Writing Monitoring Orders in the Emergency Department
For any patient in the ER, write monitoring orders that specify the vital sign parameters to measure, the frequency of measurements based on patient acuity, and the monitoring equipment required.
Essential Components of ER Monitoring Orders
Vital Sign Parameters to Include
Your monitoring order should specify measurement of:
- Heart rate (continuous cardiac monitoring for high-risk patients) 1
- Blood pressure (systolic, diastolic, and mean arterial pressure) 2
- Respiratory rate 3
- Oxygen saturation (pulse oximetry) 1
- Temperature 3
Frequency of Monitoring Based on Acuity
High-Risk Patients (abnormal vital signs, chest pain, trauma, post-sedation):
- Continuous cardiac monitoring with documented vital signs every 5 minutes initially 1
- Vital signs including oxygen saturation and heart rate must be documented at least every 5 minutes in a time-based record 1
- For patients with acute coronary syndrome, continuous monitoring through at least the first 24 hours 1
- For cardiac contusion or myocardial injury, monitoring until hemodynamically stable for at least 24 consecutive hours with no significant arrhythmias 4
Moderate-Risk Patients (stable but requiring observation):
- Vital signs every 15-30 minutes initially, then every 1-2 hours once stable 1
- Pulse oximetry for patients receiving sedation or with respiratory concerns 1
Low-Risk Patients (stable, minor complaints):
- Vital signs every 4-6 hours or per routine ward protocol 5
Specific Monitoring Equipment Orders
For patients requiring continuous monitoring, specify:
- Cardiac monitoring with ECG leads for patients with chest pain, arrhythmias, or significant cardiac risk factors 1
- Pulse oximetry for all patients receiving sedation, supplemental oxygen, or with respiratory compromise 1
- Automated blood pressure cuff for frequent measurements 1
- Capnography for patients under deep sedation or with difficult-to-observe airways (e.g., during procedures in darkened rooms) 1
Critical Trigger Criteria to Document
Include in your order the abnormal vital sign thresholds that require immediate physician notification 6:
- Heart rate <40 or >130 beats/min 6
- Respiratory rate <8 or >30 breaths/min 6
- Systolic blood pressure <90 mm Hg 6, 2
- Oxygen saturation <90% on room air 6
Sample Order Format
"Continuous cardiac monitoring with vital signs (HR, BP, RR, SpO2, temp) every 5 minutes x 30 minutes, then every 15 minutes x 1 hour, then hourly. Notify MD immediately for: HR <40 or >130, RR <8 or >30, SBP <90, SpO2 <90%."
For stable patients: "Vital signs every 4 hours. Notify MD for abnormal vital signs as above."
Special Populations Requiring Enhanced Monitoring
Post-sedation patients:
- One person must continuously observe vital signs until patient meets discharge criteria 1
- Monitoring continues until patient can remain awake for at least 20 minutes in a quiet environment 1
- Extended observation required if reversal agents (flumazenil, naloxone) were used due to resedation risk 1
Stroke patients:
- Continuous cardiac monitoring for 24-48 hours minimum 1
- Extended monitoring if cryptogenic stroke to assess for intermittent atrial fibrillation 1
Patients with electrolyte imbalances:
- Continuous monitoring until normalization of potassium or magnesium 1
Common Pitfalls to Avoid
- Don't write vague orders like "routine vitals" - specify exact frequency and parameters 3
- Don't forget to document trigger criteria for nursing notification - this significantly improves time to intervention 6
- Don't discontinue monitoring prematurely in high-risk patients - reassess need every 24-48 hours 1
- Don't rely solely on automated monitoring - clinical observation remains essential and monitoring devices should not distract from basic patient assessment 1