Respiratory rate: the neglected vital sign Cretikos, Michelle A; Bellomo, Rinaldo; Hillman, Ken ...
Medical journal of Australia,
06/2008, Letnik:
188, Številka:
11
Journal Article
Recenzirano
The level of documentation of vital signs in many hospitals is extremely poor, and respiratory rate, in particular, is often not recorded. There is substantial evidence that an abnormal respiratory ...rate is a predictor of potentially serious clinical events. Nurses and doctors need to be more aware of the importance of an abnormal respiratory rate as a marker of serious illness. Hospital systems that encourage appropriate responses to an elevated respiratory rate and other abnormal vital signs can be rapidly implemented. Such systems help to raise and sustain awareness of the importance of vital signs.
The first wave of pandemic influenza A(H1N1)2009 (pH1N1) reached New South Wales (NSW), Australia in May 2009, and led to high rates of influenza-related hospital admission of infants and young to ...middle-aged adults, but no increase in influenza-related or all-cause mortality.
To assess the population rate of pH1N1 infection in NSW residents, pH1N1-specific haemagglutination inhibition (HI) antibody prevalence was measured in specimens collected opportunistically before (2007-2008; 474 specimens) and after (August-September 2009; 1247 specimens) the 2009 winter, and before the introduction of the pH1N1 monovalent vaccine. Age- and geographically-weighted population changes in seroprevalence were calculated. HI antibodies against four recent seasonal influenza A viruses were measured to assess cross-reactions. Pre- and post-pandemic pH1N1 seroprevalences were 12.8%, and 28.4%, respectively, with an estimated overall infection rate of 15.6%. pH1N1 antibody prevalence increased significantly - 20.6% overall - in people born since 1944 (26.9% in those born between 1975 and 1997) but not in those born in or before 1944. People born before 1925 had a significantly higher pH1N1 seroprevalence than any other age-group, and against any seasonal influenza A virus. Sydney residents had a significantly greater change in prevalence of antibodies against pH1N1 than other NSW residents (19.3% vs 9.6%).
Based on increases in the pH1N1 antibody prevalence before and after the first pandemic wave, 16% of NSW residents were infected by pH1N1 in 2009; the highest infection rates (27%) were among adolescents and young adults. Past exposure to the antigenically similar influenza A/H1N1(1918) is the likely basis for a very high prevalence (49%) of prepandemic cross-reacting pH1N1 antibody and sparing from pH1N1 infection among people over 85 years. Unless pre-season vaccine uptake is high, there are likely to be at least moderate rates including some life-threatening cases of pH1N1 infection among young people during subsequent winters.
More than a quarter of Australian children are above a healthy weight (overweight or obese) and risk significant immediate and future health harms. While childhood overweight and obesity is a complex ...problem requiring multifaceted solutions, identifying children at risk and preventing these health harms should be a part of good clinical care in all health services. Effective secondary and tertiary prevention is feasible. This paper argues that health services can use serial growth assessment to routinely identify and manage children who are above a healthy weight, just as we might routinely identify and manage hypertension in older patients. We highlight the evidence for the acceptability and effectiveness of family-focused clinical intervention for weight management in children. We also outline system-level changes that health services should consider to enable and support routine clinical identification and management of affected children and their families.
Summary Objective To evaluate the ability of pre-defined clinical criteria to identify patients who subsequently suffer cardiac arrest, unplanned intensive care unit admission or unexpected death; to ...determine the ability of modified criteria to identify these patients. Design Nested, matched case–control study. Setting Seven Australian public hospitals. Patients and participants Four hundred and fifty cases and 520 controls matched for age, sex, hospital, and hospital ward. Interventions None. Measurements and results Highest and lowest respiratory and heart rates, lowest systolic blood pressure, presence of threatened airway, seizures or decrease in Glasgow Coma Scale score of greater than two points and incidence of the three adverse events were measured. Combining a heart rate greater than 140, respiratory rate greater than 36, a systolic blood pressure less than 90 mmHg and a greater than two point reduction in the Glasgow Coma Scale identified adverse events with a sensitivity of 49.1% (44.4–53.8%), specificity of 93.7% (91.2–95.6%), and positive predictive value of 9.8% (8.7–11.1%). Adding threatened airway, seizures, low respiratory rate and low heart rate did not substantially improve sensitivity (50.4%; 45.7–55.2%). After modifying the cut-off values for respiratory rate, heart rate and systolic blood pressure, the best achievable positive predictive value remained below 16%. Conclusions In combination, the respiratory rate, heart rate, systolic blood pressure, and level of consciousness identify patients at risk of cardiac arrest, unplanned intensive care admission or unexpected death with high specificity; however the sensitivity and positive predictive value are relatively low, even after modification of the activation criteria cut-off values.
In temperate countries, death rates increase in winter, but influenza epidemics often cause greater increases. The death rate time series that occurs without epidemic influenza can be called a ...seasonal baseline. Differentiating observed death rates from the seasonally oscillating baseline provides estimated influenza-associated death rates. During 2003-2009 in New South Wales, Australia, we used a Serfling approach with robust regression to estimate age-specific weekly baseline all-cause death rates. Total differences between weekly observed and baseline rates during May-September provided annual estimates of influenza-associated death rates. In 2009, which included our first wave of pandemic (H1N1) 2009, the all-age death rate was 6.0 (95% confidence interval 3.1-8.9) per 100,000 persons lower than baseline. In persons ?80 years of age, it was 131.6 (95% confidence interval 126.2-137.1) per 100,000 lower. This estimate is consistent with a pandemic virus causing mild illness in most persons infected and sparing older persons.
OBJECTIVESThe NSW Health COVID-19 Research Program was established in April 2020 to contribute to minimising the health, social and economic impacts of the coronavirus disease 2019 (COVID-19) ...pandemic in New South Wales (NSW). This paper describes the establishment and implemention of one element of the Program, the Emergency Response Priority Research (Emergency Response) workstream, which is focused on the rapid creation of evidence to support urgent operational work for the public health management of COVID-19 in NSW. METHODSNarrative description. RESULTSAs at June 2021, nine Emergency Response projects had been funded. Mechanisms used to expedite projects included: embedding academic researchers in NSW Health to work directly with routinely collected NSW Health data; adapting existing research projects to include a COVID-19 component; leveraging established research partnerships to conduct rapid pilots; and directly commissioning urgent projects with experienced and trusted local researchers. LESSONS LEARNTEvidence from Emergency Response projects has contributed directly to informing the NSW public health response. For example, findings from a study of COVID-19 transmission in schools and childcare settings in the early stages of the pandemic informed decisions around the resumption of on-campus education in 2020 and helped shape policy around higher risk activities to help reduce transmission in education settings. Similarly, findings from a project to validate methods for identifying SARS-CoV-2 virus fragments in wastewater were subsequently incorporated into the NSW Sewage Surveillance Program, which continues to provide NSW Health with information to support targeted messaging and testing. The approach to establishing and implementing the Emergency Response workstream highlights the importance of continuing to ensure a well-trained public health research community and actively supporting a collaborative research sector.
Abstract Objective To study the rate of documentation of vital signs in the period before the occurrence of an adverse event or emergency team call and to measure the effect of introducing the ...medical emergency team (MET) system on the rate of such documentation. Methods During a cluster, randomised trial of the MET in 23 Australian hospitals, we collected the data on lowest systolic blood pressure, highest and lowest respiratory rate and heart rate from 15 min to 24 h before an adverse event (cardiac arrest, death or unexpected intensive care unit admission) or emergency team call. We derived the document of these vital signs (yes/no) from the numerical values recorded. We used analytically weighted and random-effect regression models to examine the association between non-documented (missing) vital signs, hospital characteristics and MET allocation, and to examine their trend over time. Results We found marked variability in documentation, with a high proportion of missing vital signs in some hospitals. Close to 77% of patients suffering adverse events had at least one vital sign missing immediately before the event. Allocation to a MET system was associated with significantly increased documentation of respiratory rate and blood pressure before emergency team review ( P < 0.01) as well as an improvement in documentation over time ( P < 0.01). At all stages and for both MET and control hospitals, the respiratory rate was the least commonly documented vital sign ( P < 0.01). Conclusions The documentation of vital signs in the period before adverse events was commonly incomplete with a particular deficiency in the documentation of the respiratory rate. Introduction of a MET system was associated with improvement in the rate of documentation of vital signs.
There have been few studies describing how production EMR systems can be systematically queried to identify clinically-defined populations and limited studies utilising free-text in this process. The ...aim of this study is to provide a generalisable methodology for constructing clinically-defined EMR-derived patient cohorts using structured and unstructured data in EMRs.
Patients with possible acute coronary syndrome (ACS) were used as an exemplar. Cardiologists defined clinical criteria for patients presenting with possible ACS. These were mapped to data tables within the production EMR system creating seven inclusion criteria comprised of structured data fields (orders and investigations, procedures, scanned electrocardiogram (ECG) images, and diagnostic codes) and unstructured clinical documentation. Data were extracted from two local health districts (LHD) in Sydney, Australia. Outcome measures included examination of the relative contribution of individual inclusion criteria to the identification of eligible encounters, comparisons between inclusion criterion and evaluation of consistency of data extracts across years and LHDs.
Among 802,742 encounters in a 5 year dataset (1/1/13-30/12/17), the presence of an ECG image (54.8% of encounters) and symptoms and keywords in clinical documentation (41.4-64.0%) were used most often to identify presentations of possible ACS. Orders and investigations (27.3%) and procedures (1.4%), were less often present for identified presentations. Relevant ICD-10/SNOMED CT codes were present for 3.7% of identified encounters. Similar trends were seen when the two LHDs were examined separately, and across years.
Clinically-defined EMR-derived cohorts combining structured and unstructured data during cohort identification is a necessary prerequisite for critical validation work required for development of real-time clinical decision support and learning health systems.
Timely restoration of bloodflow acute ST-segment elevation myocardial infarction (STEMI) reduces myocardial damage and improves prognosis. The objective of this study was describe the association of ...demographic factors with hospitalisation rates for STEMI and time to angiography, Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in New South Wales (NSW) and the Australian Capital Territory (ACT), Australia.
This was an observational cohort study using linked population health data. We used linked records of NSW and the ACT hospitalisations and the Australian Government Medicare Benefits Schedule (MBS) for persons aged 35 and over hospitalised with STEMI in the period 1 July 2010 to 30 June 2014. Survival analysis was used to determine the time between STEMI admission and angiography, PCI and CABG, with a competing risk of death without cardiac procedure.
Of 13,117 STEMI hospitalisations, 71% were among males; 55% were 65-plus years; 64% lived in major cities, and 2.6% were Aboriginal people. STEMI hospitalisation occurred at a younger age in males than females. Angiography and PCI rates decreased with age: angiography 69% vs 42% and PCI 60% vs 34% on day 0 for ages 35-44 and 75-plus respectively. Lower angiography and PCI rates and higher CABG rates were observed outside major cities. Aboriginal people with STEMI were younger and more likely to live outside a major city. Angiography, PCI and CABG rates were similar for Aboriginal and non-Aboriginal people of the same age and remoteness area.
There is a need to improve access to definitive revascularisation for STEMI among appropriately selected older patients and in regional areas. Aboriginal people with STEMI, as a population, are disproportionately affected by access to definitive revascularisation outside major cities. Improving access to timely definitive revascularisation in regional areas may assist in closing the gap in cardiovascular outcomes between Aboriginal and non-Aboriginal people.
To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation.
...Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003--July 2005.
Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors.
During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends.
Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.
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