130
minutes. A typical standard for vital sign frequency in an inpatient (nonintensive care unit) is every 4 hours, with a
window of observation 30 minutes before and after the hour
mark considered a reasonable variation. In addition, more
acutely ill/injured patients may be admitted or die more
quickly than stable patients.

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Limitations

The major limitation of this study was that the data were
limited to handwritten notations because of the retrospective design of the study. This study was conducted at a single institution, but there is no reason to believe that our
emergency department varied in culture from others. The
sample was limited to patients with triage categories 1, 2,
and 3. Most critically ill patients (ESI 1) did not meet the
inclusion criteria because of a short length of stay; results
from this study cannot be generalized to ED patients with
high acuity.
Implications for Nurses

Although environmental factors (ie, busyness of a crowded

emergency department) have the potential to decrease vigilance in patient monitoring, the results of this study show
that emergency nurses are capable of judging the appropriate frequency of vital sign monitoring. It is important
to have the ability to recognize when the department
is crowded so that nurses can institute team principles
(ie, situational monitoring). Perhaps developing a benchmark
for the frequency of monitoring of vital signs would help the
nurses during hectic times to communicate when teamwork is
essential to provide safe, high-quality patient care.
More research is needed before establishing a standard
of care related to frequency of vital sign monitoring based
on patient acuity and length of stay. Perhaps exploring the
linkages between assigned triage category and monitoring
and processes within the nursing vigilance model would be
beneficial in establishing a standard of care for vital sign
monitoring. Understanding the timing of vital sign monitoring after an intervention such as medication administration is also essential to determining the frequency of
vital sign monitoring and could further be explored with
this model.
Conclusion

It is possible that the frequency with which vital signs are

monitored can affect outcomes, increasing the vigilance of
monitoring the patients condition. Vital sign monitoring
also may stand in as a marker of frequency of direct observation of patients, which is needed to better evaluate patient
condition changes or patient responses to interventions.
This project showed that triage status (as measured by
the ESI) had the greatest contribution to determining the
frequency of vital sign monitoring in this population.
However, it was also shown that environmental factors
(length of stay and number of routes of medications administered) also affected that frequency. More evaluation of

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ED processes and their links to patient outcomes is required to understand the implications of complexities of
care that occur in the emergency department. Measures
of outcomes do not tell us about the patient care process.
Although knowing results is important, it is an insufficient
step toward improvement.33
Further testing of the model developed for this study will
help providers to understand the factors that affect
the timeliness of patient care and help emergency nurses to
identify and address problem areas. Similarly, the effect of
crowding on patients vital sign trends for the duration of their
ED stay needs to be assessed to determine whether patient
outcomes are influenced by the presence of crowding and
not only by the care provided to them during these times.
There are limited data about the quality of nursing
care in the emergency department, and this project provided important baseline data about the typical frequency
of vital sign monitoring and factors that influenced
the frequency of vital sign records. There is currently no national standard recommending the frequency for monitoring
of vital signs among patients in the emergency department
except for selected conditions such as stroke or angina.5 It is
not known whether 2 hours between vital sign assessments is
a reasonable time period for general ED patients. Providing
high-quality care implies that emergency nurses need to ensure that standards of care are maintained for all patient populations regardless of the environment or circumstances.
Understanding factors that influence care and maintaining
optimal care in suboptimal circumstances like ED crowding
are important to practice, education, and research. Despite
the limitations, the findings of this study are reasonable to
use in guiding future studies of emergency departments
and emergency populations with characteristics similar to
those reported herein.
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2. Holcomb JB, Salinas J, McManus JM, Miller CC, Cooke WH,
Convertino VA. Manual vital signs reliably predict need for lifesaving interventions in trauma patients. J Trauma. 2005;59
(4):821-8 [discussion 828-829].
3. Lighthall GK, Markar S, Hsiung R. Abnormal vital signs are
associated with an increased risk for critical events in US veteran
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4. Armstrong B, Walthall H, Clancy M, Mullee M, Simpson H.
Recording of vital signs in a district general hospital emergency
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