ROUTINE MEASUREMENT OF RESPIRATORY RATEAN EXPENSIVE TRIBUTE TO TRADITION

Ross C. Kory, M.D., Wood, Wis.

The routine repeated measurement of therespiratory rate is of clinical value in less than5% of patients in a hospital, and furthermorephysicians themselves rarely show an interestin such measurements. As a result of such in-difference, nurses have been increasingly cas-ual in their measurement of respiratory rates,and, in many cases, though a figure is recorded,no actual measurement was made. In one care-

fully controlled experiment measurements ofrespiratory rate were carried out in 58 patientswithin minutes of the routine ward measure-ments. The ward records showed 57 of thesepatients as having a rate between 18 and 22per minute; 40 having a rate of exactly 20. Thereal range was from 11 to 33 per minute, onlyfive patients showing a rate of 20. If recordingthe respiratory rate is important, the characterof the breathing is of equal importance. Nursingpersonnel should recognize abnormal breathingpatterns and bring these abnormal findings tothe attention of the physician. It is suggestedthat routine recording of respiratory rates belimited to those cases or on those hospitalwards where the physician specifically orderssuch measurements. This not only would im-prove the accuracy of the measurements andclinical records but also would save millions ofhours of personnel time each year.

The measurement of the respiratory rate in hospitalpatients has been a routine procedure for many years.At the turn of the century a large number of hospitalpatients were admitted for acute infectious diseases,such as typhoid, malaria, and bacterial pneumonias.Since precise diagnostic procedures were not availableand since therapy for most of these diseases was non¬specific and "expectant," serial observations of the"vital signs" were of great clinical importance. Undersuch conditions, frequent measurements of the respira¬tory rate served as a valuable prognostic aid.

As medical knowledge has increased, however, withimproved methods of diagnosis and treatment, theroutine repeated measurement of the respiratory rateis of clinical value in only a small percentage of hos¬pital cases. Nevertheless, the tradition has been firmlyestablished, and hospital patients continue to havetheir respiratory rate recorded, as a matter of routine,along with the body temperature and pulse rate. Sincethis measurement has not been of particular incon¬venience to physicians, the tradition has been per¬mitted to continue unchallenged even though thephysicians themselves rarely show interest in suchmeasurements. As a result of this indifference, thenurses have been increasingly casual in their measure¬ment of respiratory rates, so that, in many cases, aroutine figure is recorded, no actual measurementhaving been made.

It is the purpose of this study ( 1 ) to reexamine theclinical value of the routine measurement of the re¬

spiratory rate, (2) to assess the accuracy of suchmeasurements in representative hospitals, and (3) topoint out the approximate annual cost of personneltime used in this routine procedure in our hospitals.

Respiratory rates can be abnormal in only two ways—an increased respiratory rate (tachypnea) or a de¬creased respiratory rate (bradypnea). The chief con¬ditions in which the respiratory rate increases arepneumonia, pleurisy, other painful conditions of thechest wall, any condition which obstructs the air pas¬sages, fever, anemia, congestive heart failure, meta¬bolic abnormalities, neurogenic and psychogenicdefects, limitation of the depth of inspiration as in peri¬tonitis or increased intra-abdominal tension, and con¬ditions which increase the carbon dioxide tension ofthe blood.1 In none of these is tachypnea per se eitherdiagnostic or of great help in management, althoughobservation of the character of the respiration is some¬times helpful. It should be noted that "an increased[respiratory] rate is often observed in the normalperson because of embarrassment or the emotionaldistress occasioned by the examination." 1A

A decreased respiratory rate is seen in such condi¬tions as lowered metabolism, drug narcosis, shock,and head trauma in which there is a marked increasein intracranial pressure.1" In the latter three conditionsthe respiratory rate may be quite important, but ofequal importance is the character of the breathing. Itis particularly important that nursing personnelrecognize at an early stage such abnormal breathingpatterns as dyspnea, stridulous breathing, the deepsighs of emotional tension, Kussmaul's respiration,and respiration of either the Cheyne-Stokes or Biottype and that such abnormal breathing be broughtto the attention of the physician.

Clinical Usefulness of Routine Measurements

In order to evaluate the clinical usefulness ofroutine measurements of respiratory rate, two ap¬proaches were used (table 1). A survey of 200 un-selected consecutive clinical records at the VeteransAdministration Hospital, Nashville, Tenn., was carriedout in which each record was carefully reviewed and

From the Investigative Medicine Service, Veterans Admin-istration Hospital, Wood, Wis., and the Department of Medi-cine, Marquette University School of Medicine, Milwaukee.

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the day by day condition of the patient evaluated as

to whether measurements of the breathing rate wouldbe of any value. This evaluation was conservative,including, for example, a blanket assumption thatrespiratory rate measurements would be of value forseveral days after each operative procedure, howeverminor. Even with this conservative approach, thesurvey revealed that in a total of 5,006 patient days,there were only 238 days (4.7%) in which measure¬

ments of the respiratory rate were of any clinical value.A similar survey of 100 consecutive unselected clinicalrecords at the Veterans Administration Hospital,Wood, Wis., suggested that respiratory rate measure¬ments were needed in only 204 (3.3%) of 6,169 totalpatient days.

The second approach was carried out by means ofdirect questioning of the 40 physicians directly re¬

sponsible for the care of 1,067 patients in the VeteransAdministration Hospital, Wood, Wis. These patientswere distributed as follows: medical, 378; surgical,322; tubercular, 160; and neuropsychiatrie, 207. Eachphysician was asked how many of the patients directlyTable 1.—Evaluation of Proportion of Total Patient Days in

Which Serial Measurements of Respiratory RateAre of Clinical Importance

Patient Days inWhich RespiratoryRate Measurements

Were ClinicallyTotal UsefulHospital No. of ,-A-,Type of Where Study No. of Patient No. %

Study Was Conducted Patients Days of Days of TotalReview of Veterans Hospital, 200 5,008 238 4.7

hospital Nashville, Tenn.charts

Review of Veterans Hospital, 100 0,169 204 3.3hospital Wood, Wis.charts

Poll of 40 Veterans Hospital, 1,007 1,007 49 4.6physicians Wood, Wis.responsiblefor patientcare

under his care would need to have measurements ofrespiratory rate taken in the event that routine measure¬ments were eliminated. Each doctor was urged to in¬clude any patient in whose respiratory rate he wasinterested for any reason whatsoever. Even with thisurging, there were only 49, or 4.6%, of a total of 1,067hospital patients for whom the patient's physicianconsidered repeated respiratory rate measurements ofany clinical importance ( table 1 ).

These studies, although carried out independently,show remarkable agreement and strongly suggest that,in a general medical and surgical hospital, measure¬ments of respiratory rate are of clinical usefulness inless than 5% of the patient days.

Accuracy of Routine MeasurementsThe lack of medical interest in respiratory rates has

resulted in apathy on the part of nurses toward thismeasurement. In many hospitals "respirations" aremeasured in a perfunctory manner and are likely tobe highly inaccurate. These inaccuracies were re¬

peatedly demonstrated by comparison of measure¬ments of respiratory rates taken in studies on patientsin a cardiopulmonary laboratory with those measure¬ments routinely recorded in the clinical record of the

same patient on the same day (fig. 1). The routinemeasurements of rates recorded on the ward recordswere between 18 and 22 per minute in 49 of the 51patients studied, and 34 of the rates were charted atexactly 20 per minute. In contrast, the respiratory ratescarefully measured in the cardiopulmonary laboratoryon the same patients on the same day ranged from 10to 35 per minute. Figure 1 illustrates the absence ofcorrelation between these sets of measurements.

In order to duplicate the conditions as nearly as

possible, careful measurements of respiratory rates

O = RESPIRATORY RATE AS MEASURED AND CHARTED ROUTINELY BV WARD PERSONNEL

= RESPIRATORY RATE CAREFULLY MEASURED IN A CARDIOPULMONARY LABORATORY

îîMîîîI^ffi^1

Fig. 1.—Comparison of respiratory rates measured in cardio¬pulmonary laboratory with routinely recorded ward "respira¬tions" for same patients on same day.were carried out at intervals during one day on allpatients on one acute medical and one acute surgicalward. Our measurements were made either a fewminutes before or a few minutes after the routinetemperature, pulse, and respiration measurements

O RESPIRATORY «Art AS MEASURED AND CHARTED ROUTINELY BY WARD PERSONNEL

— RESPIRATORY RATE MEASURED CAREFULLY ON THE WARD FOR THIS STUDY

OOOOOOOOOOOpiPïffi« J8B9B.!T|iI]jI olM0000 o

-

SB PATIENTS-

Fig. 2.—Comparison of respiratory rates, carefully measuredon the ward for this study, with routinely recorded ward re¬

spiratory rates. In all patients, the careful respiratory rate meas¬urements were made within a few minutes of the routine takingof "temperature, pulse, and respiration" by ward personnel.

(fig. 2). In this entirely separate group of patients,the routinely recorded ward respiratory rates werebetween 18 and 22 per minute in 57 of 58 patients, 40of these being recorded as exactly 20 per minute. Inthis group, our carefully measured rates ranged from11 to 33 per minute with no correlation between thetwo sets of measurements. It should be further notedthat two patients were found by us to exhibit typical

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Cheyne-Stokes respiration. No notation of this factwas found in either patient's clinical record, althoughthe respirations were charted faithfully at 20 perminute on both patients.

The data obtained in these two studies strongly sug¬gest that the routine respiratory rates recorded on thewards are much more likely to be 20±2 per minutethan to represent the correct respiratory rate. In orderto test this thesis, the clinical records of 148 patientsat Veterans Administration Hospital, Nashville, Tenn.,and 100 patients at Veterans Administration Hospital,Wood, Wis., were checked for the total number ofrespiratory rates measured in the patient and for thenumber of these rates which fell between 18 and 22per minute (table 2). Of the 6,953 recorded respira¬tory rates in 148 patients at Thayer Veterans Adminis¬tration Hospital in Nashville, 6,532, or 94%, rangedbetween 18 and 22 per minute. Of 6,757 respiratoryrate measurements in 100 patients at Veterans Ad¬ministration Hospital, Wood, Wis., 6,363, or 94%,were within the 18 to 22 range. The fact that only 6%of 13,000 respiratory rates as recorded were outside ofthe 18 to 22 range is further evidence that the recorded

Table 2.—Evaluation of Accuracy of Routine Respiratory RateMeasurements

No. of RecordedRespiratory Rates

Total Between 18 and 22No. of per Min.Respir- r-•*-,

Hospital atory No. ofType of Where Study No. of Rates Measure- %Study Was Conducted Patients Measured ments of Total

Review of Veterans Hospital 148 0,953 6,532 94hospital Nashville, Tenn.charts

Review ot Veterans Hospital, 100 6,757 0,303 94hospital Wood, Wis.charts

measurements are unreliable, particularly since thenormal range for males is more nearly 14 to 18 perminute than 18 to 22.2

Yearly Cost of Personnel TimeUsed in Unnecessary Measurements

The average daily patient population (excludingneuropsychiatrie patients) in United States hospitalsis in excess of 650,000. If 5% of these (32,500) areassumed to need respiratory rate measurements, over600,000 patients would appear to be receiving un¬

necessary routine respiratory rate measurements eachday. If we make the conservative assumptions (1)that the 600,000 patients will receive an average ofonly one measurement a day and (2) that this meas¬urement, together with the charting, will require onlyone minute's time, it still follows that 600,000 minutesof personnel time is devoted each day to this needlessmeasurement. These daily 600,000 minutes represent3,650,000 hours per year of wasted time of nurses andnursing assistants, both of whom are in extremelyshort supply in our hospitals. If a further conserva¬tive assumption is made that the average salary of suchpersonnel is $1.50 per hour, the monetary expressionof this annual wasted time is over $5,500,000.

CommentOur data have indicated that measurement of res¬

piratory rate serves a useful purpose in less than 5%of patient days and that the routinely recordedrespiratory rates are highly inaccurate. Both of thesestatements have long been recognized by many physi¬cians, but no systematic effort has previously beenmade to analyze this problem.

The repeated appearance in patients' hospitalrecords of such inaccurate and unreliable data cannever be defended as "good medical practice." Thecomplete omission of such data would appear to repre¬sent better medical practice than does perpetuationof these erroneous records. It should be emphasizedthat respiratory rate measurements may be importantin certain types of patients. In these as well as otherpatients the observation of the character of the breath¬ing is at least as important as measurement of the rate.

It is proposed, therefore, that measurement ofrespiratory rate be continued in those cases or on thosewards where the physician specifically orders thatsuch measurements be made but that measurement ofrespiratory rate be eliminated as a "pan-hospital"routine. It is further proposed that the character ofthe patient's breathing be observed and recorded alongwith an accurate measurement of respiratory rate inthose patients who need such measurements.

Summary and ConclusionsThe data herein presented demonstrate that each

year over 3,500,000 hours of personnel time ( represent¬ing over $5,500,000) are devoted to an unreliable,largely useless routine which has been continued inhospital procedure wholly because of tradition. Thethesis espoused in this report is that the elimination ofthese routine measurements would in itself improvemedical practice and patient care, by eliminating er¬roneous information from patients' hospital recordsand by freeing nursing personnel for more importantduties. In place of this routine, the physician wouldspecify those patients or particular wards in whichhe considered close observation of respiration neces¬sary. The nurse, in turn, would observe the characteras well as the rate of the "respirations" in such patients.Such a proposal should result in improved patientcare and more accurate medical records and at thesame time save over 3,500,000 hours of personnel timeeach year in United States hospitals.

References1. (a) Kampmeier, R. H.: Physical Examination in Health

and Disease, Philadelphia, F. A. Davis Company, 1950, pp.352-353. (b) Harmer, B., and Henderson, V.: Textbook ofPrinciples and Practice of Nursing, ed. 5, New York, theMacmillan Company, 1955, pp. 287-288.

1A. Footnote la, p. 303.2. Best, C. H., and Taylor, N. B.: Physiological Basis of

Medical Practice, ed. 6, Baltimore, Williams & Wilkins Com-pany, 1955, p. 348. Textbook of Physiology, edited by J. F.Fulton, with collaboration of D. H. Barron and others, ed. 17.Philadelphia, W. B. Saunders Company, 1955, p. 807. Dakin, F.,and Thompson, E. M.: Simplified Nursing, ed. 5, Philadelphia,J. B. Lippincott Company, 1951, pp. 560-561. Shepard, K.,and Lawrence, C. H.: Textbook of Attendant Nursing, ed. 2,New York, the Macmillan Company, 1942, p. 263. Rothweiler,E. L., and White, J. M.: Art and Science of Nursing, ed. 3, Phil-adelphia, F. A. Davis Company, 1943, pp. 337-338. Footnote lb.

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