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Role of Nurses in Preventing Adverse Events in Respiratory Dysfunction-JAN2005
Role of Nurses in Preventing Adverse Events in Respiratory Dysfunction-JAN2005
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 625
J. Considine
Rubins and Moskowitz (1988) 295 ICU patients, 37 with AEs 25% (73/295) patients admitted to ICU and 20% (6/30)
readmitted to ICU had respiratory insufficiency
Respiratory insufficiency was the most common reason
for ICU admission
53% (8/15) of patients readmitted to ICU required ventilation
Schein et al. (1990) 64 cardiac arrests 53% (34/64) patients had documented deterioration of
respiratory function in the 8 hours preceding arrest
20% (13/64) patients had an isolated deterioration in
respiratory function in the 8 hours preceding arrest
Ridley and Purdie (1992) 763 patients discharged 34% (256/763) patients were admitted to ICU with respiratory failure
from ICU Respiratory failure was the most common reason for ICU admission
Lee et al. (1995) 522 medical emergency team 36% (n ¼ 92/253) of calls in response to specific condition
(MET) calls criteria were for compromise to airway and breathing
Of these, 44% (40/92) were for acute respiratory failure
Hourihan et al. (1995) 265 MET calls requiring 39% (103/265) of interventions were respiratory interventions
intervention Most common respiratory intervention was administration of
O2 > 10 L/minute via mask (34%, 35/103)
Crispin and Daffurn (1998) 168 MET calls 31% (25/79) of patients with physiological abnormality in
the 24 hours preceding a MET call had respiratory dysfunction
35% of patients who required a MET call for airway or breathing
problems died
22% MET calls were for airway/breathing problems (37/168)
Airway/breathing problems were second only to cardiac arrest
(25%, 42/168) as the most common reason for MET calls
McGloin et al. (1999) 89 unexpected ICU 48% (47/89) of patients unexpectedly admitted to ICU were
admissions admitted for respiratory dysfunction
83% (10/12) of patients with unrecognised physiological
abnormalities prior to ICU admission had respiratory abnormalities
100% (19/19) of patients who had inappropriate treatment of
physiological abnormality prior to ICU admission had respiratory
abnormalities
Buist and Moore (2000) 2202 AEs 57% (915/2202) of AEs related to physiological abnormality
involved respiratory dysfunction
AE, adverse event; ICU, intensive care unit; MET, medical emergency team.
knowledge about advanced life support. The aim of the MET criteria relating to specific conditions were met (Lee et al.
is to improve patient outcomes through risk reduction, 1995, Crispin & Daffurn 1998).
primarily by promoting early recognition of physiological Many researchers regard unplanned admission or read-
abnormality and providing rapid initiation of emergency mission to ICU as an adverse event in its own right (Rubins &
treatment in patients with physiological deterioration (Buist Moskowitz 1988, McQuillan et al. 1998, Buist et al. 1999,
et al. 2002). The MET can be activated by any member of the McGloin et al. 1999). This implies that the need for ICU care
nursing or medical staff in response to specific criteria. These is a direct reflection of severe illness and a high risk of
usually consist of defined physiological abnormalities, specific mortality. In several studies, respiratory dysfunction has been
conditions and/or heightened levels of concern about the shown to be the most common reason for ICU admission
clinical status of a patient (Daffurn et al. 1994, Lee et al. (Rubins & Moskowitz 1988, Ridley & Purdie 1992)
1995, Crispin & Daffurn 1998, Buist & Moore 2000, Buist accounting for up to half (48%) of unexpected admissions
et al. 2002). Of those patients who were shown to have to ICU (McGloin et al. 1999). One-fifth (20%) of patients
physiological abnormality prior to the MET call, one-third requiring unexpected readmission to ICU were readmitted
(31%) to one half (57%) had respiratory dysfunction because of respiratory dysfunction and, of these, 53%
(Crispin & Daffurn 1998, Buist & Moore 2000). Compro- required mechanical ventilation (Rubins & Moskowitz
mise to airway and/or breathing was cited as the alerting 1988). The unexpected nature of ICU readmission coupled
factor in 22–36% of MET activations that occurred when with a need for mechanical ventilation indicates a
626 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
Integrative literature reviews and meta-analyses Preventing adverse events related to respiratory dysfunction
life-threatening degree of respiratory dysfunction. This raises been associated with mortality rates as high as 34% (Ridley
questions about the timing of identification of respiratory & Purdie 1992) and respiratory failure is cited to be the cause
dysfunction and the appropriateness of early interventions. of death in 19% of patients who die following ICU discharge
Few studies have examined the timing and appropriateness (Ridley & Purdie 1992). Pneumonia has been demonstrated
of interventions in relation to respiratory dysfunction and by numerous studies to have a strong association with
adverse events. McGloin et al. (1999) examined recognition adverse events, including cardiac arrest and death. Bedell
of physiological abnormalities and appropriateness of inter- et al. (1983) found that pneumonia was an independent
ventions prior to ICU readmission and found that respiratory predictor of in-hospital mortality and that all patients who
dysfunction was present in 83% of patients who had had pneumonia prior to cardiac arrest died. It was the most
unrecognised physiological abnormalities and 100% of common clinical diagnosis in patients who suffered cardiac
patients who had inappropriate treatment of physiological arrest (Schein et al. 1990) and the second most common
abnormality. Analysis of MET interventions by Hourihan cause of death in patients who died unexpectedly (McGloin
et al. (1995) found that, of the MET calls that required et al. 1999). Management of oxygenation has also been
intervention, over one-third (39%) required respiratory implicated as a factor in pneumonia-related mortality, with
interventions. These included the administration of high flow inadequate airway or oxygen management cited as factors in
supplemental oxygen (>10 L/minute via mask), intermittent 22% of preventable deaths (Dubois & Brook 1988). The
positive pressure ventilation, intubation and continuous studies that have examined the effect of respiratory dysfunc-
positive airway pressure. It is notable, however, that the tion prior to adverse events on subsequent mortality are
administration of high flow oxygen by mask was the most summarized in Table 2.
common respiratory intervention initiated by the MET. An These findings raise two fundamental questions about
important question related to these findings is: If nurses were nurses’ perception of patient risk of an adverse event. Patients
concerned enough about a patient to activate the MET, why with respiratory illnesses such as pneumonia, exacerbation of
did they not initiate interventions such as oxygen adminis- chronic obstructive airways disease and asthma are familiar to
tration? The finding that nurses do not always initiate oxygen most nurses working in acute care medical settings. Do nurses
administration suggests that they have difficulty in identifying working in areas where these illnesses are common perceive
respiratory dysfunction and/or do not manage respiratory these patients as being at high risk of adverse event or consider
dysfunction appropriately. that they will be at high risk of death should an adverse event
occur? If these risks were more apparent, would the result be
Effect of respiratory dysfunction prior to adverse events more frequent physiological assessment and more aggressive
on mortality intervention for respiratory abnormalities?
The presence of respiratory dysfunction before an adverse
event has been shown to have a significant impact on post-
Clinical indicators of respiratory dysfunction and adverse
event mortality, increasing the likelihood of cardiac arrest by
events
18Æ5% (P < 0Æ001) (Sax & Charlson 1987). This is an
important association, as patient outcomes once cardiac ar- Nurses’ ability to recognize and treat respiratory dysfunction
rest has occurred are often negative. Despite advances in as a key factor in adverse event prevention is based on the
resuscitation over recent decades, survival rates following premises that: (1) respiratory dysfunction is a known
in-hospital cardiac arrest have not improved. Only 43% of precursor, and (2) its presence prior to an adverse event has
patients survive initial resuscitation and approximately 13% a negative effect on survival. This raises questions about the
of patients survive and are discharged from hospital relationship between observable clinical indicators of respir-
(Camarata et al. 1971, Bedell et al. 1983, Suljaga Pechtel atory dysfunction and adverse events. The indicators that
et al. 1984, George et al. 1989, Bedell et al. 1991, Franklin & have been examined in the adverse event literature are
Matthew 1994, Buist et al. 1999). In another study, 35% of alteration in respiratory rate, and presence of dyspnoea,
patients who required MET activation for an airway or hypoxaemia and acidosis. The following section examines the
breathing problem died (Crispin & Daffurn 1998). When relationship of these indicators of respiratory dysfunction to
patients with respiratory dysfunction have an in-hospital adverse events and summarises key research findings.
adverse event they are at significant risk of death.
Patients who require ICU-level care for respiratory Alteration in respiratory rate
dysfunction have also been shown to be at significant risk Alteration in respiratory rate (bradypnoea or tachypnoea)
of death. Admission to ICU with respiratory pathology has has been shown to be an influential factor in adverse events
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 627
J. Considine
Table 2 Summary of research relating to the effect on subsequent mortality of respiratory dysfunction prior to an adverse event
Bedell et al. (1983) 294 patients with cardiac arrest Pneumonia was an independently significant predictor of mortality
after cardiac arrest (P < 0Æ05)
20% (58/294) of patients had pneumonia prior to cardiac arrest
and all of these patients died (n ¼ 58)
Dubois and Brook (1988) 182 patients who died from Pneumonia had the highest mortality rate at 53% (70/132),
pneumonia, AMI or stroke followed by AMI (44%, 62/140) and stroke (48%, 50/105)
22% of preventable deaths from pneumonia involved
inadequate airway or oxygen management
Ridley and Purdie (1992) 763 patients discharged from ICU 34% of patients admitted to ICU with respiratory failure died
Of the patients who died following ICU discharge, 19% (30/158)
died from respiratory failure.
Respiratory failure was second only to malignancy as the most
common ICU admission diagnosis in patients who died
following ICU discharge
Schein et al. (1990) 64 cardiac arrests 20% (13/64) of patients who had cardiac arrest had pneumonia
Pneumonia was the most common clinical diagnosis
McGloin et al. (1999) 16 unexpected deaths 19% (3/16) of patients died from pneumonia
Pneumonia was second to cardiac events as the most common
cause of death
Crispin and Daffurn (1998) 168 MET calls Patients who required a MET call for airway or breathing
problems had a 35% mortality rate
AMI, acute myocardial infarction; MET, emergency medical team; ICU, intensive care unit.
Table 3 Summary of research relating to alteration in respiratory rate and adverse events
Rubins and Moskowitz (1988) 295 ICU patients discharged Patients who suffered an AE following ICU discharge had significantly
from ICU higher respiratory rates (RR) on ICU discharge than those who did
not suffer an AE (mean RR: 30 vs. 26 breaths/minute) (P ¼ 0Æ002)
Lee et al. (1995) 347 MET calls* 27% (94/347) of patients had altered respiratory rates
Of these, 78% (73/94) of patients were tachypnoeic and 22% (21/94)
of patients were bradypnoeic
Hourihan et al. (1995) 213 MET calls* 18% (39/213) of patients had altered respiratory rates
Of these, 85% (33/39) of patients were tachypnoeic and 15% (6/94) of
patients were bradypnoeic
Crispin and Daffurn (1998) 126 MET calls* 29% MET calls were for airway/breathing problems (37/126)
McGloin et al. (1999) 89 unexpected ICU admissions 60% (6/10) of patients who had unrecognised physiological
abnormalities prior to ICU admission had tachypnoea
32% (6/19) of patients who had inappropriate treatment of physiological
abnormality prior to ICU admission had tachypnoea
Buist and Moore (2000) 915 AEs related to respiratory 11% (99/915) had altered respiratory rates
dysfunction Of these, 89% (88/99) of patients were tachypnoeic and 11% (11/99) of
patients were bradypnoeic
AE, adverse event; ICU, intensive care unit; MET, medical emergency team.
*For physiological abnormality.
(Table 3). Studies of patients who required activation of who suffered an adverse event following ICU discharge had
the MET have shown that up to 29% of patients had al- a significantly higher mean respiratory rate at discharge
tered respiratory rates (Hourihan et al. 1995, Lee et al. from ICU than patients whose post-ICU course was un-
1995, Buist & Moore 2000). Of these patients, the over- affected by an adverse event (30 breaths per minute vs. 26
whelming majority (78–89%) were tachypnoeic (Hourihan breaths per minute, P ¼ 0Æ002) (Rubins & Moskowitz
et al. 1995, Lee et al. 1995, Buist & Moore 2000). Patients 1988).
628 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
Integrative literature reviews and meta-analyses Preventing adverse events related to respiratory dysfunction
These results are important as, although it is non-specific, cardiac arrest (Camarata et al. 1971, Bedell et al. 1983,
tachypnoea is well-recognized as a sign of acute illness Suljaga Pechtel et al. 1984, George et al. 1989, Bedell et al.
(Rubins & Moskowitz 1988) and hypoxia (Ryerson & Block 1991, Franklin & Matthew 1994, Buist et al. 1999). Almost
1983, Crocco et al. 1987, Wesmiller & Hoffman 1989, one-third (29%) of patients admitted to hospital with acute
Crocco & Francis 1991, Kester & Stoller 1992, Gaull 1993, dyspnoea related to a chronic respiratory illness suffered an
Palmer 1993, Grap et al. 1994). Responsibility for ongoing adverse event, and adverse events occurred in 60% of
assessment of respiratory rate lies with nurses. They measure patients admitted with acute dyspnoea who suffered a
and document respiratory rate when they perform a physio- deterioration in their condition (Sax & Charlson 1987). Of
logical assessment. As most nursing observation charts patients who had a complaint documented in the 24 hours
require the documentation of respiratory rate, these data preceding an MET call, 37% complained of shortness of
are usually readily available at the bedside. However, breath (Crispin & Daffurn 1998), and dyspnoea was the
respiratory rate data are only valuable as an alerting factor alerting factor in 41% of MET calls made by nursing staff
for risk of adverse event if assessment is performed at because of non-specific concerns about a patient (Hourihan
appropriate intervals and the data are studied to identify et al. 1995).
trends such as increasing tachypnoea. In addition, they need The fact that dyspnoea was shown to be an influential
to be studied alongside other physiological data. These factor in nurses’ activation of the MET suggests that they
processes are dependent on the clinical judgements of nurses. recognize it as a negative sign and/or symptom. The import-
ance of dyspnoea in physiological assessment by nurses,
Dyspnoea however, remains unclear. Data suggesting the presence of
The presence of dyspnoea or shortness of breath is also a dyspnoea may not be as readily available as other patient
clinical indicator of respiratory dysfunction and has also been data, such as respiratory rate. The presence of dyspnoea may
identified as a significant preceding factor for adverse events be identified by objective data, such as use of accessory
(see Table 4). Patients admitted to hospital with acute dys- muscles and respiratory effort, or by subjective data, such as
pnoea are more likely to have an adverse event than patients patient complaints of shortness of breath. Documentation of
admitted for other reasons. In a study by Sax and Charlson dyspnoea is somewhat subjective, as nurses have to describe
(1987), the rate of cardiac arrest in patients admitted with degree of accessory muscle use or patient complaints of
acute dyspnoea was 22%, which is dramatically higher than shortness of breath. Any description of level or degree
the 3Æ5% cardiac arrest rate in patients admitted for other involves a judgement about physiological abnormality, and is
reasons (P < 0Æ001). As discussed previously, this is sig- open to interpretation by other staff when they read the
nificant, given the inherently high mortality associated with assessment findings. Anecdotal evidence also suggests that
Sax and Charlson (1987) 554 patients Patients admitted with acute dyspnoea were more likely to have a cardiac
arrest than those admitted for other reasons [22% (5/22) vs. 3Æ5% (15/444),
P < 0Æ001]
29% (4/14) of patients admitted with acute dyspnoea related to chronic
pulmonary disease had an AE
60% (3/5) of patients admitted with acute dyspnoea and who suffered a
deterioration in condition had a cardiac arrest
Lee et al. (1995) 522 MET calls 36% (n ¼ 92/253) of calls in response to specific condition criteria were for
compromise to airway and breathing.
Of these, 44% (40/92) were for acute respiratory failure
Of the patients who had a physiological abnormality (but did not have a
cardiac arrest), 20% (73/347) were tachypnoeic and 6% (21/374) were
bradypnoeic
Hourihan et al. (1995) 294 MET calls Of MET calls made because the nursing staff were ‘worried’, 41% had
dyspnoea as the alerting factor (9/22)
Crispin and Daffurn (1998) 168 MET calls 37% (16/43) of patients who had a documented complaint in the 24 hours
preceding a MET call complained of dyspnoea
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 629
J. Considine
most nursing observation charts do not allow for the (63Æ9%) of patients in whom acidosis was corrected were
documentation of dyspnoea, and that if this is documented successfully resuscitated, compared with only 20Æ9% of
it will be in the patient notes. This information may not, patients whose pH remained below 7Æ2 (P ¼ 0Æ05).
therefore, be available at the bedside. This also makes the When examining the relationship between hypoxaemia and
identification of a trend towards increasing dyspnoea diffi- other adverse events, hypoxaemia has been shown to be the
cult. As dyspnoea is a relatively common and subjective most common reason for MET activation, leading to 37% of
complaint, the issues previously discussed with regard to all MET calls (Buist & Moore 2000). Research also shows
perceived risk of adverse events are also applicable. that a many patients have unrecognized or inappropriately
treated hypoxaemia prior to an adverse event. In a group of
Hypoxaemia patients who had unrecognized physiological abnormalities
The presence of hypoxaemia prior to adverse events has been prior to ICU admission, 40% were hypoxaemic, as were 52%
shown to have a major effect on mortality. Studies by of patients who had inappropriate treatment of physiological
Camarata et al. (1971) and Suljaga Pechtel et al. (1984) abnormality prior to ICU admission (McGloin et al. 1999).
examined arterial blood gas findings and patient outcomes The studies that have examined the relationship between
following cardiac arrest. Although these studies were con- hypoxaemia and adverse events are summarized in Table 5.
ducted 13 years apart their findings are remarkably similar. These results have significant implications for the role of
The results of both studies show that hypoxaemia and failure nurses in preventing adverse events through early identifica-
to correct significant hypoxaemia are prominent factors in tion and correction of hypoxaemia. Pulse oximetry is now
failed resuscitations (Suljaga Pechtel et al. 1984). Acute used as a routine part of patient assessment in most clinical
anoxia was a factor in 40% of cardiac arrests that were environments (Grap 1998) and is a valuable adjunct to
considered ‘unexpected’ by virtue of the absence of acidosis clinical assessment in the detection of hypoxaemia. Routine
(pH >7Æ37) (Camarata et al. 1971). Hypoxaemia (defined as use of pulse oximetry by nurses to measure oxygen saturation
a partial pressure of oxygen of <50 mmHg or 6Æ7 kPa) was has the potential to impact positively on health outcomes by
demonstrated in 59% of patients who experienced cardiac facilitating early detection of hypoxaemia (Albin et al. 1992).
arrest (Suljaga Pechtel et al. 1984), and only 42Æ3% of Fundamental to the use of this technology is that nurses
patients who were hypoxaemic at the time of cardiac arrest recognize its limitations (Rutherford 1989b, Smart & Mark
were successfully resuscitated. This is much lower than the 1992) and consider other factors that influence oxygenation
successful resuscitation rate of 63Æ9% in patients who were such as adequacy of ventilation, plasma oxygen transport,
not hypoxaemic (P < 0Æ05) (Suljaga Pechtel et al. 1984). haemoglobin levels, cardiac output, oxygen delivery to the
Correction of hypoxaemia during the course of resuscitation tissues and cellular utilization of oxygen (Rutherford 1989b,
had a major effect on patient mortality. Almost two-thirds Goodfellow 1997, Tittle & Flynn 1997, Grap 1998). Nurses
Camarata et al. (1971) 193 cardiac arrests in 40% (13/33) of patients in whom arrest was judged to be ‘unexpected’
132 patients (pH > 7Æ37) were acutely anoxic
Suljaga Pechtel et al. (1984) 207 cardiac arrests 59% (123/207) of patients had significant hypoxaemia (PO2 < 50 mmHg)
Patients with initial PO2 > 50 mmHg were more likely to be successfully
resuscitated (58Æ3% vs. 42Æ3%, P < 0Æ05)
Patients with initial PO2 < 50 mmHg and a second PO2 > initial PO2
(correction of hypoxaemia) had increased likelihood of successful
resuscitation (63Æ9% vs. 20Æ9%, P < 0Æ05)
McGloin et al. (1999) 89 unexpected ICU 40% (4/10) of patients who had unrecognised physiological abnormalities
admissions prior to ICU admission were hypoxaemic
52% (10/19) of patients who had inappropriate treatment of physiological
abnormality prior to ICU admission were hypoxaemic
Buist and Moore (2000) 2202 AEs 37% (816/2202) of AEs were related to hypoxaemia (SpO2 < 90%) and
this was the most common AE
86% (705/816) of cases of hypoxaemia resolved with intervention
630 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
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Camarata et al. (1971) 193 cardiac arrests 74% (98/132) of patients were acidotic (pH < 7Æ35) prior to arrest
in 132 patients Of these, 66Æ3% (65/98) of patients had respiratory acidosis (pH < 7Æ35
and a PCO2 > 41 mmHg) and this was the most common cause of
prearrest acidosis
1% (1/99) of patients known to be acidotic prior to arrest survived to
hospital discharge
Suljaga Pechtel et al. (1984) 207 cardiac 39% (81/207) of patients had significant acidosis (pH < 7Æ2)
arrests Patients with initial pH > 7Æ2 mmHg were more likely to be successfully
resuscitated (55% vs. 39%, P < 0Æ05)
Patients with a second pH > than the initial pH (correction of acidosis)
had increased likelihood of successful resuscitation (67% vs. 26%, P ¼ 0Æ05)
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 631
J. Considine
632 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
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for nursing practice. International Journal of Nursing Practice 10, McGloin H., Adam S.K. & Singer M. (1999) Unexpected deaths and
21–31. referrals to intensive care of patients on general wards. Are some
Crispin C. & Daffurn K. (1998) Nurses’ responses to acute severe cases potentially avoidable? Journal of the Royal College of Phy-
illness. Australian Critical Care 11, 131–133. sicians: London 33, 255–259.
Crocco J.A. & Francis P.B. (1991) Acute oxygen therapy – when and McQuillan P., Pilkington S., Allan A., Taylor B., Short A., Morgan
how? Patient Care 25, 69–72. G., Nielsen M., Barrett D., Smith G. & Collins C.H. (1998)
Crocco J.A., Francis P.B. & Lefrak S.S. (1987) When the patient Confidential inquiry into quality of care before admission to
needs oxygen – stat. Patient Care May, 83–89. intensive care. British Medical Journal 316, 1853–1858.
Daffurn K., Lee A., Hillman K.M., Bishop G.F. & Bauman A. (1994) Palmer P.M. (1993) Prescribing supplemental oxygen. Nurse Practi-
Do nurses know when to summon emergency assistance? Intensive tioner Forum 4, 49–52.
and Critical Care Nursing 10, 115–120. Ridley S. & Purdie J. (1992) Cause of death after critical illness.
Dubois R.W. & Brook R.H. (1988) Preventable deaths: who, how Anaesthesia 47, 116–119.
often, and why? Annals of Internal Medicine 109, 582–589. Rubins H.B. & Moskowitz M.A. (1988) Discharge decision-making
Franklin C. & Matthew J. (1994) Developing strategies to prevent in in a medical intensive care unit. Identifying patients at high risk
hospital cardiac arrest: analyzing responses of physicians and nurses of unexpected death or unit readmission. American Journal of
in the hours before the event. Critical Care Medicine 22, 244–247. Medicine 84, 863–869.
Franklin C., Mamdani B. & Burke G. (1986) Prediction of hospital Rutherford K.A. (1989b) Principles and application of oximetry.
arrests: toward a preventative strategy. Clinical Research 34, 954A. Critical Care Nursing Clinics of North America 1, 649–657.
Gaull E.S. (1993) Are you overlooking O2? Emergency Medical Ryerson G.G. & Block E.R. (1983) Safe use of oxygen therapy: a
Services 22, 31–36, 78. physiologic approach. part 2. Respiratory Therapy 13, 25–30.
George A., Folk B., Crecelius D. & Barton Campbell W. (1989) Sax F.L. & Charlson M.E. (1987) Medical patients at high risk for
Pre-arrest morbidity and other correlates of survival after catastrophic deterioration. Critical Care Medicine 15, 510–515.
in-hospital cardiopulmonary arrest. American Journal of Medi- Schein R.M., Hazday N., Pena M., Ruben B.H. & Sprung C.L.
cine 87, 28–34. (1990) Clinical antecedents to in-hospital cardiopulmonary arrest.
Goodfellow L.M. (1997) Application of pulse oximetry and the Chest 98, 1388–1392.
oxyhemoglobin dissociation curve in respiratory management. Smart D. & Mark P. (1992) Oxygen therapy in emergency medicine
Critical Care Nursing Quarterly 20, 22–27. (part 1): physiology and oxygen delivery systems. Emergency
Grap M.J. (1998) Protocols for practice: applying research at the Medicine 4, 163–178.
bedside – pulse oximetry. Critical Care Nurse 18, 94–99. Suljaga Pechtel K., Goldberg E., Strickon P., Berger M. & Skovron
Grap M.J., Glass C. & Constantino S. (1994) Accurate assessment of M.L. (1984) Cardiopulmonary resuscitation in a hospitalized po-
ventilation and oxygenation. MEDSURG Nursing 3, 435–444. pulation: prospective study of factors associated with outcome.
Hourihan F., Bishop G., Hillman K., Daffurn K. & Lee A. (1995) The Resuscitation 12, 77–95.
medical emergency team: a new strategy to identify and intervene Tittle M. & Flynn M.B. (1997) Applied nursing research. Correlation
in high risk patients. Clinical Intensive Care 6, 269–272. of pulse oximetry and co-oximetry. DCCN: Dimensions of Critical
Kester L. & Stoller J.K. (1992) Ordering respiratory care services for Care Nursing 16, 88–95. http//www.cinahl.com/jrnls/DCCN/
hospitalized patients: practices of overuse and underuse. Cleveland dccn1602.htm.
Clinic Journal of Medicine 59, 581–585. Wesmiller S.W. & Hoffman L.A. (1989) Interpreting your patient’s
Lee A., Bishop G., Hillman K.M. & Daffurn K. (1995) The medical oxygenation status. Orthopaedic Nursing 8, 56–60.
emergency team. Anaesthesia and Intensive Care 23, 183–186. Wilson R.M., Runciman W.B., Gibberd R.W., Harrison B.T., Newby
McCance K. & Huether S. (2002) Pathophysiology. The Biological L. & Hamilton J.D. (1995) The quality in Australian health care
Basis for Disease in Adults and Children. Mosby Inc., St Louis. study. Medical Journal of Australia 163, 458–471.
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 633