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Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults
  1. Jack Badawy1,
  2. Oanh Kieu Nguyen1,
  3. Christopher Clark2,
  4. Ethan A Halm1,
  5. Anil N Makam1
  1. 1 Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
  2. 2 Parkland Health and Hospital System, Dallas, Texas, USA
  1. Correspondence to Dr Anil N Makam, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Anil.Makam{at}


Background Respiratory rate (RR) is an independent predictor of adverse outcomes and an integral component of many risk prediction scores for hospitalised adults. Yet, it is unclear if RR is recorded accurately. We sought to assess the potential accuracy of RR by analysing the distribution and variation as a proxy, since RR should be normally distributed if recorded accurately.

Methods We conducted a descriptive observational study of electronic health record data from consecutive hospitalisations from 2009 to 2010 from six diverse hospitals. We assessed the distribution of the maximum RR on admission, using heart rate (HR) as a comparison since this is objectively measured. We assessed RR patterns among selected subgroups expected to have greater physiological variation using the coefficient of variation (CV=SD/mean).

Results Among 36 966 hospitalisations, recorded RR was not normally distributed (p<0.001), but right skewed (skewness=3.99) with values clustered at 18 and 20 (kurtosis=23.9). In contrast, HR was relatively normally distributed. Patients with a cardiopulmonary diagnosis or hypoxia only had modestly greater variation (CV increase of 2%–6%). Among 1318 patients transferred from the ward to the intensive care unit (n=1318), RR variation the day preceding transfer was similar to that observed on admission (CV 0.24 vs 0.26), even for those transferred with respiratory failure (CV 0.25).

Conclusions The observed patterns suggest that RR is inaccurately recorded, even among those with cardiopulmonary compromise, and represents a ‘spot’ estimate with values of 18 and 20 breaths per minute representing ‘normal.’ While spot estimates may potentially be adequate to indicate clinical stability, inaccurate RR may alternatively lead to misclassification of disease severity, potentially jeopardising patient safety. Thus, we recommend greater training for hospital personnel to accurately record RR.

  • Patient safety
  • Hospital medicine
  • Healthcare quality improvement
  • safety culture
  • Electronic health record

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  • Contributors Conception or design of the work: All authors. Data collection: CC, EAH. Data analysis and interpretation: CC, AM, JB. Drafting the article: JB, AM. Critical revision of the article: all authors. Final approval of the version to be published: all authors.

  • Funding This work was supported by the Agency for Healthcare Research and Quality-funded UT Southwestern Center for Patient-Centered Outcomes Research (R24 HS022418-01); the Commonwealth Foundation (#20100323); the UT Southwestern KL2 Scholars Program supported by the National Institutes of Health (KL2TR001103); the National Center for Advancing Translational Sciences at the National Institute of Health (U54 RFA-TR-12-006); and the National Institute on Aging (K23AG052603). The study sponsors had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The authors have no conflicts of interest to disclose, financial or otherwise.

  • Competing interests None declared.

  • Patient consent The IRBs exempted the consent requirement since it was a retrospective study on electronic health records and did not contain identifiable information.

  • Ethics approval The IRBs of both UT Southwestern and Texas Health Resources.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with ‘BMJ Publishing Group’. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.