Determining severe respiratory distress in older out-of-hospital patients

This preliminary investigation represents the first step in developing a clinical decision rule (CDR) to assist out-of-hospital providers in caring for older patients in respiratory distress. The specific aims of the study were: 1) to identify up to ten candidate clinical indicators of severe respiratory distress in older out-of-hospital patients and 2) to determine the feasibility of obtaining data on these indicators from out-of-hospital treatment records, and of obtaining a measure of severe respiratory distress from the emergency department (ED) medical record.

This mixed-methods study included a qualitative component to list possible clinical indicators of severe respiratory distress, and a Delphi survey N = six experts) to reduce the comprehensive list that resulted (aim 1). The feasibility of gathering clinical indicators and a measure of severe distress was evaluated using a retrospective chart review (N = 640) of out-of-hospital and ED medical records (aim 2).

Nine clinical indicators were identified: level of consciousness/mentation, inability to speak in full sentences, position of the patient on arrival, decreased oxygen saturation, accessory muscle use, dyspnea, increased respiratory effort, altered respiratory rate, and retractions. There were sufficient data available on all indicators except dyspnea and retractions; a measure of severe distress was readily obtained from the ED medical record.

Medical record data were available on seven out-of-hospital clinical indicators and an ED measure of severe distress. Further work needs to be done to refine the operational definitions of the indicators and to standardize the way they are documented in the out-of-hospital medical record.