Improving Respiratory Rate Accuracy in the Hospital: A Quality Improvement Initiative
Respiratory rate (RR) is a predictor of adverse outcomes. However, RRs are inaccurately measured in the hospital. We conducted a quality improvement (QI) initiative using plan-do-study-act methodology on one inpatient unit of a safety-net hospital to improve RR accuracy. We added time-keeping devices to vital sign carts and retrained patient-care assistants on a newly modified workflow that included concomitant RR measurement during automated blood pressure measurement. The median RR was 18 (interquartile range [IQR] 18-20) preintervention versus 14 (IQR 15-20) postintervention. RR accuracy, defined as ±2 breaths of gold-standard measurements, increased from 36% preintervention to 58% postintervention (P < .01). The median time for vital signs decreased from 2:36 minutes (IQR, 2:04-3:20) to 1:55 minutes (IQR, 1:40-2:22; P < .01). The intervention was associated with a 7.8% reduced incidence of tachypnea-specific systemic inflammatory response syndrome (SIRS = 2 points with RR > 20; 95% CI, –13.5% to –2.2%). Our interdisciplinary, low-cost, low-tech QI initiative improved the accuracy and efficiency of RR measurement.
© 2019 Society of Hospital Medicine
Time
Before the intervention, the median time to complete vital sign measurements was 2:36 (IQR 2:04-3:20). After the intervention, the time to complete vital signs decreased to 1:55 (IQR, 1:40-2:22; P < .001), which was 41 less seconds on average per vital sign set.
SIRS Incidence
The intervention was associated with a 3.3% reduction (95% CI, –6.4% to –0.005%) in tachypnea-specific SIRS incidence per hospital-day and a 7.8% reduction (95% CI, –13.5% to –2.2%) per hospitalization (Appendix Table 1). We also observed a modest reduction in overall SIRS incidence after the intervention (2.9% less per vital sign check, 4.6% less per hospital-day, and 3.2% less per hospitalization), although these reductions were not statistically significant.
DISCUSSION
Our QI initiative improved the absolute RR accuracy by 22%, saved PCAs 41 seconds on average per vital sign measurement, and decreased the absolute proportion of hospitalizations with tachypnea-specific SIRS by 7.8%. Our intervention is a novel, interdisciplinary, low-cost, low-effort, low-tech approach that addressed known challenges to accurate RR measurement,8,9,11 as well as the key barriers identified in our initial PDSA cycles. Our approach includes adding a time-keeping device to vital sign carts and standardizing a PCA vital sign workflow with increased efficiency. Lastly, this intervention is potentially scalable because stakeholder engagement, education, and retraining of the entire PCA staff for the unit required only 6.75 hours.
While our primary goal was to improve RR accuracy, our QI initiative also improved vital sign efficiency. By extrapolating our findings to an eight-hour PCA shift caring for eight patients who require vital sign checks every four hours, we estimated that our intervention would save approximately 16:24 minutes per PCA shift. This newfound time could be repurposed for other patient-care tasks or could be spent ensuring the accuracy of other vital signs given that accurate monitoring may be neglected because of time constraints.11 Additionally, the improvement in RR accuracy reduced falsely elevated RRs and thus lowered SIRS incidence specifically due to tachypnea. Given that EHR-based sepsis alerts are often based on SIRS criteria, improved RR accuracy may also improve alarm fatigue by reducing the rate of false-positive alerts.14
This initiative is not without limitations. Generalizability to other hospitals and even other units within the same hospital is uncertain. However, because this initiative was conducted within a safety-net hospital, we anticipate at least similar, if not increased, success in better-resourced hospitals. Second, the long-term durability of our intervention is unclear, although EHR RR variability remained steady for two months after our intervention (data not shown).
To ensure long-term sustainability and further improve RR accuracy, future PDSA cycles could include electing a PCA “vital signs champion” to reiterate the importance of RRs in clinical decision-making and ensure adherence to the modified workflow. Nursing champions act as persuasive change agents that disseminate and implement healthcare change,15 which may also be true of PCA champions. Additionally, future PDSA cycles can obviate the need for labor-intensive manual audits by leveraging EHR-based auditing to target education and retraining interventions to PCAs with minimal RR variability to optimize workflow adherence.
In conclusion, through a multipronged QI initiative we improved RR accuracy, increased the efficiency of vital sign measurement, and decreased SIRS incidence specifically due to tachypnea by reducing the number of falsely elevated RRs. This novel, low-cost, low-effort, low-tech approach can readily be implemented and disseminated in hospital inpatient settings.
