Early Recognition and management of Critical Illness: A Retrospective review of Nurses’ documentation at the University of Port Harcourt Teaching Hospital Intensive Care Unit

Background: The prompt identification of critical illness plays a vital role in averting complications such as multiple organ failure and enhancing patient outcomes.

Aim: To evaluate nurses’ documentation practices and ability to recognise and escalate for prompt responses.

Methods: A retrospective review of 170 patient vital signs charts from the ICU was conducted, focusing on completeness of documentation, identification of abnormalities, escalation responses, use of Early Warning Scores (EWS), and patient outcomes. Data were collected from January 2023 to December 2024 and analysed using SPSS version 26.0.

Results: Documentation compliance was high for temperature and blood pressure (100%), with slightly lower rates for respiratory rate (98.2%), urine output (91.8%), and level of consciousness (90.0%). Abnormal respiratory rates (60%) and blood pressure (50%) were the most frequently recorded deviations. Recognition of abnormalities using pen colour changes occurred in 95.3% of cases, but only 25.3% led to documented escalation, with a mean response time of 25 minutes. EWS was recorded in just 30% of the charts. Patient outcomes included a 60% recovery rate, 20% mortality, and 20% with undocumented outcomes.

Conclusion: While ICU staff at UPTH demonstrated high awareness of abnormal vital signs, significant gaps were observed in escalation practices and EWS utilisation. These findings highlight systemic and cultural barriers to effective critical care response and underscore the need for institutional reforms, including mandatory EWS integration, staff empowerment, and continuous audit-feedback mechanisms to improve patient safety and outcomes.