VOL: 97, ISSUE: 40, PAGE NO: 32
Captain Gary Kenward, BSc, RGN, is project leader, in-hospital cardiac arrest prevention project
Nicholas Castle, DipIMC, RN, is resuscitation training officer, Frimley Park Hospital, Camberley, Surrey; Colonel Timothy Hodgetts, FRCP, FRCSEd, FFAEM, FIMC, FRGS, Dip MedEd, L/RAMC, is professor of emergency medicine and trauma, University Hospital Birmingham NHS Trust
Making ‘routine observations’ is sometimes viewed as one of the more mundane aspects of nursing care. However, recording a patient’s temperature, pulse and respiratory rate (TPR) is vital for the early detection of any deterioration in the patient’s condition.
McQuillan et al (1998) found that half of admissions to intensive therapy units could be prevented by closer monitoring of vital signs and improved care in the preceding hours and days. Up to 84% of patients demonstrate warning signs in the hours before respiratory or cardiac arrest (Schein et al, 1990; Smith and Wood, 1998), while survival to discharge following cardiac arrest on a general ward is only around 5% (according to unpublished research by Hodgetts). If vital signs are abnormal, there may be no survivors (Smith and Wood, 1998).
So which vital signs are vital? If you review a TPR chart you will usually find blood pressure, temperature and pulse have been recorded - occasionally oxygen saturation has been included. Frequently you will also find a note of when a patient last opened their bowels. But in our experience, respiratory rate is rarely recorded.
Given the importance of monitoring respiratory rate as part of routine observations, this article demonstrates how a change in clinical practice, resulting in increased recording of respiratory rate, can be achieved.
This research, funded by the Defence Secondary Care Agency (Box 1), was undertaken in a 700-bed district general hospital with a catchment population of around 365,000. As part of a wider study investigating avoidable cardiac arrest, the chart records of 132 patients suffering cardiac or respiratory arrest were reviewed. Particular attention was paid to the vital signs recorded in the 24 hours prior to cardiac or respiratory arrest.
An education programme was instituted to raise awareness of the importance of patient monitoring as part of the introduction of a medical emergency team (MET) (see pages 34-35). The MET is an acute response team activated when patients show predetermined signs of clinical deterioration that may lead to cardiac or respiratory arrest. Following education, the TPR charts of 132 control patients (who did not suffer arrest) were reviewed to determine the impact of the programme.
Before the education programme, we found that shortness of breath (SOB) was documented in either the nursing or medical notes of 52% of patients. However, only 27% of patients had a record of their respiratory rate on the TPR charts.
Following education, the recording of respiratory rate had increased to 89%. This is a highly significant change in clinical practice. Staff also reported that they had an increased awareness of the importance of recording vital signs, and in particular the significance of respiratory rate.
Our study found that before the education programme, nurses were not recording respiratory rate consistently, even on patients who were clearly unwell and who deteriorated to cardiac or respiratory arrest. Many nursing and medical staff had documented their concern about patients’ shortness of breath but had still not recorded the respiratory rates of these patients. The findings from this study suggest a training need that is likely to be required in all hospitals.
Just over half (52%) of our patients had documented SOB within 24 hours of cardiac or respiratory arrest, which is consistent with the findings of other researchers. For example, Schein et al (1990) found documented SOB in 53% of patients prior to arrest, while Fieselmann et al (1993) found respiratory rate to be predictive of cardiac arrest (54% of cardiac arrest patients had increased respiratory rate in the hours before arrest, but only 17% of controls had an increased respiratory rate during their admission).
Why was respiratory rate so infrequently recorded before the education programme? We believe there is an over-reliance on monitoring technology - specifically on pulse oximetry to measure ‘ventilation’ function - and that monitors available on the ward are not configured to record respiratory rate. Additionally, routine observations are often delegated to the least qualified members of the nursing team, who often fail to appreciate the significance of respiratory rate.
Measuring respiratory rate (Box 2) appears to have become the poor relation of pulse oximetry. However, health care professionals’ faith in pulse oximetry is partly misplaced, as it measures blood oxygenation, rather than ventilatory function. The carbon dioxide level in the blood may be rising, indicating respiratory failure, when the oxygen saturation reading is still near normal. Recording the respiratory rate gives a baseline of ventilatory function and an early indication of deterioration.
Junior members of the nursing staff must be given training to interpret the significance of changes in vital signs, and there is a need for greater emphasis on this within the preregistration curriculum. Also, health care assistants (HCAs) are increasingly taking on the task of patient monitoring. They must therefore be adequately prepared, supervised and aware of the importance of the task (Garrard and Young, 1998). HCAs’ training is a trust responsibility, and this leads to wide variations in standards of training and care delivered, between - and even within - trusts.
The education programme introduced as part of MET training had a positive impact within our trust and has changed practice. Respiratory rate is now routinely recorded.
Our experience of educating HCAs within the MET awareness training has highlighted that many do not appreciate the importance of their role, and many are unsure of normal physiological ranges. The importance of monitoring vital signs and their role in the detection of clinical deterioration and the prevention of cardiac and respiratory arrest is emphasised in the MET education programme. Normal physiological ranges and the implications of abnormal vital signs are also discussed.
After being trained, HCAs have felt empowered by the realisation that they have a critical role in the early detection of clinical deterioration. If we delegate routine observations to HCAs, we must invest in them and ensure they have the knowledge and skills required for the task. We also need to value their contribution.
Ward-based cardiac and respiratory arrests are often predictable and preventable events, with patients demonstrating warning signs. The aim of routine observations is to detect subtle changes which, if acted upon, may reduce the incidence of avoidable cardiac and respiratory arrest and detect clinical deterioration earlier.
Respiratory rate is a highly sensitive marker, yet nurses do not routinely record this. However, a change in practice is achievable as long as education encompasses all staff who are involved in delivering patient care.