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Respiratory Rate: The Forgotten Vital Sign—Make It Count!

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The Joint Commission Journal on Quality and Patient Safety 2018; 44:494–499
Respiratory Rate: The Forgotten Vital Sign—Make It
Count!
Patrick C. Loughlin, PhD; Frank Sebat, MD, FCCM; John G. Kellett, MD
Respiratory rate is the sentinel and arguably most impor-
tant vital sign because its normal values are breached
before those of other vital signs in nearly all states of clini-
cal decline. Changes in respiratory rate are often the earli-
est warning of sepsis, systemic inammatory response syn-
drome, shock, and respiratory insuciency, among others.
In these conditions, abnormalities in respiratory rate rst
herald the need for additional patient assessment and rapid
intervention to prevent further decline and unexpected car-
diac arrest.
1–8 It is well established that prompt detection
of worsening physiology is critical in reducing failure to
rescue, with its associated suering, death, and costs; yet,
on the general hospital wards where there are more pa-
tients per nurse and less monitoring, failure to rescue con-
tinues to be a major problem.
9,10 Despite strong evidence
that abnormalities in respiratory rate are an early predictor
of preventable patient deterioration,
1–3 , 6,11 it remains the
most inaccurately measured and recorded vital sign.
3 , 12–18
Lack of understanding of its importance, as well as time
constraints and diculty in measuring it compared with
other vital signs, have all been cited as reasons for these
errors and oversights.
13,19 , 20 Education of all stakeholders
(bedside clinicians, Hospital Quality Improvement Com-
mittees, hospital decision makers, institutional and profes-
sional societies, regulatory and oversight bodies) regarding
the ramications of inaccurate respiratory rate acquisition
and recording is the rst necessary step to bring about the
change in hospital culture and work practices required to
further reduce failure to rescue and its associated suering,
mortality, and cost.
THE PROBLEM
Normal adult respiratory rate is generally reported to be be-
tween 12 and 18 breaths per minute (bpm).
21 Tachypnea
(respiratory rate > 20 bpm) is often the rst sign of sys-
temic inammatory response syndrome, sepsis, shock, and
respiratory insuciency,
22–24 while bradypnea (respiratory
rate < 8 bpm) is an early indicator of narcotic and sedative
complications.
25,26
Thus, the importance of measuring the
respiratory rate accurately and promptly, and then commu-
nicating and charting abnormalities, cannot be overempha-
sized. Despite this, on general wards vital sign measurement
1553-7250/$-see front matter
© 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jcjq.2018.04.014
has been assigned to the least trained personnel who have
little if any education regarding their meaning and value.
There is no gold standard for respiratory rate mea-
surement; on general wards the traditional method is to
manually count the number of breaths for one minute,
which is not as easy as it might seem, given the signi-
cant inter-observer measurement variability among trained
clinicians.
27 Because respiratory rate is not always regular
and is less frequent than, for example, heart rate, the use of
shortcuts—such as the multiplication of breaths observed
over a shorter time period—magnies any error in obser-
vation.
12,16 In one study, nurses recorded nearly 72% of
all respiratory rates as either 18 or 20 bpm, whereas only
13% measured by trained observers had these values, con-
rming a signicant bias and/or multiplication artefact.
16
A larger study of 36,966 hospitalizations also showed that,
in contrast to heart rates, there was a skewing of respira-
tory rates toward a perceived normal patient” range with
even-number values of 18 or 20 bpm.
12 Clinicians report
that they estimate rather than actually measure respiratory
rate.
20
There is also a tendency for bedside providers to bias
estimates of respiratory rate into a range that does not cause
clinical concern.
16
Common anecdotes that highlight these
issues include a registered nurse reported, “No one has time
to count breaths for one minute”; a patient held her breath
while respiratory rate was being measured and yet it was
recorded as 16 bpm; a bedside nurse charted a respiratory
rate of 18 bpm on a deteriorating patient, which the rapid
response team measured as 28 bpm a few minutes later. In
an eort to improve vital sign measurement, a blinded ob-
servational study of certied nursing assistants taking respi-
ratory rate was carried out in a single hospital. In this study,
50% of recorded rates were done without the benet of hav-
ing a wristwatch or other timepiece in the room. Therefore,
at best, the respiratory rates were estimated and, at worst,
they were fabricated.
28
In addition to the diculty of its measurement, a num-
ber of other factors have led to an underappreciation of res-
piratory rate’s importance in patient assessment ( Sidebar 1 ).
In our technology-based hospital culture, clinicians have
moved away from the bedside to computers and have more
reliance on laboratory tests, even though they are more ex-
pensive, are more time consuming, and may not even ap-
preciably improve care.
29
This paradigm shift has led to less
appreciation of the importance of the bedside exam and ob-
servation of vital signs, particularly respiratory rate. Quite
apart from vital sign measurement errors, key vital sign
Volum e 44, No. 8, August 2018 495
Sidebar 1. Why Is Respiratory Rate Poorly Acquired and Recorded?
Inaccurate respiratory rate determinations on non-ICU patients. Hospital EHR respiratory histograms surveyed do not have a
normal distribution (skewed to a narrow range of 16–20 breaths/minute) with predominantly even numbers, reecting
“guesstimated” values.
It is time consuming and difcult. Accurate respiratory rate acquisition is not easy to do and is often performed by the least
trained staff.
Knowledge decit. Clinicians and hospital decision makers are generally unaware of the importance of accurate and prompt
respiratory rate measurement.
Absence of hospital audits or compliance measures. This results in a lack of motivation to get respiratory acquisition right.
Laissez-faire institutional culture regarding accuracy of vital sign acquisition. Results in a de-emphasis of respiratory rate as
well as other vital signs.
EHR, electronic health record.
abnormalities often go unrecognized and/or are responded
to too late. Prompt diagnosis and early administration of
best-practice interventions are of proven benet in trauma,
acute myocardial infarction, and stroke—all conditions that
are often easily recognized.
30–33
However, prompt recogni-
tion of sepsis, systemic inammatory response syndrome,
hypovolemia, and respiratory compromise, which account
for the vast majority of preventable failure-to-rescue cases,
28
can be dicult because of the subtlety of their initial mani-
festations. Because respiratory rate abnormalities occur be-
fore other vital sign changes, it is particularly useful in the
early recognition of these conditions. A six-month audit of
a teaching hospital identied unrecognized abnormal vital
signs and biochemical results as the cause of suboptimal
pre-ICU admission care and avoidable mortalities.
34 Re-
searchers in another study found that, based on abnormal
vital signs, more than half of the patients who suered from
a serious adverse event could have been identied as at risk
up to 24 hours earlier, with a specicity of over 95%.
11 A
more recent study has shown that a delay of six hours or
more in recognizing abnormal vital signs is associated with
an increase in ICU transfer, length of hospital stay, and mor-
tality.
9
Respiratory Rate and Vital Signs as Part of Early
Warning Scores
Derangement in vital signs, particularly respiratory rate,
is a core component of all early warning scores (EWSs) or
“track-and-trigger systems.” Many hospitals use these scores
to identify patient deterioration and prompt an appropriate
response such as increased bedside assessment/monitoring,
alerting the rapid response team, or transfer to the ICU.
35
These EWSs range from single-parameter rapid response
team criteria
36
to the widely used multiparameter National
Early Warni n g Score,
37 along with newer early at-risk
patient recognition tools such as 10 SOV (10 signs of vi-
tality)
33 and the more complex eCART (electronic cardiac
arrest risk triage) system.
38 Also relying heavily on the
respiratory rate are disease- and syndrome-specic alerts for
early diagnosis and severity assessment of community-
acquired pneumonia (CURB-65 score [ C onfusion,
U rea > 7 mmo/L, R espiratory rate 30/minute, low
B lood pressure—systolic < 90 mmHg or diastolic 60
mmHg—and age 65 ])
39 and PSI (pneumonia severity
index),
40 and the recently developed sepsis alert qSOFA
(quick sepsis-related organ failure).
22,41
As key component
of all EWSs, inaccuracies of respiratory rate measurements
reduce their predictive value, and can be best described by
the adage garbage in, garbage out .”
Respiratory Rate Compared to Other Vital Signs
Although multiple vital sign changes take place as a pa-
tient deteriorates, some occur earlier and are more infor-
mative than others. Tachypnea with respiratory alkalosis
is the rst manifestation of many serious conditions.
23 If
these conditions are recognized and treated prior to devel-
opment of metabolic acidosis and/or hypoxia, outcomes are
improved.
23,24 , 42,43
Respiratory rate is more signicantly correlated with the
severity of sepsis than either heart rate or blood pressure,
44
and Subbe et al. highlight that although there can be ab-
normalities in blood pressure and heart rate prior to a se-
vere adverse event, these are tiny compared to the changes
in respiratory rate and, therefore, more likely to be missed
in the clinical setting.
5
Numerous other trials have demon-
strated the prognostic power of respiratory rate abnormal-
ities for predicting patient deterioration with tachypnea
( > 30 bpm) independently associated with severe adverse
events irrespective of heart rate.
2
Respiratory rate > 27 bpm
is also a better predictor of cardiac arrest within 72 hours
than heart rate or blood pressure.
45 In a recent study that
observed more than 68,000 patients, lowering the respira-
tory rate threshold to 20 bpm—along with the addi-
tion of other vital signs to prompt further patient evalua-
tion and intervention—signicantly reduced cardiac arrest
and hospital mortality rates (unpublished data).
46
Another
study ( N = 44,531) found that changes in respiratory rate
are highly prognostic of in-hospital mortality and that this
instability predicted patient outcome days in advance of any
other obvious deterioration.
4
A large retrospective study of
269,999 patients, to evaluate the predictive value of 29 elec-
tronic health record variables for the composite outcome of
496 Patrick C. Loughlin, PhD, et al. Respiratory Rate: The Forgotten Vital Sign
Sidebar 2. Solutions for Improving Respiratory Rate Acquisition
Education. Increase awareness of bedside clinicians, hospital QI department/committee, hospital decision makers, and
institutional and professional societies of the problem and recruit them to assist in the solutions.
New technology. There are now available accurate, easy-to-use, inexpensive devices for near continuous respiratory rate
measurement with telemetry to the EHR.
Compliance measures and audits. Accurate respiratory rate acquisition and recording can be easily audited within minutes by
an EHR query of the respiratory rate histogram.
Studies. Ongoing to determine the magnitude of clinical benet of promptly and accurately acquiring respiratory rate for
general ward patients.
General awareness campaign. Form a multispecialty, multisociety international group to raise consciousness and design and
implement processes for the general wards that focus on “Back to basics . . . back to bedside,” with an emphasis on respiratory
rate as the sentinel vital sign to reduce failure to rescue.
Engage thought leaders. Approach the National Quality Forum, the Health and Medicine Division (formerly the Institute of
Medicine) of the National Academies of Sciences, Engineering, and Medicine, and The Joint Commission to advocate for
accurate respiratory rate measurement and recording.
QI, quality improvement; EHR, electronic health record.
Sidebar 3. Problems and Uncertainties of Automated Respiratory Rate Monitoring
Alarm fatigue due to false or excessive alarms
Can be constraining to the patient
Increased rather than decreased workload?
Economic feasibility
Normal variations in respiratory rate in response to arousal state, physical activity pain, stress, etc.
Specicity of abnormal respiratory rate—when is it clinically signicant?
Does identifying patients with abnormal respiratory rate tangibly improve patient outcomes?
Sidebar 4. Key Points: Importance of Accurate Respiratory Rate Measurements
Respiratory rate is the sentinel vital sign of early clinical decline.
All early warning scores signicantly weight respiratory rate to detect early deterioration.
Accurate and prompt detection of new respiratory rate abnormalities on general ward patients will improve early warning scores
and reduce failure to rescue and its associated suffering, mortality, and cost.
cardiac arrest, ICU transfer, and death, found that abnor-
mal respiratory rate was the most prognostic.
2 These data
conrm the importance of consistent and accurate measure-
ment of respiratory rate as a rst step in early recognition
of patients at risk of further clinical decline.
THE SOLUTION
This and other recent articles
8 , 12–15 , 18,47
are part of the rst
essential step to raise awareness of both the need and ways
in which we can improve on how vital signs are acquired,
recorded, and responded to. When awareness is raised and
a clear pathway outlined, then awareness campaigns and
education eorts can focus on the solutions ( Sidebar 2 ).
As with any quality improvement activity, we rst need to
measure the baseline performance and any changes or im-
provements associated with designed interventions. How-
ever, there are currently no hospital baseline measurements
on the quality of respiratory rate or other vital sign mea-
surements. This is exacerbated by the fact that there are
no regulations or standards requiring the accurate acqui-
sition and recording of respiratory rate or other vital signs.
This lack of monitoring and oversight has led to the im-
pression that these tasks are unimportant and their per-
formance is a mere ritual of no clinical value. It is com-
mon knowledge that nursing and physician leadership are
well aware that respiratory recordings are incorrect in many
general ward patients. Yet there is little or no eort to rec-
tify the situation. Why is this? One explanation is hospitals
are overwhelmed with regulatory requirements that, if not
met, have costly penalties. Thus, all resources and eorts go
to meeting these specically dened regulations, so there
is nothing extra left to improve care outside these man-
dates. Thus, the rst step in xing this problem is to mea-
sure it. Education and studies highlighting the need for ac-
curate respiratory rate acquisition and charting are needed
and are important, but unless they are reinforced by tech-
nological advancements to improve the ease and accuracy
of its measurement and audits to insure compliance, it is
unlikely that they will have a dramatic eect on improv-
ing the current situation. This is because although educa-
tion and vital sign charts improve recording of respiratory
rate,
18,47 they do not necessarily improve accuracy.
27 In a
recent study, a multipronged approach implemented by a
Volum e 44, No. 8, August 2018 497
robust four-arm rapid response system provided an eec-
tive structure for education, oversight, and compliance in
vital sign measurement and prompt communication of ab-
normalities.
46
These interventions, coupled with the inclu-
sion of additional vital signs, signicantly decreased cardiac
arrest and hospital mortality. In this study, compliance in
measurement and timely communication of signicant vi-
tal sign abnormalities was initially 20% and 217 reached a
high of 80% after 33 months (unpublished data, Frank Se-
bat, MD).
46
However, the accuracy of these measurements
was not determined. This demonstrates the benet of ed-
ucation and oversight in vital sign acquisition, yet there is
clearly room for further improvement in timeliness, accu-
racy, and communication of vital sign measurements and
abnormalities.
Another piece in the puzzle to improve respiratory rate
acquisition is the introduction of automated, near-real-time
respiratory rate monitoring interfaced with the electronic
record that is cost-eective, convenient, comfortable, and
nonconstraining for the ward patient and equally user-
friendly for the clinician.
48–50
These devices have been de-
ployed on the general wards in a small number of hospitals
in the United States and the United Kingdom. Currently
there are limited data supporting their use; however, small
pilot studies showing the utility and accuracy of these non-
invasive, nonconstraining, easy-to-use, continuous respira-
tory rate sensors have been conducted,
48,50
and larger stud-
ies are currently in progress. However, their broad adoption
is likely to be slow until benets are proven and hospitals
or regulatory agencies care about accurate, timely vital sign
measurement.
Potential Problems
There are very real questions and concerns regarding the
economic feasibility and clinical eectiveness of automated
respiratory rate monitoring on general wards and possi-
ble unintended consequences ( Sidebar 3 ). Adding another
monitor with another alarm may increase costs and would
need to be backed up with evidence that it adds clinically
relevant information to this already crowded space. False-
positive or frequent alerts can lead to alarm fatigue in clin-
icians by adding noise, increased workload, at-times un-
necessary concern, and interruption of work ow. Some
automated respiratory rate sensors are constraining to the
patient and can present situations that increase work to
maintain their function. Motion-induced false positives,
along with pain and anxiety–induced respiratory rate alerts,
are also a concern. These problems need to be addressed
prior to adoption of this technology.
51 A recent meta-
analysis of approaches to reduce overall alert burden and
(in theory) reduce alarm fatigue identied a number of
successful interventions, including customizing threshold
parameters, notication delays, and integration of other
physiologic data prior to alarm.
52
For example, automated
respiratory rate acquisition with motion-canceling technol-
ogy could average the rate over a ve-minute interval, with
alarm thresholds individualized to the patient, all of which
is intended to reduce false alarms (for example, alarm for
a respiratory rate > 20 bpm for a patient whose admis-
sion baseline is 18 bpm or less, whereas a 15% increase
in alarm threshold may be more appropriate for a patient
whose baseline respiratory rate is > 20 bpm). The authors
argue for an integrated approach, indicating that incorpo-
rating these and other processes will likely be required to
successfully implement the automated monitoring of vital
signs, including respiratory rate, on the general wards. Prop-
erly measuring, recording, and communicating respiratory
rate and the other vital signs is time consuming and has a
cost, which automatic devices could potentially save.
53
Un-
til now broad use of continuous respiratory rate monitoring
has been limited to patients receiving continuous sedation
or analgesic with demonstrated benet.
54
It is hard to imag-
ine that expanding the use of automated respiratory rate ac-
quisition that is accurate with prompt reporting of new ab-
normalities within a well-thought-out and well-tested sys-
tem will not have a positive impact on recognizing at-risk
patients sooner, with likely improved outcomes; the ques-
tion is at what cost and how long will it take to work out
the bugs?
The Future
Existing technology can inexpensively provide near contin-
uous streams of time-averaged respiratory rates on all ward
patients. As a result, for the rst time, data sets of respiratory
rate distribution for general ward patients are being gener-
ated that can be analyzed to rene appropriate alarm thresh-
olds and algorithms that will more accurately and promptly
alert the need for further patient assessments and interven-
tions.
55,56 Already there is evidence that clinicians have a
positive outlook on how continuous vital sign monitoring
can improve patient outcomes, albeit with concerns regard-
ing reduced clinician-patient interaction and the previously
mentioned potential for false alarms.
57
If this technology is
to be introduced into general hospital wards, current work
practices will have to change to accommodate it. Clearly the
current culture of not measuring respiratory rate accurately
and not taking readings seriously will have to evolve, partic-
ularly as all the automated, accurate information collected
will be time-stamped and indelibly stored for retrospective
analysis. Thus, a combination of increased awareness, ed-
ucation, audits with compliance measures, and technology
is needed to ensure that general ward patient assessment is
timely and accurate, with signicant abnormalities commu-
nicated promptly. Because respiratory rate is the sentinel
and, therefore, arguably the most important vital sign, it
should be addressed rst ( Sidebar 4 ). When this is accom-
plished, reduction in failure to rescue and improvement in
the quality of thousands of hospital lives should follow.
498 Patrick C. Loughlin, PhD, et al. Respiratory Rate: The Forgotten Vital Sign
CONCLUSION
We describe the problem of inaccurate respiratory rate mea-
surement and the underappreciation of the importance of
its abnormalities, along with the important next steps to
bring about signicant improvements in the way respira-
tory rates are acquired, recorded, and, when indicated, acted
upon. These changes will not be easy and there are likely
many hurdles ahead, so we call to action all stakeholders,
including bedside clinicians, hospitals decision makers, pro-
fessional societies, and regulatory bodies, to raise awareness
of the problems, barriers to remedy, and the solutions. Do-
ing so, as has been done for patient restraints, wrong-site
surgeries, catheter-related infections, and sepsis, will likely
result in further decrease in general ward failure to rescue
and its associated hospital suering, morbidity, mortality,
and cost.
Funding. Funding for the first rough draft of this manuscript was provided
by PMD Solutions (manufacturer of a respiratory rate monitor in Ireland) to
Dr. Loughlin as a consultant in 2016. Since then, the article has added two
additional authors and has undergone major additions and revisions—no
funding was provided for that work. There is no mention of PMD Solutions
or any other company or product in this article.
Conicts of Interest. All authors report no conflicts of interest.
Patrick C. Loughlin, PhD , Past Honorary Research Fellow, University of
Sydney, currently resides in Bellevue Heights, South Australia, Australia.
Frank Sebat, MD, FCCM , is Internal Medicine Faculty, Mercy Medical
Center, Redding, California, and Director, Kritikus Foundation, Redding.
John G. Kellett, MD , is Faculty, Department of Emergency Medicine,
Hospital of South West Jutland, Esbjerg, Denmark.. Please address cor-
respondence to Frank Sebat, fsebat@aol.com .
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... Neither systolic blood pressure nor heart rate had any meaningful Se or LR-; therefore, the implications of respiratory rate differ from those of other vital signs. This may reflect the finding that tachypnea is observed in almost all conditions of clinical decline before the detection of abnormalities in other vital signs [8]. The Sp was also higher when the respiratory rate was ≥26 bpm (0.887) in the present study. ...
... For instance, respiratory rate recordings were skipped for about 15% of eligible participants in the current study; however, given the importance of respiratory rate, healthcare providers should not omit this measurement. Despite the clinical significance of abnormalities in respiratory rate, tachypnea is easily overlooked [8]. Respiratory rate was the most neglected factor recorded in the current study. ...
Article
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The emergency department (ED) is a complex and busy environment that requires rapid decision making. We assessed the relationship between disposition from the ED and information that can be obtained at a glance in the ED. The presentation of the implications of commonplace information could assist healthcare providers in ensuring smooth and safe ED care. Thus, we aimed to quantitatively assess how readily obtainable findings, such as age, sex, and vital signs, are involved in the disposition of adult patients transferred to the ED. This retrospective observational study was conducted in the ED of a regional university hospital containing approximately 600 beds. Of the 685 patients included in the analysis, 351 patients were admitted to the hospital (including 12 deaths in the ED) and 334 patients were discharged from the ED. A multiple logistic regression model that included age, sex, systolic blood pressure, heart rate, respiration rate, temperature, and SpO2 as variables identified independent associations between age (p=0.003), sex (p<0.001), systolic blood pressure (p=0.023), heart rate (p<0.001), and respiratory rate (p=0.028) and admission from the ED. The receiver operating characteristic curves drawn from the multiple logistic regression model comprising these five variables had an area under the curve (AUC) of 0.701 (95% confidence interval: 0.657-0.744, p<0.001). Examination of sensitivity, specificity, and likelihood ratios (LRs) for these five variables for clinical utility showed a slightly higher sensitivity for age ≥50 years (0.849) and respiratory rate ≥18 bpm (0.769); higher specificity for systolic blood pressure ≤100 mmHg (0.938), pulse rate ≥100 bpm (0.834), and respiratory rate ≥26 bpm (0.887); higher positive LR for systolic blood pressure ≤100 mmHg (2.039) and pulse rate ≥110 bpm (2.729); and slightly lower negative LR for age ≥50 years (0.656), male sex (0.647), respiratory rate ≥20 bpm (0.669). These results are meaningful as they quantify the intuition of a skilled clinician, which can help in clinical decision making, reduce errors, and promote clinical education. Our study provides a basis for explaining to novice healthcare providers that the careful observation of ED patients, even in the absence of special laboratory tests, can help them to make judgments regarding the disposition of the patients from the ED. In conclusion, age, sex, systolic blood pressure, heart rate, and respiratory rate were independently associated with a disposition from the ED. A multivariate model including these five variables showed the moderate-quality potential to predict admission from the ED. The sensitivity, specificity, and LR of systolic blood pressure, heart rate, and respiratory rate showed the characteristics of each vital sign. These provide healthcare providers in the ED an immediate clue regarding the patient's illness.
... In these conditions, abnormalities in RR first herald the need for additional patient assessment and rapid intervention to prevent further decline. Tachypnea is often the first sign of SIRS, sepsis and respiratory insufficiency (17). Therefore, although traditional resuscitation goals such as normalization of respiratory rate may be insufficient to detect tissue hypoxia, these parameters should not be ignored (15). ...
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Canine parvovirus (CPV) is an important cause of morbidity and mortality for dogs younger than 1 year-old. Canine parvoviral enteritis(CPE) is a predisposing factor for the development of sepsis. The inflammatory response to the disease may have predictive value for thealterations in the presence of sepsis. Therefore, the diagnostic approach to a septic dog with CPE should include clinical examinationsfollowed by routine laboratory examinations such as hemogram. In this study, a total of 61 dogs, aged 4-6 months, 7 healthy (ControlGroup) and 54 diseased dogs with clinical signs of CPE such as anorexia, vomiting and hemorrhagic enteritis (CPE Group) were used. CPEgroup was divided into Septic CPE (n: 25) and Non Septic CPE (n: 29) subgroups in accordance with 2001 systemic inflammatory responsesyndrome (SIRS) criterias. Clinical examinations and hemogram analysis from venous blood samples were performed. When compared tothe Control group, the respiratory rate (RR), heart rate (HR) and body temperature of the dogs in the CPE group were higher (p<0.000)and the capillary refill time (CRT) was shorter (p<0.014). In the comparison of Septic CPE and Non Septic CPE groups, the RR was higher inthe Septic CPE group (p<0.001). When compared to the Control group, the leukocytes (WBC), granulocyte, mean corpuscular hemoglobin(MCH), mean corpuscular hemoglobin concentration (MCHC) and hemoglobin (Hb) values of the CPE group were lower (p<0.031) and thereticulocyte distribution width (RDW) value was higher (p<0.001). In the comparison of Septic CPE and Non Septic CPE groups, WBC,lymphocyte, monocytes and granulocyte values of the Septic CPE group were lower (p<0.006) and MCH values were higher (p<0.004). Asa result, it was concluded that in accordance with the receiver operating characteristic (ROC) based diagnostic performance analysis, RR,WBC, lymphocyte, MCH, monocytes and granulocyte values can provide useful diagnostic information in differentiating dogs with septicand non septic CPE and may help identifying the disease severity earlier in triage and increase survival rate with early intervention .
... However, RR remains neglected in clinical records since most clinics continue to rely on trained staff to measure it by manually counting chest wall movements, measuring breath sounds through the stethoscope, and self-reports by posing a question as follow: "Is your breathing faster, slower, or the same as normal?". These methods are unreliable and time-consuming [7,8]. ...
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Wearable health devices and respiratory rates (RRs) have drawn attention to the healthcare domain as it helps healthcare workers monitor patients’ health status continuously and in a non-invasive manner. However, to monitor health status outside healthcare professional settings, the reliability of this wearable device needs to be evaluated in complex environments (i.e., public street and transportation). Therefore, this study proposes a method to estimate RR from breathing sounds recorded by a microphone placed inside three types of masks: surgical, a respirator mask (Korean Filter 94), and reusable masks. The Welch periodogram method was used to estimate the power spectral density of the breathing signals to measure the RR. We evaluated the proposed method by collecting data from 10 healthy participants in four different environments: indoor (office) and outdoor (public street, public bus, and subway). The results obtained errors as low as 0% for accuracy and repeatability in most cases. This research demonstrated that the acoustic-based method could be employed as a wearable device to monitor RR continuously, even outside the hospital environment.
... Globally, patients in healthcare facilities, have an increased acuity and are more likely to experience clinical deterioration during their hospital stay (Anstey et al., 2019). Abnormalities in vital signs often precede clinical deterioration (Brekke et al., 2019;Loughlin et al., 2018), however, changing and aberrant vital signs often go unreported. International studies report a 23% rate of omissions in reporting vital signs leading to deterioration, high rates of avoidable Intensive Care Unit (ICU) admissions and increased patient mortality (Donaldson et al., 2014;National Confidential Enquiry into Patient Outcomes and Death, 2017). ...
Article
Aim The aim of this scoping review was to identify empirical literature on simulation used to develop undergraduate nursing student's clinical assessment skills to recognise and respond to patient deterioration. Background Early recognition and response to clinical deterioration is necessary to ensure the best outcome for the patient. Undergraduate nursing students have limited exposure to deteriorating patient situations, therefore simulation is widely implemented in nursing courses to address this educational need. It is imperative to identify the simulation modalities and features that best optimise student learning. Design Scoping review using the Joanna Briggs Institute scoping reviews methodology and the Arksey and O’Malley framework. Review Methods Seven health databases were searched electronically for relevant literature and complemented with hand searching for additional relevant sources. A total of 344 potential articles were identified from the seven databases: Cumulative Index to Nursing and Allied Health Literature (n= 234); PubMed (n=16); Medline (n=51); Scopus (n=21); Embase (n=3); American Psychological Association PsychInfo (n=13); and JBI (n=6). After applying inclusion and exclusion criteria, 15 research articles were included in the review. Results Most research on clinical deterioration simulation was quantitative (n=12), two were qualitative and one used a mixed method approach. Findings included a lack of situational awareness, distractors causing incomplete patient assessment and failure to recognise deterioration. Repeated simulation showed positive results. Conclusions Findings of this review suggest students lack situational awareness, perform incomplete assessment and fixate on single cues rather than an entire clinical picture. The use of a variety of simulation modalities was effective in improving student performance. Repeated practice within a single simulated learning experience, was shown to improve performance and situational awareness. This approach to simulation is under-researched in nursing and needs further exploration.
... Normal values of f R in adults' range between 12 breaths/min and 18 breaths/min, while for newborns and infants, it ranges between 20 breaths/min and 30 breaths/ min. Abnormal values of f R , such as tachypnea (f R is greater than 20 breaths/min) and bradypnea (f R is less than eight breaths/min) could indicate respiratory problems (Loughlin et al., 2018;Ganfure, 2019). Moreover, in clinical scenarios, an increased value of f R is a specific predictor of serious events such as cardiac arrest and unplanned intensive care unit admission (Cretikos et al., 2008). ...
Article
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The measurement of physiological parameters is fundamental to assess the health status of an individual. The contactless monitoring of vital signs may provide benefits in various fields of application, from healthcare and clinical setting to occupational and sports scenarios. Recent research has been focused on the potentiality of camera-based systems working in the visible range (380–750 nm) for estimating vital signs by capturing subtle color changes or motions caused by physiological activities but invisible to human eyes. These quantities are typically extracted from videos framing some exposed body areas (e.g., face, torso, and hands) with adequate post-processing algorithms. In this review, we provided an overview of the physiological and technical aspects behind the estimation of vital signs like respiratory rate, heart rate, blood oxygen saturation, and blood pressure from digital images as well as the potential fields of application of these technologies. Per each vital sign, we provided the rationale for the measurement, a classification of the different techniques implemented for post-processing the original videos, and the main results obtained during various applications or in validation studies. The available evidence supports the premise of digital cameras as an unobtrusive and easy-to-use technology for physiological signs monitoring. Further research is needed to promote the advancements of the technology, allowing its application in a wide range of population and everyday life, fostering a biometrical holistic of the human body (BHOHB) approach.
... Despite its clinical importance, the respiratory rate is the least accurately measured vital sign. Its assessment is often neglected or inaccurately performed owing to a lack of training or knowledge or a lack of time under heavy workload 31 . Therefore, highlighting assessment of the respiratory rate is important in nursing education, particularly critical care training. ...
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This article summarises the history of the establishment of the first maternal special care (MSC) unit in Hong Kong. The authors highlight the use of obstetric early warning system, the levels of care for critically ill mothers, the equipment used in MSC, and the midwifery training in maternal critical care. The authors also present the statistics of MSC admissions at Prince of Wales Hospital from 2018 to 2020.
... Respiration is one of the most important vital signs, able to detect early clinical decline [1]. It can be monitored in hospital wards to detect critical events and respiratory irregularities. ...
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Both Respiratory Flow (RF) and Respiratory Motion (RM) are visible in thermal recordings of infants. Monitoring these two signals usually requires landmark detection for the selection of a region of interest. Other approaches combine respiratory signals coming from both RF and RM, obtaining a Mixed Respiratory (MR) signal. The detection and classification of apneas, particularly common in preterm infants with low birth weight, would benefit from monitoring both RF and RM, or MR, signals. Therefore, we propose in this work an automatic RF pixel detector not based on facial/body landmarks. The method is based on the property of RF pixels in thermal videos, which are in areas with a smooth circular gradient. We defined 5 features combined with the use of a bank of Gabor filters that together allow selection of the RF pixels. The algorithm was tested on thermal recordings of 9 infants amounting to a total of 132 minutes acquired in a neonatal ward. On average the percentage of correctly identified RF pixels was 84%. Obstructive Apneas (OAs) were simulated as a proof of concept to prove the advantage in monitoring the RF signal compared to the MR signal. The sensitivity in the simulated OA detection improved for the RF signal reaching 73% against the 23% of the MR signal. Overall, the method yielded promising results, although the positioning and number of cameras used could be further optimized for optimal RF visibility.
Article
Ventilation or breathing is vital for life yet is not well monitored in hospital or at home. Respiratory rate is a neglected vital sign and tidal volumes together with breath sounds are checked infrequently in many patients. Medications with the potential to depress ventilation are frequently administered, and may be accentuated by obesity causing airway obstruction in the form of sleep apnea. Sepsis may adversely affect ventilation by causing an increase in respiratory rate, often a very early sign of infection. Changes in ventilation may be early signs of deterioration in the patient.
Article
A low cost, wearable textile-based respiratory sensing system is proposed and experimentally demonstrated. A highly sensitive D-shaped plastic optical fiber (POF) sensor that responds to bending is integrated into an elastic band structure to form a respiratory sensing system. The curvature sensing experiments were conducted on the D-shaped POF sensor, which has a coefficient of determination (R <sup xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">2</sup> ) of 0.9977. The system can be used to monitor not only the respiratory rate (RR) of the human body under different movement states (resting, walking, and running) but also the RR of steady and unsteady respiratory signals due to different physiological states. In addition, using the proposed signal processing technique, the interference of motion noise can be removed and the influence of body movement on the sensor response can be eliminated. The advantages of the system are its low cost, compactness, and simplicity in design. Thus, the application of the proposed respiratory sensing system provides a simple and inexpensive optical solution for wearable health.
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Objective: Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment. Data sources: PubMed, SCOPUS, Embase, and CINAHL. Study selection: We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; "what interventions have been attempted and resulted in the success of reducing alarm fatigue?" and 3-secondary key questions; "what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?" Data extraction: Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool. Data synthesis: We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of "alarm fatigue." For our primary key question 1, the relevant studies focused on three main areas: quality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly. Conclusions: There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.
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Vital signs are the simplest, cheapest and probably the most important information gathered on patients in hospital. In this narrative review we present a large amount of evidence that vital signs are currently little valued, not regularly or accurately recorded, and frequently not acted on appropriately. It is probable that few hospitals would keep their accreditation with regulatory bodies if they collected and acted on their laboratory results in the same way that they collect and act on vital signs. Professional societies and regulatory bodies need to address this issue: if vital signs were more accurately and frequently measured, and acted on promptly and appropriately hospital care would be safer, better and cheaper.
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Objective: The aim of this study was to determine the impact of end tidal carbon dioxide or capnography monitoring in patients requiring patient-controlled analgesia (PCA) on the incidence of opioid-induced respiratory depression (OIRD) in the setting of rapid response. Methods: A retrospective analysis was conducted in an urban tertiary care facility on the incidence of OIRD in the setting of rapid response as defined by a positive response to naloxone from January 2012 to December 2015. In March 2013, continuous capnography monitoring was implemented for all patients using PCA. Results: The preintervention incidence of OIRD in the setting of rapid response was 0.04% of patients receiving opioids. After the implementation of capnography, the incidence of OIRD in the setting of rapid response was reduced to 0.02%, which was statistically significant (χ = 46.246; df, 1; P < 0.0001). The rate of transfers to a higher level of care associated with these events was also reduced by 79% (baseline, 7.6 transfers/month; postintervention, 1.6 transfers/month). Conclusions: Continuous capnography monitoring in patients receiving PCA significantly reduces the incidence of OIRD in the setting of rapid response and unplanned transfers to a higher level of care.
Article
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Background Respiratory rate (RR) is an independent predictor of adverse outcomes and an integral component of many risk prediction scores for hospitalised adults. Yet, it is unclear if RR is recorded accurately. We sought to assess the potential accuracy of RR by analysing the distribution and variation as a proxy, since RR should be normally distributed if recorded accurately. Methods We conducted a descriptive observational study of electronic health record data from consecutive hospitalisations from 2009 to 2010 from six diverse hospitals. We assessed the distribution of the maximum RR on admission, using heart rate (HR) as a comparison since this is objectively measured. We assessed RR patterns among selected subgroups expected to have greater physiological variation using the coefficient of variation (CV=SD/mean). Results Among 36 966 hospitalisations, recorded RR was not normally distributed (p<0.001), but right skewed (skewness=3.99) with values clustered at 18 and 20 (kurtosis=23.9). In contrast, HR was relatively normally distributed. Patients with a cardiopulmonary diagnosis or hypoxia only had modestly greater variation (CV increase of 2%–6%). Among 1318 patients transferred from the ward to the intensive care unit (n=1318), RR variation the day preceding transfer was similar to that observed on admission (CV 0.24 vs 0.26), even for those transferred with respiratory failure (CV 0.25). Conclusions The observed patterns suggest that RR is inaccurately recorded, even among those with cardiopulmonary compromise, and represents a ‘spot’ estimate with values of 18 and 20 breaths per minute representing ‘normal.’ While spot estimates may potentially be adequate to indicate clinical stability, inaccurate RR may alternatively lead to misclassification of disease severity, potentially jeopardising patient safety. Thus, we recommend greater training for hospital personnel to accurately record RR.
Background Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated. Methods A prospective five-year before-and-after comparison of adult ward patient outcomes was conducted at a community regional medical center. The key intervention was expanded administrative oversight of the system, which led to (1) restructuring the content and depth of ward nurse education regarding early recognition of at-risk patients; (2) system changes empowering prompt mobilization of the RRT; (3) development of RRT treatment protocols; and (4) a more frequent and comprehensive data collection and analysis for system compliance and performance improvement. Results Some 28,914 patients were observed in the 24-month control period, and 39,802 patients were observed in the 33-month intervention period. RRT activations increased from 10.2 to 48.8/1,000 discharges (p <0.001), ward cardiac arrest decreased from 3.1 to. 2.4/1000 discharges (p = 0.04), hospital mortality decreased from 3.8% to 3.2% (p <0.001), and the observed-to-expected ratio decreased from 1.5 to 1.0 (p <0.001). Conclusion Expanded administrative involvement of an existing RRS that focused on early recognition of patient deterioration by the bedside nurse led to improved performance of the system, with a significant increase in number of RRTs and decreases in cardiac arrests and hospital mortality.
Article
Routine hospital laboratory testing is common, and unnecessary tests can harm patients.¹ Multiple professional societies have recommended against routine laboratory testing in hospitalized patients.
Article
IMPORTANCE: The Third International Consensus Definitions Task Force defined sepsis as “life-threatening organ dysfunction due to a dysregulated host response to infection.” The performance of clinical criteria for this sepsis definition is unknown. OBJECTIVE: To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis. DESIGN, SETTINGS AND POPULATION: Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706 399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013. EXPOSURES: Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤100 mm Hg], tachypnea [≥22/min], or altered mentation). MAIN OUTCOMES AND MEASURES: For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay ≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC). RESULTS: In the primary cohort, 148 907 encounters had suspected infection (n = 74 453 derivation; n = 74 454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome. CONCLUSIONS AND RELEVANCE: Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis.
Article
Background: Previous research investigating the impact of delayed intensive care unit (ICU) transfer on outcomes has utilized subjective criteria for defining critical illness. Objective: To investigate the impact of delayed ICU transfer using the electronic Cardiac Arrest Risk Triage (eCART) score, a previously published early warning score, as an objective marker of critical illness. Design: Observational cohort study. Setting: Medical-surgical wards at 5 hospitals between November 2008 and January 2013. Patients: Ward patients. Intervention: None. Measurements: eCART scores were calculated for all patients. The threshold with a specificity of 95% for ICU transfer (eCART ≥ 60) denoted critical illness. A logistic regression model adjusting for age, sex, and surgical status was used to calculate the association between time to ICU transfer from first critical eCART value and in-hospital mortality. Results: A total of 3789 patients met the critical eCART threshold before ICU transfer, and the median time to ICU transfer was 5.4 hours. Delayed transfer (>6 hours) occurred in 46% of patients (n = 1734) and was associated with increased mortality compared to patients transferred early (33.2% vs 24.5%, P < 0.001). Each 1-hour increase in delay was associated with an adjusted 3% increase in odds of mortality (P < 0.001). In patients who survived to discharge, delayed transfer was associated with longer hospital length of stay (median 13 vs 11 days, P < 0.001). Conclusions: Delayed ICU transfer is associated with increased hospital length of stay and mortality. Use of an evidence-based early warning score, such as eCART, could lead to timely ICU transfer and reduced preventable death. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
Article
Objective Early detection of patient deterioration and prevention of adverse events are key challenges to patient safety. This study investigated clinical staff perceptions of current monitoring practices and the planned introduction of continuous monitoring devices on general wards. Design Multi-method study comprising structured surveys, in-depth interviews and device trial with log book feedback. Setting Two general wards in a large urban teaching hospital in Sydney, Australia. Participants Respiratory and neurosurgery nursing staff and two doctors. Results Nurses were confident about their abilities to identify patients at risk of deterioration, using a combination of vital signs and visual assessment. There were concerns about the accuracy of current vital signs monitoring equipment and frequency of intermittent observation. Both the nurses and the doctors were enthusiastic about the prospect of continuous monitoring and perceived it would allow earlier identification of patient deterioration; provide reassurance to patients; and support interdisciplinary communication. There were also reservations about continuous monitoring, including potential decrease in bedside nurse–patient interactions; increase in inappropriate escalations of patient care; and discomfort to patients. Conclusions While continuous monitoring devices were seen as a potentially positive tool to support the identification of patient deterioration, drawbacks, such as the potential for reduced patient contact, revealed key areas that will require close surveillance following the implementation of devices. Training and improved interdisciplinary communication were identified as key requisites for successful implementation.