Understanding the way paediatric healthcare professionals measure respiratory rate is vitally important. It gives us an insight into the different practices used and also the impact this could have on the accuracy and potential variability of measurements obtained.
2.5.1 Participants
The questionnaire captured a range of paediatric healthcare professionals who take children’s respiratory rate. Over half of the respondents were doctors and just over a quarter were nurses. There was also a wide range of experience levels captured. This sample however was not representative of day to day clinical practice where nurses will usually measure RR more often than their doctor colleagues.
2.5.2 Length of measurement
The current WHO standard for a respiratory rate measurement is a count over a full minute (WHO, 2002). However we know that in practice many healthcare professionals may make a count over a shorter period of time (15, 20, or 30 seconds) and this is known to lead to inaccuracies (Berman et al., 1991, Simoes et al., 1991). Only 28% of the paediatric healthcare professionals who answered the questionnaire stated that they measured RR over a full minute. Doctors were less likely to measure over a full minute than their nursing colleagues. The more junior nurses and healthcare workers were the most likely to complete a measurement over one minute.
These differences may be explained by how often each professional is required to carry out a RR measurement as part of their role and at what point during the patient journey this occurs. Nurses will often take a RR multiple times during their shift and may also be the first healthcare professional to measure the RR on the child. As such a nurse may be more thorough in their assessment, spending a longer time taking the measurement. Doctors however may measure a respiratory rate less frequently within their role. They may also see the patient after another healthcare professional has already taken a RR, and rely on this measurement. As such the length of time taken for their own measurement may become shorter.
Consultant paediatricians reported taking the least amount of time to measure the RR. This could be explained by a longer time since they were trained and a lack of awareness of the current standard required for measuring a RR. However it is more likely that they are making a rapid overall assessment of the child and their clinical state, of which RR is only one part of their assessment.
2.5.3 Method of timing
A variety of timing methods were reported with clear distinctions seen between doctors and nurses. The majority of nurses would use a fob/wrist watch or the timer on the axillary thermometer. Doctors would rely on a phone timer or wall clock. Nurses are more likely to wear a
fob watch as part of their standard uniform. However, doctors tend not to wear these and with trusts requiring staff to be ‘bare below the elbows’ for infection control purposes, doctors will therefore rely on alternative methods of timing.
An interesting finding in this section was some doctors describing an ‘internal sense of time’ that they used to measure respiratory rate. This method of timing has not been previously described and is likely to be extremely inaccurate for the majority of RR measurements.
2.5.4 Method of measurement
The WHO standard for RR measurement states that the count should be performed by observing abdominal or chest wall movements (WHO, 2002). Auscultation, palpation of the chest and palpation for breaths are other methods used. Our data showed that the observation of breathing movements was the most common method of measurement across all paediatric healthcare professionals. Observation is the simplest and most straight forward method of RR measurement. It is non-contact and does not risk agitating the child and altering their RR. This is likely to account for the high numbers of healthcare professionals that we see opting to use this method.
However, in neonates and younger children (up to 12 months) there is an increased use of the other methods of measurements by all professionals regardless of experience. This is potentially due to observed movements being less obvious and harder to measure in these children. The professional, by using a different method, may be attempting to negate the difficulty encountered and use other methods that feel more reliable in this age group. It was only when analysing nurses and doctors methods in this cohort that significant differences were seen. After observation nurses would prefer to palpate for breaths and chest movements. However doctors would use the method of auscultation. This may be due to the differences in the training of doctors and nurses and their respective roles. Doctors are more practiced in using auscultation as part of their clinical examination and as such may be more likely to opt for this method. This may however have implications to the accuracy of measurements obtained. In babies auscultation of breath sounds has been shown to yield a higher rate to that obtained by observation (Rusconi et al., 1994).
2.6 Limitations
This questionnaire study had some limitations that must be taken into account when analysing the findings. This was an observational study and was not powered to show any statistical differences. Also although the sample size was large there was not an even distribution of paediatric healthcare professionals, with almost twice the number of doctors to nurses responding. There was also a small number of consultant paediatricians that responded, and caution must be taken in interpreting their responses.
As this data was gathered using a questionnaire, respondents were unable to freely express their opinions and were forced to choose their answers based upon pre-defined options. This may have led to answers being selected even if they did not reflect the respondent’s true practices. Also, even though this was an anonymous questionnaire there was still a potential for respondents to give answers based on what they thought reflected best practice rather than what was their actual practice.