How Can Clinicians Take Observations During a Remote Consultation?

We will look at ways in which clinicians may be able to carry out observations (sometimes referred to as vital signs) during a remote consultation, either over the phone or via a video appointment.

The following observations are most commonly monitored:

• Heart/pulse rate (beats per minute)
• Respiratory rate (breaths per minute)
• Temperature (°C/°F)
• Oxygen saturation (%)
• Blood pressure (mm/Hg)

Pro-tip! These parameters form the basis of the National Early Warning Score (NEWS2) calculation in the UK, which is used as a prompt to escalate patients often in a hospital setting and its popularity in the community setting is growing. It should be noted that there is no evidence to support the use of NEWS2 in patients with suspected COVID-19 and NEWS2 should be used alongside a wider clinical assessment. That being said, being aware of such escalation tools remains useful. Take a moment to check for a similar score used where you are. We will discuss risk stratification tools in more detail during step 2.5.

During face to face consultations we would usually measure these observations using calibrated equipment. This is often not possible during remote consultations for two reasons:

1) The patient may not be in possession of the equipment.

2) The equipment may not be calibrated correctly.

Fortunately, not all of the observations require calibrated equipment to be measured. Heart rate and respiratory rate and can be measured by the patient (or someone accompanying them with consent) manually.

Heart/pulse rate

The heart/pulse rate is a key observation to take when patients present with acute and/or chronic illness. In a clinical setting we would normally report on 3 things, rate, rhythm and character however during a remote consultation it may be better to focus on:

• rate
• rhythm

Pro tip! Whilst the following instructions should work over the phone, a video consultation is preferable as you can actually see what the patient is doing.

The following steps can be used as a guided script to help patients measure their own pulse rate during a remote consultation:

1) Ensure patient is relaxed / in rested state.

2) Stretch your arm out, palm facing upwards (either arm).

3) Place two fingers from the other hand (usually the index and middle finger) at the base of your thumb on the outstretched arm and feel around that area until you can feel a pulsing sensation.

4) Ask the patient to count the number of times they can feel the bumping sensation while you time them for 30 secs.

5) Now multiply that number by 2 to get the pulse in beats per minute.

6) Ask the patient if the pulse feels ‘regular’, like the beat of a drum or ‘irregular’. You could even get them to call out a word (such as “dum” for each beat to assess this yourself).

The following video from the British Heart Foundation is a useful demonstration.

https://www.youtube.com/watch?v=qaZrzoH8Jvk

Brachial pulse

For those patients who struggle to find their pulse in the wrist, they can be asked to check for their brachial pulse in the following manner (this is also a more useful way to check the pulse in children):

1) Ensure patient is relaxed / in rested state.

2) Stretch either arm out, palm facing upwards (as before).

2) Place two fingers (usually index and middle finger) from the other hand, just above the crease of the elbow, slide down the inside of the arm/bicep by around 1-2 cm until they can feel an indentation.

3) When applying some light pressure, they should feel a pulsing sensation.

3) Ask the patient to count the number of times they can feel the pulsing sensation, whilst you time them for 30 secs.

4) Now multiply that number by 2 to get the pulse in beats per minute.

5) Ask the patient if the pulse feels ‘regular’, like the beat of a drum or ‘irregular’. You could even get them to call out a word (such as “dum” for each beat to assess this yourself).

The following video on YouTube is a useful demonstration.

https://www.youtube.com/watch?v=tZCPZUHgFks

Smart phones

Some patients may have smartphones or smart watches that are able to measure pulse rates however we offer a word of caution about smartphone apps: they are not medically approved devices and so the results should be treated with caution. Studies have shown a lack of correlation between readings obtained on smartphone apps and approved heart rate monitors [1], [2].

Respiratory rate

Respiratory rate is a key observation to take for any patient presenting with acute and/or chronic illness. It is defined as the number of breaths (in and out once = one breath) within one minute.

Pro tip! When patients are aware that their breathing is being monitored, this can lead to unintentional changes to breathing pattern. It may be worth taking the respiratory rate at the beginning and end of the consultation to ensure results are reliable.

Respiratory rate can be measured during a remote consultation in a number of ways:

Telephone consultation

1) Ask the patient to time the number of breaths breathing using a stopwatch / smartphone.

2) Ask the patient if they have someone in the vicinity that can assist in counting the breaths.

Clinicians should avoid trying to count breaths by listening over the phone. The Oxford Centre for Evidence-Based Medicine (CEBM) found no evidence that attempts to measure a patient’s respiratory rate over the phone would give an accurate reading [3].

Video consultation

1) In addition to the above techniques, you may be able to visualise the rise and fall of the chest during the breathing cycle giving you the opportunity to count the number of breaths per minute.

Temperature

Monitoring temperature is extremely useful, particularly in patients presenting with acute illness. Many patients will have a thermometer and so you should always try and check this as part of your remote consultation.

Pro tip! Don’t forget to ask if the patient has recently taken any anti-pyretic medication as part of your clinical history taking, such as paracetamol or ibuprofen, as these can mask a high temperature!

Oxygen saturation

Whilst oxygen saturation is a key observation to measure for a sick patient, it is not always possible during a remote consultation. Most patients will not have access to a pulse oximeter unfortunately.

That being said, we as clinicians can make an assessment of oxygen saturation by other means such as asking questions about discolouration (blue tinge) of the lips and tongue. This is also something that we might notice during a video consultation.

Additionally, we can make an assessment of any difficulty in breathing (dyspnoea).

So, how might we make an assessment of dyspnoea in a remote setting?

The Oxford Centre for Evidence-Based Medicine (CEBM) have completed a rapid review of the evidence, to determine if there are any evidence-based ways to assess dyspnoea by telephone or video. They found no validated tests to for assessing breathlessness in an acute primary care setting [3].

Based on expert consensus of 50 clinicians who regularly assess patients by phone, CEBM then recommended asking patients four questions to make an assessment of dysponea:

1) In their own words, ask the patient to describe the problem with their breathing.

2) Align with the NHS 111 symptom checker:

“Are you so breathless that you are unable to speak more than a few words?”

“Are you breathing harder or faster than usual when doing nothing at all?”

“Are you so ill that you’ve stopped doing all of your usual daily activities?”

3) Ascertain a clear story of deterioration.

4) Interpret the breathlessness in the context of the wider history and physical signs.

The evidence suggest that use of the Roth Score should be avoided in acute respiratory distress. The Roth Score [4] is a test for dyspnoea and indicates the severity of hypoxia. At the beginning of the COVID-19 pandemic, the Roth Score gained popularity in primary care in the UK, as a means of assessing breathlessness in patients, without having to assess them in a face to face setting.

The test is not validated for use in an acute primary care setting, and evidence for its use at all is weak, based on a single cohort study with small numbers of patients [4]. The test is also particularly unreliable in patients presenting with COVID-19 (3).

The Roth Score is not evidence-based and it’s use should be discouraged [3].

Blood Pressure

In a face to face setting we would routinely monitor the blood pressure of patients’ presenting with illness. Whilst a high blood pressure can lead to chronic damage of organs, a very low blood pressure can cause more acute problems such as falls, which in turn can lead to serious injury.

For patients that own their own blood pressure machines, you may decide to make use of these during remote consultations. You should however take into consideration the following before making clinical decisions based on the information you receive;

1) The patients’ own machine may not be calibrated correctly.

2) User error may lead to inaccurate results.

Pro tip! Ask screening questions that might indicate the patient has low blood pressure, for example;

1) How much fluid are you drinking through the day?

2) Do you feel light-headed when changing position?

Without an accurate blood pressure reading, calculating a score such as National Early Warning Score (NEWS2) is not possible. Despite this, we as clinicians should be able to make a clinical judgement with the information that we do have available and escalate patients accordingly. If you are unsure, always check with a more senior colleague.

[1] Bouts, A.M., Brackman, L., Martin, E., Subasic, A.M. and Potkanowicz, E.S., 2018. The accuracy and validity of iOS-based heart rate apps during moderate to high intensity exercise. International journal of exercise science, 11(7), p.533.

[2] Coppetti, T., Brauchlin, A., Müggler, S., Attinger-Toller, A., Templin, C., Schönrath, F., Hellermann, J., Lüscher, T.F., Biaggi, P. and Wyss, C.A., 2017. Accuracy of smartphone apps for heart rate measurement. European journal of preventive cardiology, 24(12), pp.1287-1293.

[3] Are there any evidence-based ways of assessing dyspnoea (breathlessness) by telephone or video – CEBM, 2020

[4] Chorin, E., Padegimas, A., Havakuk, O., Birati, E.Y., Shacham, Y., Milman, A., Topaz, G., Flint, N., Keren, G. and Rogowski, O., 2016. Assessment of respiratory distress by the Roth score. Clinical cardiology, 39(11), pp.636-639.