Avoid recording inaccurate respiratory rates at triage
Do you always measure a patient’s respiratory rate at triage? Would it surprise you to know that what you’re documenting often is inaccurate, according to new research.1
"Many of the respiratory rate measurements we write down are meaningless," says Paris Lovett, MD, the study’s principal investigator and an ED physician at Columbia University Medical Center in New York City. "This has nothing to do with the quality or dedication of triage nurses."
Researchers found that neither triage nurses nor an electronic monitor provided accurate measurements of respiratory rate in the ED. It’s difficult to measure respiratory rate accurately, since the patients have to be relaxed, not talking, not moving, unaware that respiratory rate is being measured, and their chest rise and fall has to be visible, says Lovett.
Also, you need a full minute to record it accurately, he says. "Do any of these things sound like working in triage?" he asks.
At best, it’s a waste of time to record meaningless information, and in some cases, it’s dangerous, Lovett maintains. "We run the risk of mistriaging and misdiagnosing patients if we miss an abnormal respiratory rate — for example, the diabetic who is tachypneic because they have ketoacidosis," he says. "However, we are mandated by many regulators and payers to record vitals. We are unlikely to see respiratory rate abandoned any time soon."
To improve respiratory rate measurements at triage, Lovett suggests the following:
- Choose between auscultation and observation. "I prefer observation, when sufficiently unclothed, because it is less intrusive and less likely to influence the variable being measured," he says. "However, you do need to have a good view of the chest."
- Use a one-minute counting period. "This is very hard to achieve, but necessary for accuracy," Lovett says. Fifteen seconds is insufficient, he says. "At a minimum we should take 30 seconds," Lovett says.
- Don’t record bad data. Triage nurses may be more likely to count respiratory rate carefully and formally in patients who look very sick, but for other patients, they may write down a quick estimate, says Lovett.
Unfortunately, to comply with charting guidelines, they have to state any guesses as numbers, not impressions, he says. "We’re constrained by guidelines that aren’t likely to change any time soon, but maybe one day we can simply write bradypneic,’ normal,’ or tachypneic’ if there isn’t time to formally count out the respiratory rate," Lovett says. "That way, we’re not capturing bad data on the chart and misdirecting clinical decisions."
- Lovett PB, Buchwald JM, Sturmann K, et al. The vexatious vital: Neither clinical measurements by nurses nor an electronic monitor provides accurate measurements of respiratory rate in triage. Ann Emerg Med 2005; 45:68-76.
For more information, contact:
- Paris Lovett, MD, Department of Emergency Medicine, Columbia University Medical Center, New York City. Telephone: (212) 305-2995. E-mail: firstname.lastname@example.org.