Bad data: When everyone breathes at the same rate

It was my second day of residency, and something was afoot. As I made my way around my first rotation on the cardiac floor, my medical senses were tingling. There was something strange happening to all of my patients, I saw. As I peaked over my cohort’s shoulders, I secretly saw that it was happening to their patients too, though they hadn’t seemed to notice.

Only I did, and I was going to report it to my senior. Together we were going to report it to the New England Journal of Medicine, and I was going to win the Nobel Prize of awesome doctors. Yes, I alone noticed that all of the patients on the floor were somehow inexplicably breathing at the exact same respiratory rate. Not only this, but they were breathing fast, at a rate of 20, clearly something must be causing all of them to do this. Surely this could not have been due to documentation error, since all the of the other vital signs seemed to vary, it was only the respiratory rates which seemed to stay the same among all the patients.

That day was more than 10 years distant, I still don’t have my Nobel Prize, and the NEJM isn’t returning my calls. The answer to the question that I posed back then about a phenomenon I now see daily is only too easy to find. It sits in every hospital ward, at the end of the hallway. There a bank of mobile machines that is wheeled around the ward to check vital signs sits recharging in wall outlets. As nurses and assistants scramble to administer medications, change bedsheets, turn patients, answer call lights, help patients around the halls, answer the phones, answer family questions, speak with clinicians, and pass food trays, they wheel these devices to their patients’ bedside.

They quickly first attach a blood pressure cuff and press the cycle button. As the cuff inflates, they attach a finger sat monitor from the same machine which takes a few seconds to get a reading. As this is taking a reading, they ask the patient to open their mouth and insert a temperature probe to get a temperature. Around this time, the BP cuff says “error,” so they cycle it once more. While this cycles, they now have a reading for temperature, and the finger monitor gives them readings for oxygen saturation and heart rate.

They have a few paper towels left over from feeding the patient in the next bed, so they start jotting down numbers in it, and just as they finish this, they get a reading from the BP cuff, which they write down as well. They would like to put this in the computer right away, but in the hallway call light buzzers are sounding, somebody wants to get up. Another person wants their pain medications, the radiology suite wants the patient in the next bed sent for their ultrasound immediately. But wait, aren’t they supposed to be fasting for that test? And there’s 4 more patients who need to have their vital signs checked.

So several moments later, as the nurse finally sits down to enter all the vital signs into the chart, values will be entered for heart rate, blood pressure, temperature, oxygen saturation. But since no respiratory rate was checked, the default number of 18 or 20 is often entered. Why is the respiratory rate not checked?

Because the vital signs machine does not check respiratory rate.

The measurement of the respiratory rate, it turns out, is still an old fashioned vital sign. It requires a person to stay at the bedside for at least 30 seconds and manually count the patient’s respirations. Put simply, it is an analog measurement in a digital, multi-tasking age.

In a recent issue of Chest, this phenomenon was highlighted in a unique study. While this is not the first time this issue has been brought to light, what was unique was the manner in which the authors did so. They took a uniquely modern phenomenon, the flash mob, and used it to highlight the degree of the problem. A flash mob, as Wikipedia describes it, is “a group of people who assemble suddenly in a public place, perform an unusual and seemingly pointless act for a brief time, then quickly disperse, often for the purposes of entertainment, satire, and artistic expression.”

Add scientific research to that list of purposes.

The flash mob, made up of medicine residents, noted what had been recorded as the patients vital signs, then checked vital signs themselves, including the respiratory rate. They found little variation between the documented vital signs and their own measurements, other than of course, respiratory rate, which was documented by nurses as 18 or 20 most of the time.

This again highlights a common problem: RN’s and LPN’s do not have have the technology they need to make the measurements they need, and the result is bad data. How is it that such a thing could occur in this digital age? Surely it begs the question WWETD (What would Eric Topol Do?)

In the coming cataclysm of meaningful use, pay for performance, and data mining, data points like these are going to be used to drive interventions and show outcomes. It is going to be incredibly important that we get things like input of basic patient data right. And it shouldn’t take a flash mob of people to get it.

On another note, I admire the authors of this study for showing us a new way to conduct research. The use of the flash mob approach was genius for several reasons. It involved a residency program and got young doctors excited about research, hospital processes, and quality improvement. It allowed the data collection to be completed in a matter of minutes, therefore the subjects did not have time to alter behavior. And perhaps most importantly, it led to the term “flash mob” being published in the title of a major medical journal.

And so it is for all these reasons that I would like personally extend my gratitude to the authors and hereby nominate them for the Nobel Prize of awesome doctors.

Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.  He can be reached on Twitter @Caduceusblogger.

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  • azmd

    Uniform respiratory rates of 20 across entire units were being recorded even before we had automated pulse/blood pressure machines. I personally always thought we should just educate the techs on what a normal respiratory rate was, and call it a day.

    Fun idea about the flash mob, though.

  • precordialthump

    Synypnea was described in a classic Annals of EM article in 2005:

    “Synypnea is seen across the country and is defined as when emergency department waiting room patients have the same respiratory rate. We think it is pathophysiologically linked to menstrual synchrony. There is little scientific exploration on this topic, however, which represents fertile grounds for original research.”

    Goyal M, Hollander JE, Gaieski DF. Images in emergency medicine. Synypnea. Ann Emerg Med. 2005 Nov;46(5):469. Epub 2005 Jul 22. PubMed PMID: 16271679.

    • Deep Ramachandran

      LOL! Classic!

  • Barefootmeds

    Maybe I am revealing my ignorance, but I always wonder how valuable resp count truly is in ALL patients… I think it is obviously important the first time you examine a patient, and if they have a pneumonia/severe PTB/ heart failure/ etc, it should be monitored when all vitals are monitored. (So, I guess, in your cardiac ward.)
    But need it be taken every single time for every patient, when clearly it’s going awry?
    Sometimes I wonder if we don’t just request a resp count to ensure the patient is alive. One of our doctors once had a patient who died overnight, yet was charted as stable vitals all through the night.

  • meyati

    I was just hospitalized. They had the newest nifty machines next to every bed. They take BP, the finger thing, and temp for sure and send the results god knows where. OK-but the machine can’t register the temp that’s below 98 or around there. They sent in nurse after nurse-I call them all nurses-to take an oral temp. They didn’t know how. I was wondering if my backward body had dropped to 94, like it did when I had a thyroid storm. I finally was told that my temp was too low to measure-and they weren’t getting it orally. I had the nurse untie one of my hands, and I placed the thermometer under my tongue next to the tongue stem. She got a temp of 97.4. Anyway, I taught them how to take a temp, and I’m facing a new problem. Nobody knows what my temp is and the system doesn’t care-by the way 95% of the time my temp is 96.00-and if it gets up to 97 something-it’s like a person having a fever that’s almost a 100.
    I said 95% of the time-well the other 5 percent can be from 95.8-96.6, unless I have a fever. I hope that somebody gets a Nobel Prize for getting machines that actually work. In the post-hospital stay survey- that was the thing that I ranted about. Oh, I’m not a mental patient-hands tied-I had an IV in one wrist, and a draining infection in the other arm–medical people were ignoring this because my temp wasn’t 98-then pus started coming out-I was also given the wrong antibiotics based on my temp. Oh for the 1950s -1980s. They at least knew and cared about my temp even if it was an argument. .

  • Chinmay Singh

    West Wireless (Eric Topol’s) organization published a report earlier this year on med device to EHR connectivity. The data from such devices should directly go to EHR using a Wi-Fi connection.

  • Dorothygreen

    Why don’t you talk about this to a pulmonologist or some respiratory therapists? Do they take the respiratory rate if giving treatments. This would make sense, And even then it may not be a big deal. There are also various respiratory patterns like cheyne-stokes that are kind of interesting to watch adn may have some dx value but ..

    The patient where the vitals were reported when the patient was dead did not just involve a respiratory rate. It meant no one even looked at the patient, touched the patient. That is frightening.

    I checked my mother’s vital chart when she was dying and found the same thiing, In her case it fluctuated because she was bleeding and was beign given MS.but again so what.

    Enough other vitals go hand in hand with a respiratory rate that indeed, it might be better record the degee of warmth in a patient’s hand. At least, there would be a hands on.

  • Rabid Response

    Oh this used to drive me crazy as a rapid response nurse. FYI in the ICU the respiratory rate is electronically monitored through one of the telemetry chest leads, but its accuracy varies depending on body habitus, the patient’s position in bed, and how much he or she is moving around. In the ICU, the charted respiratory rate varied by patient, but as soon as the patient was moved out to the med/surg floors the rr was always 18 or 20. This upset me because often rr is the first vital sign to change when a patient is going septic. I had to round on patients just transferred from ED and ICU. I could look at the electronic chart for a patient, and everything would look great, but then walk into the room and realize that they looked on the verge of crashing. I would count a rr of 35, not 18. All the other signs would be as recorded in the chart. Likewise, when I found patients unresponsive d/t narcotics or CO2 retention (often both), the rr by my count was less than 6 but would have been recorded in the chart an hour earlier as 20. I reported this to management so many times, but the practice is so widespread that they would have had to fire every nurse and nurse’s aid in the hospital for false charting. At least I see now that it is not unique to my hospital. I do wonder how we ALL settled on a rate of 18 or 20 since almost nobody breathes that fast. Did the practice spread via travel nurses? It would make an interesting epidemiology study!

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