Quantitative systematic review: Sources of inaccuracy in manually measured adult respiratory rate data

Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review

AIM(S)

To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients.

DESIGN

Scoping review of international, peer-reviewed research studies.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023.

REPORTING METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

RESULTS

Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies).

CONCLUSION

Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Improving diagnosis of early complications (<1 week) through continuous vital sign monitoring following oncological gastrointestinal surgical procedures

BACKGROUND

Patients undergoing major oncological abdominal surgery are prone to postoperative complications, making early recognition crucial. Clinical deterioration is often preceded by changes in vital signs, which are typically measured thrice a day by a nurse. However, intermittent measurements may delay recognizing clinical deterioration. Continuous vital parameter monitoring may lead to earlier recognition and management of complications and reduce nursing workload.

OBJECTIVE

To compare vital parameter measurements between ward nurses and a wireless continuous monitoring system (Sensium® wireless patch) and assess whether this patch can detect clinical deterioration earlier in patients with complications in the first postoperative week.

METHODS

Vital parameters (heart rate, respiratory rate, and temperature) were collected in patients undergoing an oncological resection of the liver, colorectal, or pancreas. Sensium® patch measurements were compared to nurses' measurements to assess the percentages of discordant measurements. In patients with complications in the first postoperative week, time discrepancies between nurses and Sensium® patch measurements were identified in cases of clinical deterioration (respiratory rate ≥15/min, heart rate ≥100/min, and temperature ≥38°C).

RESULTS

Among 227 patients, 22% of the patients experienced complications. Nurse and Sensium® measurements were discrepant in 586/2272 measurements (26%). In 506/586 discrepancies (86%), this was due to the respiratory rate (difference ≥4/min). Compared to nurses, the Sensium® patch detected an elevated respiratory rate 14 h earlier and heart rate 2 h earlier within complications in the first postoperative week. For temperature, no difference was observed.

CONCLUSION

Continuous monitoring with the Sensium® wireless patch holds promise for earlier recognition of complications in patients who underwent major oncological abdominal surgery.

Using the NEWS2 and ABCDE assessment to identify early signs of clinical deterioration

Nurses may encounter deteriorating patients in their clinical practice, so they require an understanding of the early physiological signs of deterioration and a structured approach to patient assessment. This enables appropriate management and a timely response to the most life-threatening issues identified, such as a compromised airway. This article describes how nurses can use early warning scores and a structured patient assessment, using the ABCDE (airway, breathing, circulation, disability, exposure) framework, to identify early signs of deterioration and facilitate the timely escalation of patient care where necessary.

Aluminum Nitride Thin Film Piezoelectric Pressure Sensor for Respiratory Rate Detection

In this study, we propose a low-cost piezoelectric flexible pressure sensor fabricated on Kapton® (Kapton™ Dupont) substrate by using aluminum nitride (AlN) thin film, designed for the monitoring of the respiration rate for a fast detection of respiratory anomalies. The device was characterized in the range of 15-30 breaths per minute (bpm), to simulate moderate difficult breathing, borderline normal breathing, and normal spontaneous breathing. These three breathing typologies were artificially reproduced by setting the expiratory to inspiratory ratios (E:I) at 1:1, 2:1, 3:1. The prototype was able to accurately recognize the breath states with a low response time (~35 ms), excellent linearity (R2 = 0.997) and low hysteresis. The piezoelectric device was also characterized by placing it in an activated carbon filter mask to evaluate the pressure generated by exhaled air through breathing acts. The results indicate suitability also for the monitoring of very weak breath, exhibiting good linearity, accuracy, and reproducibility, in very low breath pressures, ranging from 0.09 to 0.16 kPa. These preliminary results are very promising for the future development of smart wearable devices able to monitor different patients breathing patterns, also related to breathing diseases, providing a suitable real-time diagnosis in a non-invasive and fast way.

Assessments of perioperative respiratory pattern with non-contact vital sign monitor in children undergoing minor surgery: a prospective observational study

PURPOSE

Nurses routinely assess respiration of hospitalized children; however, respiratory rate measurements are technically difficult due to rapid and small chest wall movements. The aim of this study is to reveal the respiratory status of small children undergoing minor surgery with load cells placed under the bed legs, and to test the hypothesis that respiratory rate (primary variable) is slower immediately after arrival to the ward and recovers in 2 h.

METHODS

Continuous recordings of the load cell signals were performed and stable respiratory waves within the 10 discriminative perioperative timepoints were used for respiratory rate measurements. Apnea frequencies were calculated at pre and postoperative nights and 2 h immediately after returning to the ward after surgery.

RESULTS

Continuous recordings of the load cell signals were successfully performed in 18 children (13 to 119 months). Respiratory waves were appraisable for more than 70% of nighttime period and 40% of immediate postoperative period. There were no statistically significant differences of respiratory rate in any timepoint comparisons (p = 0.448), thereby not supporting the study hypothesis. Respiratory rates changed more than 5 breaths per minute postoperatively in 5 out of 18 children (28%) while doses of fentanyl alone did not explain the changes. Apnea frequencies significantly decreased 2 h immediately after returning to the ward and during the operative night compared to the preoperative night.

CONCLUSION

Respiratory signal extracted from load cell sensors under the bed legs successfully revealed various postoperative respiratory pattern change in small children undergoing minor surgery.

CLINICAL TRAIL REGISTRATION

UMIN (University Hospital Information Network) Clinical Registry: UMIN000045579 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052039 ).

Respiratory rate monitoring and early detection of deterioration practices

BACKGROUND

Growing evidence points to respiratory rate (RR) being the most important vital sign for early detection of patient deterioration. However, RR is the vital sign most likely to be inaccurate or missed.

AIMS

To measure prevalence of early detection of deterioration protocols, examine whether RR was perceived as the leading indicator of deterioration, and understand RR monitoring practices used by nurses around the world.

METHODS

A double-blinded survey of nurses in Asia Pacific, Middle East, and Western Europe.

FINDINGS

161 nurses responded. Most (80%) reported having an initiative for early detection of patient deterioration; 12% indicated RR was the most important indicator of deterioration, 27% captured RR for all medical/surgical patients, and 56% take 60 seconds or longer to measure RR.

CONCLUSION

Nurses across all regions generally underestimated the importance of capturing an accurate RR for all patients' multiple times per day. This study reinforces the need to enhance international nursing education regarding the importance of RR.

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning

A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.

Characteristics of low acuity prehospital emergency patients with 48-h mortality, an observational cohort study

BACKGROUND

Every year an emergency medical technician or paramedic treats and transports up to several hundred patients. Only some patients are acutely seriously ill, and a few of these show only discrete signs and symptoms of their condition. This study aims to describe patients who died within 48 h of being admitted non-emergently to hospital by ambulance, examine the extent to which critically ill patients are recognized prehospitally, and identify clinical warning signs that might be frequently overlooked.

METHOD

Registry based follow-up study on patients receiving an ambulance from the Copenhagen EMS in 2018. Data was included regarding the dispatch of the ambulance from the emergency services disposition system, ICD-10 hospital admission diagnoses from the National Patient Register, 48-h mortality from the Central Person Register and assessment and treatment in the ambulance by reviewing the electronic pre-hospital patient record.

RESULTS

In 2018 2279 patients died within 48 h after contact with the EMS, 435 cases met inclusion criteria. The patients' median age was 83 years (IQR 75-90), and 374 (86.0%) had one or more underlying serious medical conditions. A triage category based on vitals and presentation was not assigned by the EMS in 286 (68.9%) cases, of which 38 (13.3%) would meet red and 126 (44.1%) orange criteria. For 409 (94.0%) patients, it was estimated that death within 48 h could not have been avoided prehospitally, and for 26 (6.0%) patients it was uncertain. We found 27 patients with acute aortic syndrome as admission diagnosis, of these nine (33.3%) had not been admitted urgently to a hospital with vascular surgery specialty.

CONCLUSIONS

It was estimated that death within 48 h could generally not be avoided prehospitally. The patients' median age was 83 years, and they often had serious comorbidity. Patients whose vital parameters met red or orange triage criteria were to a lesser degree triaged prehospitally, compared to patients in the yellow or green categories. Patients with acute aortic syndrome were not recognized by EMS 33.3% of the time.

How registered nurses are measuring respiratory rates in adult acute care health settings: An integrative review

AIMS AND OBJECTIVES

This integrative review aimed to draw conclusions from evidence on how registered nurses are measuring respiratory rates for acute care patients.

BACKGROUND

Despite the growing research supporting respiratory rate as an early indicator for clinical deterioration, respiratory rate has consistently been the least frequently measured and accurately documented vital sign.

DESIGN

An integrative review.

METHODS

A systematic literature search was conducted in June 2022 in four databases: CINAHL, PubMed, Medline and Scopus. Quality appraisal was undertaken using the Joanna Briggs Institute's Checklist. PRISMA guidelines were followed to ensure explicit reporting and reported in the PRISMA checklist.

RESULTS

Overall, 9915 records were identified, and 19 met the inclusion criteria. Of these 19 articles, seven themes emerged: estimation and digit preference, lack of understanding and knowledge, not valuing the clinical significance of respiratory rate, oxygen saturation substitute, interobserver agreement, subjective concern and count duration. A high prevalence of bias, estimation and incorrect technique was evident. A total of 15 articles reported specifically on how registered nurses are measuring respiratory rates on general medical and surgical wards.

CONCLUSIONS

Despite its importance, this integrative review has determined that respiratory rates are not being assessed correctly by nursing staff in the acute care environment. Evidence of using estimation, value bias or quick count and multiply techniques are emerging themes which urgently require further research. No patient or public contribution.

Novel wearable and contactless heart rate, respiratory rate, and oxygen saturation monitoring devices: a systematic review and meta-analysis

We performed a systematic review and meta-analysis to identify, classify and evaluate the body of evidence on novel wearable and contactless devices that measure heart rate, respiratory rate and oxygen saturations in the clinical setting. We included any studies of hospital inpatients, including sleep study clinics. Eighty-four studies were included in the final review. There were 56 studies of wearable devices and 29 of contactless devices. One study assessed both types of device. A high risk of patient selection and rater bias was present in proportionally more studies assessing contactless devices compared with studies assessing wearable devices (p = 0.023 and p < 0.0001, respectively). There was high but equivalent likelihood of blinding bias between the two types of studies (p = 0.076). Wearable device studies were commercially available devices validated in acute clinical settings by clinical staff and had more real-time data analysis (p = 0.04). Contactless devices were more experimental, and data were analysed post-hoc. Pooled estimates of mean (95%CI) heart rate and respiratory rate bias in wearable devices were 1.25 (-0.31-2.82) beats.min^-1 (pooled 95% limits of agreement -9.36-10.08) and 0.68 (0.05-1.32) breaths.min^-1 (pooled 95% limits of agreement -5.65-6.85). The pooled estimate for mean (95%CI) heart rate and respiratory rate bias in contactless devices was 2.18 (3.31-7.66) beats.min^-1 (pooled limits of agreement -6.71-10.88) and 0.30 (-0.26-0.87) breaths.min^-1 (pooled 95% limits of agreement -3.94-4.29). Only two studies of wearable devices measured S_p O₂ ; these reported mean measurement biases of 3.54% (limits of agreement -5.65-11.45%) and 2.9% (-7.4-1.7%). Heterogeneity was observed across studies, but absent when devices were grouped by measurement modality and reference standard. We conclude that, while studies of wearable devices were of slightly better quality than contactless devices, in general all studies of novel devices were of low quality, with small (< 100) patient datasets, typically not blinded and often using inappropriate statistical techniques. Both types of devices were statistically equivalent in accuracy and precision, but wearable devices demonstrated less measurement bias and more precision at extreme vital signs. The statistical variability in precision and accuracy between studies is partially explained by differences in reference standards.

Revising Vital Signs Criteria for Accurate Triage of Older Adults in the Emergency Department

Objective

Because of physiologic changes in older adults, their vital signs need to be assessed differently. This study aimed to determine appropriate vital sign cut points for triage designation in older patients presented to the emergency department (ED).

Patients and Methods

Data from 78,524 ED visits of patients aged ≥65 years in Linkou Chang Gung Memorial Hospital (LCGMH) between 2016 and 2017 were collected. New cut points for vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature [BT], and Glasgow Coma Scale [GCS]) were determined using the critical event rate (the composite of admission to ICU and mortality in hospital) for each vital sign. The newly proposed triage scale was then validated using two other databases (Chang Gung Research Database [CGRD] and Taipei City Hospital [TPECH] database). The Taiwan Triage and Acuity Scale (TTAS) was used in this study.

Results

In the LCGMH derivation group, older patients presenting with SBP < 80 mmHg, HR < 40 or > 140 beats per minute (bpm), BT < 35°C, and GCS score 3–8 had a critical event rate of >20% and were proposed to be uptriaged to TTAS level 1. Following a reclassification, a portion of older patients are uptriaged by the newly proposed TTAS, and increase in the critical event rate in TTAS level 1 and level 2 groups compared to the existing TTAS. The newly proposed TTAS exhibited comparable discriminatory ability for triage in older patients compared to the existing TTAS (the area under the receiver operating characteristics curve: CGRD, 0.76 vs 0.62; TPECH, 0.71 vs 0.59).

Conclusion

Revising the vital signs triage criteria for older patients could be a way to improve the identification of patients with critical event outcomes in high TTAS level, thereby improving triage accuracy among older patients visiting the ED.

Selecting intervention content to target barriers and enablers of recognition and response to deteriorating patients: an online nominal group study

Background

Patients who deteriorate in hospital wards without appropriate recognition and/or response are at risk of increased morbidity and mortality. Track-and-trigger tools have been implemented internationally prompting healthcare practitioners (typically nursing staff) to recognise physiological changes (e.g. changes in blood pressure, heart rate) consistent with patient deterioration, and then to contact a practitioner with expertise in management of acute/critical illness. Despite some evidence these tools improve patient outcomes, their translation into clinical practice is inconsistent internationally. To drive greater guideline adherence in the use of the National Early Warning Score tool (a track-and-trigger tool used widely in the United Kingdom and parts of Europe), a theoretically informed implementation intervention was developed (targeting nursing staff) using the Theoretical Domains Framework (TDF) version 2 and a taxonomy of Behaviour Change Techniques (BCTs).

Methods

A three-stage process was followed: 1. TDF domains representing important barriers and enablers to target behaviours derived from earlier published empirical work were mapped to appropriate BCTs; 2. BCTs were shortlisted using consensus approaches within the research team; 3. shortlisted BCTs were presented to relevant stakeholders in two online group discussions where nominal group techniques were applied. Nominal group participants were healthcare leaders, senior clinicians, and ward-based nursing staff. Stakeholders individually generated concrete strategies for operationalising shortlisted BCTs (‘applications’) and privately ranked them according to acceptability and feasibility. Ranking data were used to drive decision-making about intervention content.

Results

Fifty BCTs (mapped in stage 1) were shortlisted to 14 (stage 2) and presented to stakeholders in nominal groups (stage 3) alongside example applications. Informed by ranking data from nominal groups, the intervention was populated with 12 BCTs that will be delivered face-to-face, to individuals and groups of nursing staff, through 18 applications.

Conclusions

A description of a theory-based behaviour change intervention is reported, populated with BCTs and applications generated and/or prioritised by stakeholders using replicable consensus methods. The feasibility of the proposed intervention should be tested in a clinical setting and the content of the intervention elaborated further to permit replication and evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08128-6.

Fever, Tachypnea, and Monocyte Distribution Width Predicts Length of Stay for Patients with COVID-19: A Pioneer Study

(1) Background: Our study investigated whether monocyte distribution width (MDW) could be used in emergency department (ED) settings as a predictor of prolonged length of stay (LOS) for patients with COVID-19. (2) Methods: A retrospective cohort study was conducted; patients presenting to the ED of an academic hospital with confirmed COVID-19 were enrolled. Multivariable logistic regression models were used to obtain the odds ratios (ORs) for predictors of an LOS of >14 days. A validation study for the association between MDW and cycle of threshold (Ct) value was performed. (3) Results: Fever > 38 °C (OR: 2.82, 95% CI, 1.13−7.02, p = 0.0259), tachypnea (OR: 4.76, 95% CI, 1.67−13.55, p = 0.0034), and MDW ≥ 21 (OR: 5.67, 95% CI, 1.19−27.10, p = 0.0269) were robust significant predictors of an LOS of >14 days. We developed a new scoring system in which patients were assigned 1 point for fever > 38 °C, 2 points for tachypnea > 20 breath/min, and 3 points for MDW ≥ 21. The optimal cutoff was a score of ≥2. MDW was negatively associated with Ct value (β: −0.32 per day, standard error = 0.12, p = 0.0099). (4) Conclusions: Elevated MDW was associated with a prolonged LOS.

Respiratory fabric sensor based on the side luminescence and photosensitivity mechanism of polymer optical fibers

It is significant to monitor respiration conveniently and in real time for people suffering from respiratory diseases. Polymer optical fibers (POFs) have the advantages of flexibility and light weight, which is highly desirable for wearable respiratory monitoring. However, in most current applications, the POFs are stitched on the textile substrates in the form of macro-bending. This method is complex to fix the bending with certain curvatures and uncomfortable compared with the POF sensors woven into the textile. In this paper, a respiratory fabric sensor based on the side luminescence and photosensitivity mechanism of POF is proposed and demonstrated. The 750µm-diameter POFs were woven into a fabric as warp and laser marking was performed at their designed positions to make them release or couple light. The spacing change between the POFs caused by the respiratory movement accordingly makes the light intensity change in the photosensitive fiber. We chose four fabric widths (10cm, 8cm, 6cm and 4cm) and four fabric weaves (plain weave, honeycomb weave, 1/3 right twill weave and 8/3 warp satin weave) to implement the full-factor experiment for exploring the measurement effect of the respiratory fabric sensor. The result is that the fabric with width of 4cm and weave of 8/3 warp satin is optimal. The calm and deep respiratory tests of the human chest and abdomen in sitting and standing posture were carried out and the test performance of the fabric sensor is almost comparable to that of the medical monitor. The proposed respiratory fabric sensor is comfortable, easily woven and high in precision, which is expected to realize industrialized scale production.