FOCUS
Respiratory rate monitoring and early
detection of deterioration practices
Susan A Kayser, Rachel Williamson, Gabriela Siefert, Dan Roberts and Angela Murray
ABSTRACT
Background: Growing evidence points to respiratory rate (RR) being the most
important vital sign for early detection of patient deterioration. However, RR
is the vital sign most likely to be inaccurate or missed. Aims: To measure
prevalence of early detection of deterioration protocols, examine whether RR
was perceived as the leading indicator of deterioration, and understand RR
monitoring practices used by nurses around the world. Methods: A double-
blinded survey of nurses in Asia Pacific, Middle East, and Western Europe.
Findings: 161 nurses responded. Most (80%) reported having an initiative
for early detection of patient deterioration; 12% indicated RR was the most
important indicator of deterioration, 27% captured RR for all medical/surgical
patients, and 56% take 60 seconds or longer to measure RR. Conclusion:
Nurses across all regions generally underestimated the importance of
capturing an accurate RR for all patients’ multiple times per day. This study
reinforces the need to enhance international nursing education regarding the
importance of RR.
Key words: Deteriorating patient ■ Respiratory rate ■ Deterioration
protocols ■ Vital signs
P
atient deterioration events are commonly preceded
by a period of abnormal vital signs (Lighthall et al,
2009; Fagan et al, 2012; Hands et al, 2013). Among
the standard vital signs, growing evidence suggests
that respiratory rate (RR) is the most important
Susan A Kayser, Health Economist, Baxter International,
Batesville, Indiana, USA
Rachel Williamson, Director, Global Strategic Marketing,
Baxter International, Batesville, Indiana, USA,
rachel_williamson@baxter.com
Gabriela Siefert, Associate Director of Strategy, Baxter
International, Omaha, Nebraska, USA
Dan Roberts, Health Economist, Baxter International, Scottsville,
Virginia, USA
Angela Murray, Senior Director of Health Economics, Baxter
International, Chicago, Illinois, USA
Accepted for publication: June 2023
This is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License
(CC BY-NC 4.0, http://creativecommons.org/licenses/by-nc/4.0/).
620
(Cretikos et al, 2008; Rolfe, 2019). RR is a strong predictor
for detection of early patient deterioration (Churpek et al,
2013; 2016), cardiac arrest (Cretikos et al, 2008), and it is an
early indicator of hypoxia, hypercapnia, and metabolic and
respiratory acidosis (Rolfe, 2019).
Despite its importance in early detection of deterioration,
RR is often the least likely vital sign to be monitored or
automated, particularly in medical/surgical wards (Leuvan
and Mitchell, 2008; Semler et al, 2013; Elliott and Baird, 2019;
Palmer et al, 2022). Several studies have reported that RR was
missed in the range of 76% to 83% of the times that other
vital signs were recorded (McGain et al, 2008; Ludikhuize et
al, 2012; Tirkkonen et al, 2013; Cardona-Morrell et al, 2016;
Difonzo, 2019). RR is also more likely to be inaccurately
recorded, in part because it is not often measured for the full
60 seconds needed for an accurate count (Rimbi et al, 2019;
Takayama et al, 2019; Kallioinen et al, 2021).
RR may not be measured and/or recorded due to either a
lack of understanding of its importance, a misconception that
oxygen saturation is a sufficient substitute, lack of time, or the
subjective nature of measuring RR (Hogan, 2006; Philip et
al, 2013; Ansell et al, 2014; Mok et al, 2015; Smith and Aitken,
2016; Elliott, 2016; Flenady et al, 2017; Elliott and Baird,
2019). Evidence of the general undervaluing of RR has been
found in many studies and from countries spanning Australia
to the USA. However, to the best of the authors’ knowledge
at the time of publication, no studies included representation
from multiple countries, making comparisons across countries
and regions difficult. Moreover, it remains unclear whether
monitoring practices may have been an anomaly in a few
institutions and are not representative of country-wide or
regional practices.
This article addresses three research objectives and involved
an international survey of 161 medical/surgical ward nurses
each from a different institution. The three objectives were:
■ To measure the perceived prevalence of early detection of
deterioration protocols
■ To examine which vital sign parameter respondents
perceived as the leading indicator of deterioration
■ To better understand current practices related to RR
monitoring.
© 2023 The Authors
British Journal of Nursing, 2023, Vol 32, No 13
Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.

Each research objective was examined globally and
compared across regions. These findings provide critical
insight into current global beliefs and practices related to
RR monitoring. Educational initiatives underscoring the
value of RR in early detection of patient deterioration could
improve nursing practice and, as a result, improve the earlier
recognition of patient deterioration and patient outcomes.
Methods
Survey methodology
This descriptive, non-experimental study surveyed nursing
professionals (nurse managers, staff nurses) from eight different
countries: the UK, France, Germany,Australia, mainland China,
Singapore, the Kingdom of Saudi Arabia, and the United Arab
Emirates (UAE). Survey responses were completed between
1 December 2019 and 31 January 2020.
The 25-item online survey was developed by DJS Research
(Stockport, UK) in partnership with HillRom, Inc (now
Baxter International). Questions covered nurse demographics,
hospital characteristics, deterioration detection indicators
and protocols, and RR monitoring practices within each
respondent’s facility. All questions were provided in the survey
respondent’s native language.
This survey was conducted in a double-blinded fashion
by DJS Research. No protected health information or
personally identifiable information were solicited or collected,
and respondents were compensated for their time. Data
processing occurred in full compliance with the European
Union’s General Data Protection Regulations. Participants
received an email invitation to participate in the online survey.
Participation was voluntary and completing the survey served
as informed consent.
Inclusion criteria
The study sample included nurse managers and staff nurses who
worked in acute care hospitals with at least 100 medical/surgical
beds. Nurses who did not work in direct patient care of adults
on medical/surgical wards were excluded. All respondents
were required to have prior experience with electric beds
and digital vital signs machines. Eligible respondents must
have been working in their current role for at least 1 year.
Respondents were eligible only if no other respondents had
yet participated from their hospital to avoid the potential for
oversampling a few hospitals within a country.
Statistical analyses
Responses were analysed by geographic region: Asia-Pacific
(Australia, mainland China, Singapore), the Middle East (UAE,
Saudi Arabia), and Western Europe (UK, France, Germany).
These countries represent a wide variation in healthcare system
practices (for example in access to technology, treatment
guidelines) and cultures.
Descriptive statistics summarised respondent demographics,
© 2023 The Authors
including years of respondent experience, hospital funding
type, hospital size, country, region, electronic medical record
(EMR) use and smartphone use.
To examine the perceived prevalence of early patient
British Journal of Nursing, 2023, Vol 32, No 13
FOCUS
deterioration initiatives/protocols, each respondent was asked:
‘Does your medical/surgical setting have initiatives to help
with the early detection of patient deterioration?’
To determine whether RR was perceived as a leading
indicator for early detection of patient deterioration,
respondents were asked to identify which indicators/
parameters they used to assess potential patient deterioration.
These indicators/parameters included: heart rate (HR), RR,
blood pressure (BP), temperature, oxygen saturation (SpO2),
an early warning score system (EWS), a visual assessment,
telemetry monitoring, end-tidal carbon dioxide rate (EtCO2),
or other. These parameters were chosen based on a search of
the recent literature on assessing risk of patient deterioration.
First, the five standard vital signs (BP, HR, RR, SpO2,
and temperature) were included because these are considered
the cornerstone of patient monitoring. Second, EWS
systems were included because the combination of multiple
physiological changes can determine the severity of illness
in a patient. Visual assessment was included as nurses use it
in combination with physiological parameters to determine
the patient’s overall condition, which includes the assessment
of skin colour, facial expressions, and other physical and/or
mental changes. Telemetry and EtCO2 were included due
to their use for monitoring patients with particularly acute
respiratory or cardiac conditions, and, in some countries, these
technologies are used more routinely to monitor patients in
medical units. Finally, respondents were able to document
options they felt were missing.The order of these parameters
was randomised for respondents, and multiple responses could
be chosen. Respondents were then asked to rank the top
five in order of importance. Results were summarised as
the percentage of respondents who chose each option as the
most important indicator.
Finally, to understand current RR monitoring practices,
respondents were asked how frequently each of the following
parameters were monitored: HR, RR, SpO2, EtCO2,
temperature, and BP. Respondents could select from the
following options: continuously, every couple of hours, two
or three times per day, once a day, less than once a day, or not
at all for medical/surgical patients. Responses were allocated
in post-processing to either ‘multiple times per day’ or ‘once
a day or less’ for ease of interpretation. ‘Multiple times per
day’ included continuously, every couple of hours, and two or
three times per day, while ‘once a day or less’ included once
a day, less than once a day, not at all.
Respondents were asked an open-ended question: ‘In
which types of medical/surgical patients do you measure
RR?’. Responses were translated and then categorised as
either indicating they measured RR for all medical/surgical
patients, for one or more specific conditions or as having
never measured RR for medical/surgical patients.
Respondents were asked how they measure RR and
whether they visually count breaths for less than 60 seconds
or 60 seconds or longer.
Results were analysed by country, by region, and globally.
Analyses were performed in Stata 17.0 software (StataCorp,
2021).
621
Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.
FOCUS

Table 1. Characteristics of survey respondents (N=161) Table 2. Perceived presence of patient deterioration
detection initiatives by country/region (N=161)
Variable n %
Country/region Respondents %
Years of experience reporting
initiatives in
1−5 years 38 24%
their facilities
6−10 years 54 34% (total responses)

11−15 years 35 22% Asia Pacific 45 (57) 79%

16−25 years 24 15% Australia 13 (20) 65%

Over 25 years 10 6% China 19 (20) 95%

Hospital funding type Singapore 13 (17) 76%

Not for profit 6 4% Middle East 40 (40) 100%

Private 53 33% Saudi Arabia 20 (20) 100%

Public/government 102 63% UAE 20 (20) 100%

Hospital size Western Europe 43 (64) 67%

100−199 32 20% France 10 (19) 53%

200−299 28 17% Germany 10 (20) 50%

300−499 28 17% UK 23 (25) 92%

Over 500 71 44% Total 128 (161) 80%

Unsure 2 1% NB: Totals may not add up to 100% due to rounding

Region/country
Table 3. Percentage of nurses monitoring vital signs two
Asia Pacific 57 35% or more times per day or once or less per day (N=161)
Australia 20 12% Vital sign Two or more Once or less
per day per day
China 20 12%
Blood pressure 157 (98%) 4 (2%)
Singapore 17 11%
EtCO2 96 (60%) 65 (40%)
Middle East 40 25%
Heart rate 158 (98%) 3 (2%)
Saudi Arabia 20 12%
Respiratory rate 145 (90%) 16 (10%)
UAE 20 12%
SpO2 147 (91%) 14 (9%)
Western Europe 64 40%
Temperature 151 (94%) 10 (6%)
France 19 12%
Key: EtCO2=end-tidal carbon dioxide; SpO2=oxygen saturation
Germany 20 12%
NB: Totals may not add up to 100% due to rounding
UK 25 16%

Technology use
Respondents were most likely to have worked in nursing for
EMR 155 96% 6 to 10 years (34%) and work in hospitals with more than 500
beds (44%); most respondents worked in public/government
Smartphone 115 71%
hospitals (63%). The UK had the most respondents (n=25),
Key: EMR=electronic medical record and Singapore had the fewest (n=17). Most respondents (96%)
NB: Totals may not add up to 100% due to rounding reported using EMRs in their medical/surgical wards to capture
patient information, while 71% reported using smartphones to
communicate with caregivers, receive patient status alerts, or
© 2023 The Authors

Results receive EMR information.

Survey population
Demographic characteristics of the 161 study respondents are Early patient deterioration initiatives
reported in Table 1. Eighty per cent of respondents (n=128/161) indicated that

622 British Journal of Nursing, 2023, Vol 32, No 13

Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.

 FOCUS

their medical/surgical ward had initiatives to detect patient

deterioration early, although results varied by region. For
example, every respondent from the Middle East indicated
that their facilities had deterioration detection initiatives, while HR
only 67% of respondents in Western Europe indicated this. Tele
However, even within Western Europe considerable variation RR
existed, with 92% of UK respondents reporting a deterioration BP
initiative, whereas only 50% of German respondents did so. Global SpO2
Table 2 describes results by country and region. Visual
EWS
Most important indicators of patient deterioration ETCO2
Respondents were asked to select which of nine indicators T
they used to assess possible patient deterioration. HR was the
indicator most frequently selected (n=145; 90%), followed by
RR (n=140; 87%), BP (n=138; 86%), SpO2 (n=132; 82%), HR
temperature (n=126; 78%), visual assessments (n=107; 66%), Tele
telemetry (n=97; 60%), EtCO2 (n=75; 47%), and EWS (n=69; RR
43%). Only 21% selected all nine indicators (n=34), while 58%
SpO2
(n=94) reported using at least five standard vital signs (BP, HR, Asia
Pacific BP
RR, temperature, and SpO2) in their determinations.
ETCO2
Globally (Figure 1), 158 of the 161 respondents then ranked
Visual
the top five indicators of patient deterioration they used in
T
patient care. Respondents ranked HR highest (n=50/158; 32%),
followed by telemetry (n=23/158; 15%), RR (n=19/158; 12%) EWS
and BP (n=19/158; 12%). Fewer than 10% of respondents
ranked any of the remaining indicators as their top indicator
of patient deterioration. HR
These rankings demonstrated considerable variation across Tele
geographic regions. HR was ranked the most important indicator RR
of deterioration by respondents in Asia-Pacific (n=22/55; 40%) SpO2
Middle
and the Middle East (n=19/40; 48%); in these regions, RR East
Visual
was ranked the third most important indicator. In Western ETCO2
Europe (n=63), responses were more evenly distributed across BP
BP (n=14; 22%), EWS (n=13; 21%), and visual assessments T
(n=12; 19%); nearly 10% (n=6) of respondents ranked RR EWS
as their most important indicator of patient deterioration.
Figure 1 summarises indicator rankings by region. Full results
for countries are available in supplemental materials available BP
from the corresponding author. EWS
Visual
Respiratory rate monitoring practices HR
Nearly all respondents reported measuring patient HR and BP Western
SpO2
more than once daily (98% and 98%, respectively), while slightly Europe
RR
fewer reported measuring temperature and SpO2 more than
Tele
once per day (94% and 91%, respectively). Of the five standard
T
vital signs, RR was the least likely to be measured more than
ETCO2
once per day (n=145/161; 90%). For respondents who reported
monitoring EtCO2, only 60% (n=96) indicated monitoring
this indicator more than once per day. Full results of 161 are 0 5 10 15 20 25 30 35 40 45 50
presented in Table 3.
Number of responses
When asked what types of medical/surgical ward patients
they measure RR for, only 27% (n=43/160 responses) indicated Key
they monitored RR for all medical/surgical patients; 68% BP=blood pressure; EtCO2=end-tidal carbon dioxide; EWS=early warning score;
© 2023 The Authors

(n=109/160) indicated they monitored RR for only patients
with specific concerns, such as respiratory or cardiac conditions.
The final 5% (n=8/160) either never monitored RR or were
unaware of when they would need to monitor RR (see Figure 2).
HR=heart rate; RR=respiratory rate; SPO2=oxygen saturation; T=temperature;
Tele=telemetry
Figure 1. Count of responses for each indicator of patient deterioration selected
as most important globally and by region

British Journal of Nursing, 2023, Vol 32, No 13 623

Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.
FOCUS

using a different method or were unsure.

Again, results varied considerably by region and country
with 70% of respondents from the Middle East reported
All measuring RR for 60 seconds or longer (n=28/40). However,
within this region, reports varied greatly by country with all
Global
Some respondents from the UAE having reported measuring RR for
60 seconds or longer, compared to 40% of respondents from
None Saudi Arabia (n=8/20). Similarly, responses varied widely in
Asia Pacific with Australia and Singapore reporting 70% and
82% measured RR 60 seconds or longer respectively, yet 0
respondents in China reported measuring RR for 60 seconds
or longer. Responses varied considerably less within Western
All
Europe, where 45%, 56%, and 61% of respondents reported
Asia measuring RR 60 seconds or longer in Germany, UK, and
Some
Pacific France respectively. See Figure 3 for results of RR monitoring
technique by country and region. All counts and percentages
None
are available in supplemental materials.

Discussion
This study investigated patient deterioration detection
All initiatives and vital sign assessment practices in medical/
surgical environments in Asia-Pacific (Australia, mainland
Middle East China, Singapore), the Middle East (UAE, Saudi Arabia), and
Some
Western Europe (France, Germany, UK). Survey respondents
None represented 161 unique medical/surgical wards in hospitals
with at least 100-bed capacity and where both EMR and
smartphones were commonly used.

Perceived prevalence of early patient deterioration

All
initiatives
Western Most respondents (80%) reported that their medical/surgical
Some
Europe ward had implemented initiatives for early detection of patient
deterioration including EWS tracking such as the Modified
None
EWS (MEWS) or the National EWS (NEWS2). Although
most respondents indicated having at least one such initiative
0 10 20 30 40 50 60 70 80 90 100 110
in place within their unit, vital signs’ monitoring practices and
methodologies varied greatly by region and country.
Number of responses
Most important indicator of patient deterioration
Figure 2. Number of nurses indicating they measure respiratory rate for either all
Abnormal RR is a sign of both hypoxia and metabolic acidosis
patients, some patients based on their condition, or no patients and therefore indicates failure of a multitude of systems
(Cretikos et al, 2008). High rates can be the first sign of sepsis
and shock and low rates can indicate opioid overdoses (Kellett
and Sebat, 2017). RR is a strong predictor of in-hospital cardiac
Results varied considerably by country and region. For arrest (Fieselmann et al, 1993; Cuthbertson et al, 2007; Cretikos
example, no respondents in the Middle East indicated they et al, 2008; Churpek et al, 2012), early deterioration (Churpek
monitored RR for all patients compared to 44% of respondents et al, 2013; 2016), intensive care unit transfer (Kipnis et al,
in Western Europe (n=28/63). However, there was considerable 2016), and is the best physiological parameter to differentiate
variation within the region; 75% (n=18/24) of respondents between stable and at-risk patients (Subbe et al, 2003).
in the UK indicated they monitored RR for all patients, Despite this evidence, this study found nurses were most
compared to 25% and 26% of respondents from Germany likely to identify HR as the most important indicator of patient
and France, respectively. Table 4 summarises results by country deterioration (n=50/158; 32%).And whereas most respondents
and region. said they used RR as an indicator of patient deterioration
© 2023 The Authors

In reporting how they measure RR, just over half (n=140/161; 87%), only 12% viewed RR as the most important
(n=90/160; 56% ) indicated they monitor RR for 60 seconds indicator. These results are consistent with other studies that
or longer compared to 39% who indicated monitoring for have found RR is systematically undervalued by nurses (Mok
less than 60 seconds (n=62/160) and 5% who reported either et al, 2015; Elliott and Baird, 2019).

624 British Journal of Nursing, 2023, Vol 32, No 13

Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.

 FOCUS

Respiratory rate monitoring practices

Of the five standard vital signs, the present survey found
RR was the least likely to be monitored more than once Total
per day (n=145/161; 90%). Nearly all respondents (98%)
stated HR and BP were monitored more than once per day, Asia Pacific
while 94% reported that temperature was monitored more
than once per day. In a systematic literature review, Difonzo
(2019) found that RR was consistently the least likely of the Australia
vital signs to be documented, with a recording rate typically
between 14% and 17%.These findings highlight the possibility
China
that these survey results found a higher prevalence of RR
documentation than what is happening in practice given the
survey asked nurses how often they capture each indicator Singapore
of deterioration.
Although 87% of study respondents reported that RR is an
Middle East
important indicator of deterioration and 90% said they capture
RR two or more times per day, only 27% of respondents
(n=43/161) indicated RR was captured for all medical/surgical Saudi Arabia
ward patients. Most respondents (63%) indicated that they
captured RR only for patients with specific conditions and not
for every medical/surgical ward patient despite recording a full UAE
set of vital signs (HR, BP, RR, and temperature) at least daily
is considered standard care for all acute care patients (Cretikos Western Europe
et al, 2008). Finally, the survey found only 56% (n=90/160) of
respondents reported taking 60 seconds or longer to measure
RR, which is recommended for an accurate reading and for France
identifying deteriorating patients (Rimbi et al, 2019;Takayama
et al, 2019; Kallioinen et al, 2021).
Germany

Limitations and future research

This study had several limitations. First, although the survey UK
was translated into the respondents’ native languages, it was
not possible to eliminate all variability in how respondents 0 50 100 150
interpreted the questions. Second, the study was subject to
Number of responses
possible selection bias as nurses who responded might be
more knowledgeable regarding patient deterioration than Key
those who did not respond.Third, self-reported measurements ■ Over 60 seconds
of vital sign monitoring practices could have been impacted ■ Under 60 seconds
by recall errors or common method bias. Respondents may ■ Other or none
have felt compelled to report their belief that all indicators
of deterioration are important or to overestimate the rate at Figure 3. Number of responses for measuring RR for more or less than 60
which they capture these indicators, possibly inflating some seconds by country and region
of the results. Fourth, limiting the sample to one respondent
per hospital prevented overlap in responses, but did limit the to these parameters. Finally, different education systems across
sample size and may have impacted the generalisability of the countries and different healthcare system structures may lead
results. Finally, the relatively small sample sizes within each nurses to over or under emphasise RR. Educators could
country and region make it difficult to generalise results and leverage insights from future work comparing different nursing
limits the authors’ ability to interpret differences between education systems and their vital sign monitoring practices.
countries and regions.
It is important to note that there are other parameters that Conclusion
help nurses identify patients at risk of deterioration. In fact, This study reinforces the importance of enhancing international
six respondents documented urine output and blood results. nursing education regarding the significance of RR as the most
Early warning scores such as the NEWS2 includes whether important leading indicator of patient deterioration. Most
© 2023 The Authors

the patient’s level of consciousness has changed (Smith et al, nurses who responded to this survey reported that their ward
2019). MEWS includes patient’s urine output and level of had an initiative for the early detection of patient deterioration.
consciousness (Morgan et al, 1997). Future research would However, the results suggest that many nurses may view HR
benefit from examining nurse monitoring practices related as the most important indicator of deterioration. Not only

British Journal of Nursing, 2023, Vol 32, No 13 625

Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.
FOCUS

org/10.12968/bjon.2014.23.8.414
Table 4. Respiratory rate monitoring by patient condition and country/region Cardona-Morrell M, Prgomet M, Lake R et al.Vital signs monitoring and
nurse–patient interaction: A qualitative observational study of hospital
Country/ All % Condition % None % n practice. Int J Nurs Stud. 2016;56:9–16. https://doi.org/10.1016/j.
region patients specific ijnurstu.2015.12.007
Churpek MM, Adhikari R, Edelson DP. The value of vital sign trends for
Asia Pacific 15 26% 40 70% 2 4% 57 detecting clinical deterioration on the wards. Resuscitation. 2016;102:1–5.
https://doi.org/10.1016/j.resuscitation.2016.02.005
Australia 14 70% 5 25% 1 5% 20 Churpek MM,Yuen TC, Edelson DP. Predicting clinical deterioration in the
hospital: the impact of outcome selection. Resuscitation. 2013;84(5):564–
568. https://doi.org/10.1016/j.resuscitation.2012.09.024
China 0 0% 20 100% 0 0% 20
Churpek MM,Yuen TC, Park SY, Meltzer DO, Hall JB, Edelson DP.
Derivation of a cardiac arrest prediction model using ward vital signs.
Singapore 1 6% 15 88% 1 6% 17 Crit Care Med. 2012;40(7):2102–2108. https://doi.org/10.1097/
CCM.0b013e318250aa5a
Middle East 0 0% 39 98% 1 3% 40 Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A.
Respiratory rate: the neglected vital sign. Med J Aust. 2008;188(11):657–
Saudi 0 0% 19 95% 1 5% 20 659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x
Arabia Cuthbertson BH, Boroujerdi M, McKie L, Aucott L, Prescott G.
Can physiological variables and early warning scoring systems
UAE 0 0% 20 100% 0 0% 20 allow early recognition of the deteriorating surgical patient? Crit
Care Med. 2007;35(2):402–409. https://doi.org/10.1097/01.
Western 28 44% 30 48% 5 8% 63 CCM.0000254826.10520.87
Europe Difonzo M. Performance of the afferent limb of rapid response systems in
managing deteriorating patients: a systematic review. Crit Care Res Pract.
2019;2019:1–16. https://doi.org/10.1155/2019/6902420
France 5 26% 13 68% 1 5% 19
Elliott M. Why is respiratory rate the neglected vital sign? A narrative review.
International Archives of Nursing and Health Care. 2016;2(3). https://
Germany 5 25% 13 65% 2 10% 20 doi.org/10.23937/2469-5823/1510050
Elliott M, Baird J. Pulse oximetry and the enduring neglect of respiratory
UK 18 75% 4 17% 2 8% 24 rate assessment: a commentary on patient surveillance. Br J Nurs.
2019;28(19):1256–1259. https://doi.org/10.12968/bjon.2019.28.19.1256
Total 43 27% 109 68% 8 5% 160 Fagan K, Sabel A, Mehler PS, MacKenzie TD.Vital sign abnormalities, rapid
response, and adverse outcomes in hospitalized patients. Am J Med Qual.
Key: UAE=United Arab Emirates 2012;27(6):480–486. https://doi.org/10.1177/1062860611436127
Fieselmann JF, Hendryx MS, Helms CM, Wakefield DS. Respiratory rate
predicts cardiopulmonary arrest for internal medicine inpatients. J Gen
Intern Med. 1993;8(7):354–360. https://doi.org/10.1007/BF02600071
was HR the vital sign most likely to be listed as the number Flenady T, Dwyer T, Applegarth J. Explaining transgression in respiratory
rate observation methods in the emergency department: A classic
one indicator of patient deterioration, but it was also the grounded theory analysis. Int J Nurs Stud. 2017;74:67–75. https://doi.
vital sign most likely to be taken more than once per day. org/10.1016/j.ijnurstu.2017.06.001
Hands C, Reid E, Meredith P et al. Patterns in the recording of vital signs
Although 90% of responding nurses said they capture RR and early warning scores: compliance with a clinical escalation protocol.
more than once per day, only 27% reported capturing RR BMJ Qual Saf. 2013;22(9):719–726. https://doi.org/10.1136/bmjqs-
for all patients, and only 56% reported taking the full 60 2013-001954
Hogan J. Why don’t nurses monitor the respiratory rates of patients?
seconds to capture this vital sign. To improve early detection Br J Nurs. 2006;15(9):489–492. https://doi.org/10.12968/
of patient deterioration, nursing education should be enhanced bjon.2006.15.9.21087
Kallioinen N, Hill A, Christofidis MJ, Horswill MS, Watson MO. Quantitative
to emphasise the importance of capturing RR often and systematic review: sources of inaccuracy in manually measured adult
accurately for all patients. BJN respiratory rate data. J Adv Nurs. 2021;77(1):98–124. https://doi.
org/10.1111/jan.14584
Kellett J, Sebat F. Make vital signs great again – a call for action. Eur J Intern
Declaration of interest: the authors are employees of Baxter Med. 2017;45:13–19. https://doi.org/10.1016/j.ejim.2017.09.018
International Kipnis P, Turk BJ, Wulf DA et al. Development and validation of an electronic
medical record-based alert score for detection of inpatient deterioration
Ansell H, Meyer A, Thompson S. Why don’t nurses consistently take outside the ICU. J Biomed Inform. 2016;64:10–19. https://doi.
patient respiratory rates? Br J Nurs. 2014;23(8):414–418. https://doi. org/10.1016/j.jbi.2016.09.013
Leuvan CH, Mitchell I. Missed opportunities? An observational study of vital
sign measurements. Crit Care Resusc. 2008;10(2):111–115
Lighthall GK, Markar S, Hsiung R. Abnormal vital signs are associated
KEY POINTS with an increased risk for critical events in US veteran inpatients.
■ Most hospitals have protocols to help nurses detect early signs of patient Resuscitation. 2009;80(11):1264–1269. https://doi.org/10.1016/j.
resuscitation.2009.08.012
deterioration Ludikhuize J, Smorenburg SM, de Rooij SE, de Jonge E. Identification of
■ Those protocols typically involve the monitoring of standard vital signs for deteriorating patients on general wards; measurement of vital parameters
and potential effectiveness of the Modified Early Warning Score. J Crit
all patients Care. 2012;27(4):424.e7-13. https://doi.org/10.1016/j.jcrc.2012.01.003
McGain F, Cretikos MA, Jones D et al. Documentation of clinical review and
■ Growing evidence suggests respiratory rate (RR) is the strongest of the vital signs after major surgery. Med J Aust. 2008;189(7):380–383. https://
standard vital signs for predicting early patient deterioration doi.org/10.5694/j.1326-5377.2008.tb02083.x
Mok W, Wang W, Cooper S, Ang ENK, Liaw SY. Attitudes towards vital signs
■ However, RR is often undervalued by nurses, leading to it often being monitoring in the detection of clinical deterioration: scale development
missed or inaccurately recorded and survey of ward nurses. Int J Qual Health Care. 2015;27(3):207–213.
© 2023 The Authors

■ Furthermore, RR monitoring practices vary considerably across regions and
international guidelines are needed to promote improved recording of RR
https://doi.org/10.1093/intqhc/mzv019
Morgan RJM, Williams F, Wright MM. An early warning scoring system for
detecting developing critical illness. Clinical Intensive Care. 1997;8(2):100
Palmer JH, James S, Wadsworth D, Gordon CJ, Craft J. How registered
nurses are measuring respiratory rates in adult acute care health settings:

626 British Journal of Nursing, 2023, Vol 32, No 13

Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.

 FOCUS

an integrative review. J Clin Nurs. 2022; September 12. https://doi.
org/10.1111/jocn.16522. Epub ahead of print
Philip K, Richardson R, Cohen M. Staff perceptions of respiratory rate
measurement in a general hospital. Br J Nurs. 2013;22(10):570–574.
https://doi.org/10.12968/bjon.2013.22.10.570
Rimbi M, Dunsmuir D, Ansermino JM, Nakitende I, Namujwiga T, Kellett
J. Respiratory rates observed over 15 and 30 s compared with rates
measured over 60 s: practice-based evidence from an observational study
of acutely ill adult medical patients during hospital admission. QJM.
2019;112(7):513-517. https://doi.org/10.1093/qjmed/hcz065
Rolfe S. The importance of respiratory rate monitoring. Br J Nurs.
2019;28(8):504–508. https://doi.org/10.12968/bjon.2019.28.8.504
Semler MW, Stover DG, Copland AP et al. Flash mob research: a single-
day, multicenter, resident-directed study of respiratory rate. Chest.
2013;143(6):1740–1744. https://doi.org/10.1378/chest.12-1837
Smith DJ, Aitken LM. Use of a single parameter track and trigger chart and
the perceived barriers and facilitators to escalation of a deteriorating
ward patient: a mixed methods study. J Clin Nurs. 2016;25(1-2):175–185.
https://doi.org/10.1111/jocn.13104
Smith GB, Redfern OC, Pimentel MAF, et al. The national early warning
score 2 (NEWS2). Clin Med (Northfield Ill). 2019;19(3):260. https://doi.
org/10.7861/clinmedicine.19-3-260
Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of
introducing the Modified Early Warning score on clinical outcomes,
cardio-pulmonary arrests and intensive care utilisation in acute medical
admissions. Anaesthesia. 2003;58(8):797–802. https://doi.org/10.1046/
j.1365-2044.2003.03258.x
Takayama A, Takeshima T, Nakashima Y,Yoshidomi T, Nagamine T, Kotani
K. A comparison of methods to count breathing frequency. Respir Care.
2019;64(5):555–563. https://doi.org/10.4187/respcare.06451
Tirkkonen J,Ylä-Mattila J, Olkkola KT, Huhtala H, Tenhunen J, Hoppu S.
Factors associated with delayed activation of medical emergency team and
excess mortality: an Utstein-style analysis. Resuscitation. 2013;84(2):173–
178. https://doi.org/10.1016/j.resuscitation.2012.09.021

CPD reflective questions

■ How do the practices in your own clinical setting relate to those described in the study?
■ Do caregivers in your clinical setting view respiratory rate (RR) as a leading indicator of patient deterioration?
■ What barriers prevent your clinicians from monitoring RR accurately for all patients?
© 2023 The Authors

British Journal of Nursing, 2023, Vol 32, No 13 627

Downloaded from magonlinelibrary.com by 111.248.131.022 on April 10, 2024.