Exploring the Usefulness of Vital Signs in Subspecialty Clinics

From the 2021 HVPAA National Conference

Matthew Shneyderman (Johns Hopkins University), Edward Yin, Adam Levin, Daniel Sun, Oluseyi Aliu, Andrew Cohen


Medical dogma dictates that a patient’s pulse, respiration rate, blood pressure, and temperature are paramount in identifying clinical deterioration when routinely measured. While the utility of vital signs in triage and critical care is well established, their impact on outpatient subspecialty care is unclear. Evaluating vital signs turns futile when, for example, an ambulatory patient has dangerously high vitals that is not noted, recognized, or acted upon. We hypothesize that the majority of patients presenting to subspecialty clinics will have normal vitals, and any abnormal results will result in inaction.


To explore vital sign measurement in specialty clinics.


We performed a retrospective chart review of 442 outpatients presenting to tertiary care centers. We included patients presenting to Urology, Plastic Surgery, Orthopedics, and Otolaryngology from October 2019 to January 2020. All vital signs entries (BP, pulse, sp02, temperature, and respiratory rate) were collated. The American Heart Association (AHA)’s guidelines defined abnormal blood pressure. Demographics, day of week and time of the appointment, , tardiness, visit result, Charlson comorbidity index, insurance, language, medication list, any result of the vital sign, and problem list at the time of data collection were all recorded. STATA was used to perform basic statistical analysis.


273 patients (61.8%) of patients had at least one abnormal vital sign. Pulse and blood pressure were most commonly abnormal. Age was a strong predictor for the incidence of abnormal vitals (Table 1). There were no differences in the incidence of abnormal vitals whether patients arrived late, based on visit type, which member of the care team commanded the visit, the time of day, or Charlson comorbidity (all ). 417 (94.3%) had at least two vitals checked (Table 2), whereas 0% of patients had all 5 vital signs checked. One patient incurred a SBP of 185 and three patients had pulses documented of 127, 128, and 133, respectively. 2 patients incurred overtly erroneous temperatures: 36 and 125 degrees Fahrenheit, respectively. 2 patients with abnormal blood pressure (162/104 and 74/48, respectively), were told to go the ER. Otherwise, there was no documentation in the chart for any other patient with abnormal vitals to discuss with their primary care doctor, seek emergency rooms care, or take additional medication.


Our results provide evidence warranting a re-evaluation of the utility of vital signs in subspecialty clinics. Vital signs were not universally measured, and the results did not seemingly impact the clinical encounter.

Clinical Implications

The input of abnormal vitals into the health record system demonstrates priorities are elsewhere during subspecialty visits. This study shows that most patients presenting to subspecialty clinics with abnormal vitals are not having their vital signs noted, recognized, or acted upon, which is an immense issue in patient safety.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog