Understanding Respiratory Rate Assessment by Emergency Nurses: A Health Care Improvement Project

Abstract

Introduction

Respiratory rate is the first sign of patient decline. Monitoring and recording respiratory rate are essential nursing competencies. However, health care system emergency nurses’ ability to differentiate normal from abnormal respiratory rates was unknown. We conducted a health care improvement project to assess emergency nurses’ accuracy in “spot” and “formal” assessments, understand assessment practices, and determine competency and training needs.

Methods

In an anonymous cross-sectional survey, 78 emergency nurses from 1 health care system viewed 3 “spot” and 3 “formal” mock patient videos and answered questions in REDCap (Vanderbilt University, Nashville, TN). Accuracy (abnormal/normal), systematic error (bias), and random error (imprecision) were assessed. Descriptive statistics, bivariate analyses, and qualitative content analysis of open-ended questions were reported.

Results

Most emergency nurses identified respiration as abnormal in spot and formal assessment videos. Accuracy was lowest for the video displaying 6 breaths per minute. Emergency nurses were more likely to identify abnormal breathing in all formal assessment videos (n = 59, 75.7%) than in all spot assessment videos (n = 41, 52.6%) (McNemar χ² = 10.32, P = 0.001). Most emergency nurses reported a willingness to use formal assessments and thought that respiratory rate was a good indicator of a patient's condition. The barriers to accurate assessment included time limitations, prior training focusing on assessments lasting less than 30 seconds, and monitor and staff errors.

Discussion

Respiratory rate assessment may be best assessed formally, particularly for bradypnea, where formal checks may outperform spot checks. The results present areas for improving respiratory rate assessment training and clinical practice.

Introduction

Respiratory rate (RR), or the number of breaths a person takes per minute, is a clinical sign of the movement of air in and out of the lungs.¹ RR abnormalities are the primary early indicator of clinical deterioration,² including in patients in the emergency department.³ Abnormalities in RR herald the need for additional patient assessment by the clinical care team and rapid intervention to prevent further decline, unexpected cardiac or respiratory arrest, admission to higher levels of care, increased length of stay, and mortality.^2,4,5 It is therefore vital that RR is collected regularly, obtained correctly, and recorded accurately for each patient. The gold standard for RR assessment is to auscultate, or visually observe, breaths for 1 minute, or observe for a minimum of 30 seconds and multiply observed breaths by 2 to obtain breaths per minute (BPM).^5,6 Despite its clinical importance, research has shown that RR may not be recorded routinely or accurately by medical staff,^3,4,6, 7, 8, 9, 10, 11 for reasons including time pressures, nurses’ perception of patient acuity, work interruptions, inadequate knowledge regarding respiratory assessment, and rationalized judgments.^3,7,10 A recent qualitative study of 79 Australian emergency nurses found that ED RR observations were often omitted or recorded erroneously, thus compromising patient safety.³ Although the emergency nurses were aware of the organizational policy regarding RR observations, they still believed that assessment was unnecessary for all patients and wasted valuable time; hence, they just “tick[ed] and flick[ed]” RR on patients’ observation charts.³ Likewise, a study in the United Kingdom found that clinical staff did not have confidence in the accuracy of RR recordings in observation charts, believing the rates to be estimated or even fabricated, and not formally assessed using recommended methods.¹⁰ In addition, the staff reported using “spot” assessment of RR, in which they estimated the rate by looking briefly at the patient.¹⁰

Although some studies have been conducted on RR assessment internationally, few are available in the United States. To address this knowledge gap and potentially improve patient care at the health care system, we conducted a health care improvement project that assessed the accuracy of emergency nurses’ “spot” and “formal” RR assessments using videos depicting a mock patient breathing at different abnormal RRs, along with postvideo questions.¹⁰¹¹ Our primary aims were 2-fold:

• assess the accuracy (abnormal/normal, range, bias, and imprecision) of emergency nurses’ spot and formal RR assessments; and

• understand emergency nurses’ self-reported methods used to calculate and record RR, barriers to recording RR accurately and routinely, and perceptions of the importance of RR.

  A secondary aim tested the hypothesis that the number of years of emergency nursing experience in the health care system’s emergency departments would affect RR assessment accuracy.