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Effectiveness of Respiratory Rates in Determining Clinical Deterioration: a Systematic Review Protocol

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Effectiveness of Respiratory Rates in Determining Clinical Deterioration: a Systematic Review Protocol SYSTEMATIC REVIEW PROTOCOL Effectiveness of respiratory rates in determining clinical deterioration: a systematic review protocol 1 2 2 Rikke Rishøj Mølgaard Palle Larsen Sasja Jul Ha˚konsen 1Department of Nursing, University College of Northern Denmark, Hjørring, Denmark, 2Danish Centre of Systematic Reviews: an Affiliate Center of the Joanna Briggs Institute; The Centre of Clinical Guidelines – Danish National Clearing House Review question/objective: The objective of this systematic review is to identify, appraise and synthesize the best available evidence on the effectiveness of manually measuring respiratory rates for 60 s or less in detecting clinical deterioration of inpatients. More specifically, the review question is: Is measurement of respiratory rates for 60 s more effective in detecting clinical deterioration than a shorter duration of measurement? Keywords Detection of clinical deterioration; inpatients; nursing; respiratory rate measurement; vital sign measurement Background several hours before other signs as the first indication 11,12 t is a universal practice to measure vital signs in of deterioration. Measurement of respiratory patients at the time of admission in hospitals. rate as a vital sign is important in detecting deteriora- I tion, as the respiratory rate often increases before Measurement of vital signs has been found to be 1,5,12–15 important and useful in detecting clinical deteriora- other vital signs show deterioration. Studies 1–5 have shown an increase in respiratory rates of up tion of inpatients. ‘‘A deteriorating patient is one 16,17 who progresses from one clinical state to a worse until 24 h prior to ICU admission. Nurses do not measure respiratory rates routinely clinical state which increases their individual risk of 5,9,15 morbidity, including organ dysfunction, protracted for many reasons. A qualitative study has high- hospital stay, disability, or death.’’6(p.1031) Different lighted that nurses tend not to measure the respir- types of early warning scoring systems for clinical atory rate if they judge that the patient’s condition is deterioration have been developed and evaluated. A stable. In cases where nurses do measure the respir- Cochrane review published in 20077 concluded that atory rates, they do not do so for a full minute implementation of early warning scoring systems is because it takes too much time, it is likely to be complex and its impact on practice can be variable. interrupted or the patient becomes agitated. It has Although algorithms for nurses’ interventions fol- also been noted that the reason for respiratory rate lowing measurement of vital signs have been devel- measurement being omitted is that some nurses do not think that it is important to measure the respir- oped, it was found that nurses’ knowledge base and 10 skills are lacking, particularly with regard to the atory rate routinely. Another issue with regard to rationale for the measurement of vital signs and the measurement of the respiratory rate is the hetero- how to respond adequately to these measure- geneity in the technique of measuring respiratory ments.7–10 rates by medical and nursing professionals. This, in It is widely acknowledged that detecting clinical turn, has generated a wide range of respiratory rates deterioration early is vital in avoiding intensive care and as a consequence of this, important information about the patient’s condition lacks an adequate unit (ICU) admission or cardiac arrest and death, 1 sepsis and other acute clinical conditions.2–4,11 An clinical response. increase in respiratory rates can often be detected It is considered best practice for manual measure- ment of respiratory rates to be carried out over a full minute to gain an effective measurement.1,11,14,18–20 Correspondence: Rikke Rishøj Mølgaard, [email protected] However, several methods were described in the There is no conflict of interest in this project. literature in which the rates were measured over a DOI: 10.11124/JBISRIR-2016-002973 JBI Database of Systematic Reviews and Implementation Reports ß 2016 THE JOANNA BRIGGS INSTITUTE 19 ©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited. SYSTEMATIC REVIEW PROTOCOL R.R. Mølgaard et al. period of 15, 30 or 60 seconds. In one study, it was It is important to determine whether measure- found that there was a significant difference between ment of respiratory rate for a full minute or less has a manually measured rate and a recorded rate as the an impact on the detection of clinical deterioration. recorded rate was often likely to be 18 and 20 per It is asserted that an increase of three to five respir- minute, which was higher than a manually measured ations per minute may constitute a sign of clinical rate and was considered as a high rate.3 This deterioration. If the respiratory rate is counted for indicates an overrepresentation of even values when less than 60 seconds, there is a risk of overlooking an respiratory rates are recorded. A respiratory rate of increase in the total respiratory rate, and signs of more than 20 is defined as tachypnoe.19 It was also deterioration are at risk of being overlooked. It found that, if the respiratory rate increases by more isargued that an increase in respiratory rates often than three to five respirations per minute from the deteriorates before other vital signs. It is therefore patient’s normal rate, it is a sign of clinical deteriora- important to synthesize knowledge on best practice tion relating to respiratory distress or potential in accordance with the correct method to measure hypoxemia.11 respiratory rates to optimize detection of clinical A measurement of respiratory rate considered deterioration so that ICU admission, cardiac arrest, appropriate is to count for a full minute to assess sepsis and other acute clinical conditions can the respiratory condition and to detect clinical be reduced. deterioration. Measurement of respiratory rates An initial search of the topic in the databases includes counting the number of breaths, usually CINAHL, The Cochrane Library, The JBI Database per minute. The patient is unaware of the counting of Systematic Reviews and Implementation Reports of the respiratory rate. As the respiratory rate is one and PubMed did not identify previous reviews. Sys- of the first signs of deterioration, it is important to tematic reviews of topics regarding vital sign measure the respiratory rate accurately.1,3,8,21 It is measurement and different types of early warning therefore important to evaluate whether a difference scoring systems exist, but none of them investigate in the duration of manually measured respiratory the topic described in this review protocol. rates (for a full minute or less than 60 seconds) has an impact on clinical practice in detecting clinical Inclusion criteria deterioration. Types of participants Finally, the issues of lack of knowledge base, and The current review will consider studies that have competency in undertaking measurement and inter- included adult patients aged at least 18 years admit- preting the respiratory rates by nursing professionals ted to a surgical or medical ward and who therefore were also highlighted in the literature.10 However, have had their respiratory rates measured in the other studies demonstrated that it was possible to ward to detect clinical deterioration. increase the number of measured and recorded Types of interventions respiratory rates and vital signs if nurses were taught The current review will consider studies that have how and why it is important, and this intervention evaluated manual measurement of respiratory rates was shown to be ratified at follow-up in the way that for a full minute compared with durations of less respiratory rates were more often measured and 2,5,9,15 9 than 60 seconds. Studies that may have measured recorded. Bunkenborg showed in 2014 that respiratory rates for more than 60 seconds will, the development and implementation of a bedside when appropriate and relevant to the review ques- track and trigger system to detect clinical deteriora- tion, be analyzed and included in the discussion of tion had an effect in the prevention of unexpected the results. death and consequently a positive effect on patient safety. Bunkenborg also asserted that, in consider- Outcomes ation of the beneficial effects of measuring the Clinical deterioration can be measured by physio- respiratory and heart rates, it might benefit patient logic instability as abnormal values of vital signs safety to ensure optimization of these two vital such as tachypnea, tachycardia, hypotension and signs.9 It is therefore important to investigate if this decreased oxygen saturation.13,19 This review will optimization could include how the respiratory rate consider studies that include the following outcome is manually measured. measures: respiratory rate, blood pressure, pulse JBI Database of Systematic Reviews and Implementation Reports ß 2016 THE JOANNA BRIGGS INSTITUTE 20 ©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited. SYSTEMATIC REVIEW PROTOCOL R.R. Mølgaard et al. rate, oxygen saturation and temperature, all of validity prior to inclusion in the review, using stand- which are considered as the actual measurement ardized critical appraisal instruments from the (continuous data). Mortality will also be considered Joanna Briggs Institute Meta Analysis of Statistics if reported in the included studies. Assessment and Review Instrument (JBI-MAStARI) (Appendix
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