As we start to recover from the first wave of COVID-19, anticipate a second wave and prepare for the annual flu season while also looking at how to rebuild routine healthcare, we need to reflect on the lessons learnt. Central to this is that core nursing skills remain essential in treating patients and yet, all too often, we tend to forget these skills.
In 1999–2000, I was part of a research project that aimed to see if cardiac arrests were preventable and avoidable (Hodgetts et al, 2002). This research was born out of the frustration of seeing many post-cardiac arrest review audits, which all too often demonstrated a clear and gradual patient deterioration leading up to a fatal cardiac arrest. Our research identified that upwards of 60% of in-hospital ward-based cardiac arrests were at least potentially avoidable and our findings have been replicated in many other studies. Central to cardiac arrest prevention is early decision-making around ceilings of care and the use of a patient scoring system. To this end, patient scoring systems are now strongly recommended by the international resuscitation community as they are essential pillars of cardiac arrest prevention (Soar et al, 2015).
A key element of patient scoring remains accurate recording of vital signs, as well as interpretation and understanding what the vital signs indicate. For example, has the respiratory rate increased because of pain and not clinical deterioration, or is the urinary output low because the catheter is bypassing? It is important to remember that the ‘number’ generated is not the whole story.
And yet, all too often, recording vital signs is seen as a ‘chore to be completed’ and not as an integral part of patient care. For example, how often have you seen staff pushing an automatic blood pressure (BP) machine between multiple patients, using the same sized BP cuff, placing a BP cuff over clothes and relying on Sp02 to measure both saturations and heart rate, having never actually manually recorded a pulse? How many of your colleagues are aware that the size of the BP cuff, whether the cuff is placed directly onto skin or over clothes, the position of the patient's arm, and whether the patient is sitting or lying down, can all affect the accuracy of the recorded blood pressure (Beevers et al, 2001; Pickering et al, 2005). This is particularly true of BP cuff size (Pickering et al, 2005).
More importantly, when was the last time you observed a colleague actually record a respiratory rate (Kenward et al, 2001)? If a respiratory rate is recorded, how confident are you that the respiratory rate has been accurately measured—or is it just a guess? Amusingly, during our research in 2000, nurses more frequently recorded ‘bowels open’ than they ever recorded respiratory rate. And yet, when a respiratory rate is accurately recorded, it is a very early indicator of patient deterioration. This early detection is regardless of whether the deterioration is due to shock or impending respiratory failure, which is especially useful during a respiratory-related pandemic, such as COVID-19.
So why is respiratory rate so poorly recorded by nurses? Although it could be that all the patients are holding their breathy because everyone is ‘opening their bowels’, I fundamentally believe it is multifactorial. Firstly, there is no machine that goes ‘ping’ to record a respiratory (unless you are monitoring end-tidal C02), there is a lack of understanding as to the importance of respiratory rate, as well as a lack of clinical supervision by qualified nurses of junior staff recording vital signs. So as I reflect on what has been an extremely difficult time for health professionals, it is also time to relearn/revisit core skills that are essential elements of patient safety.