Early indicators for patient health decline: Respiratory rate – IN, heart rate and blood pressure – OUT

Melanie Grably

Respiratory rate (RR) is the early predictor of preventable patient deterioration (not heart rate, not blood pressure) and ironically, it remains the most inaccurately measured and recorded vital sign. Furthermore, there are no regulations or standards requiring the accurate recording of respiratory rate.

Respiratory rate is defined as the number of breaths per minute. Normal respiration rates for an adult person at rest range from 12 to 18 breaths per minute (bpm). Tachypnea (respiratory rate > 20 bpm) is often the first sign of eminent cardiac arrest, systemic inflammatory response syndrome, sepsis, shock, and respiratory insufficiency, 22–24 while bradypnea (respiratory rate < 8 bpm) is an early indicator of narcotic and sedative complications. Respiratory rate is an important indicator of a severe instability in many body systems, not just the respiratory system.

Why then is it neglected?

1- Methodology

The lack of appropriate equipment to measure respiratory rate entails medical staff to count the number of breaths for one minute. Under circumstances where RR is recorded, breaths are commonly counted for 15 seconds and multiplied by 4 instead of a full minute. This is a poor estimate, since small fluctuations in RR may have a huge impact on the conclusions drawn. Furthermore, numerous studies have shown that respiratory rates are estimated or fabricated.

2- Lack of knowledge

Even though respiratory rate is associated with life-threatening conditions, a recent study found that only 4 out of 30 medical textbooks examined emphasized the importance of respiratory rate as a vital sign in adults. In addition, there is a misconception that respiratory rate needs to be recorded if a patient is receiving oxygen therapy. Health professionals need to be made aware that even small changes in respiratory rate have the potential to be a sign of deterioration. Measuring respiratory rate is often recognized as an unimportant factor in patient assessment.

3- Misconceptions

Pulse oximetry monitors the amount of oxygen saturation. At the early stage of a patient’s deterioration, oxygen saturation is likely to be normal. Health professionals often rely on pulse oximetry to evaluate respiratory function. However, pulse oximetry is not an indicator of adequate ventilation. There are no demonstrations for pulse oximetry to be a specific indicator of serious illness, and evidence shows that it lacks specificity.

4- Resources

On average, it takes up to six minutes and twenty-six seconds (06:26) for a nurse to take and record the vital signs of a single patient, which most likely does not include respiratory rate. To add a whole minute to measure respiratory rates across a hospital ward would simply crash the healthcare system. The health ecosystem does not have the manpower to perform this task, since it is suffering from a chronic nurse shortage due to heavy workload and burn out.

The challenges

The time between clinical assessments can be critical as warning signs of deteriorating health conditions may occur before symptoms appear and medical staff is made aware, possibly causing health complications, or relapse and readmission to the ICU in the best-case scenario. Since fluctuations in vital signs occur before adverse events, it is imperative to detect them in a timely manner to enable early and adequate intervention. Inappropriate staffing (as is the case in most health institutions) can have detrimental effects regarding patient outcome.

Passive monitoring can help

Keeping track of vitals around the clock in general hospital wards, not just ICU, enables medical staff to be ahead of the game. Acute health trends, only possible with continuous monitoring, provide medical staff with clinical insights into the patients’ health status and medical progression. The ability to assess the health status of a patient at any given time can have tremendous significance for patient outcome.

Current methodology for the clinical collection and monitoring of respiratory rate are monotonous, tedious and time consuming. Neteera 130H records respiratory rate passively, continuously, and most importantly accurately, while medical staff can be notified when the parameter falls outside of doctor-defined parameters.

The power of passive, continuous patient monitoring becomes particularly valuable when nurses and doctors are making personalized care decisions.

 

 

Cretikos, M.A. et al. (2018) MJA 188, 657.

Elliott, M. (2016) Int. Arch. Nurs. Health Care 2, 050.

Loughlin, P.C. et al. (2018) Jt. Comm. J. Qual. Patient Saf. 44, 494.

Mochizuki, K. et al. (2017) Acute Med. Surg. 4, 172.

Nicolo, A. et al. (2020) Sensors 20, 6396.

Rolfe, S. (2019) Br. J. Nurs. 28, 504.