R E S U S C I T A T I O N P L U S 20 (2024) 100768

Available online at www.sciencedirect.com

Resuscitation Plus
journal homepage: www.elsevier.com/locate/resuscitation-plus

Clinical paper
The optimal duration of continuous respiratory rate
monitoring to predict in-hospital mortality within
seven days of admission – A pilot study in a low
resource setting

Franck Katembo Sikakulya a,b,*, Immaculate Nakitende c, Joan Nabiryo c,

Rezvan Pakdel d, Sylivia Namuleme e, Alfred Lumala f, John Kellett g,
on behalf of the Kitovu Hospital Study Group

Abstract
Background: Currently there are no established benefits from the continuous monitoring of vital signs, and the optimal time period for respiratory
rate measurement is unknown.
Setting: Low resource Ugandan hospital,
Methods: Prospective observational study. Respiratory rates of acutely ill patients were continuously measured by a piezoelectric device for up to
seven hours after admission to hospital.
Results: 22 (5.5%) out of 402 patients died within 7 days of hospital admission. The highest c-statistic of discrimination for 7-day mortality (0.737 SE
0.078) was obtained after four hours of continuously measured respiratory rates transformed into a weighted respiratory rate score (wRRS). After
seven hours of measurement the c-statistic of the wRRS fell to 0.535 SE 0.078. 20% the patients who died within seven days did not have an ele-
vated National Early Warning Score (NEWS) on admission but were identified by the 4-hour wRRS. None of the 88 patients whose average respi-
ratory rate remained between 12 and 20 bpm throughout four hours of observation died within 7 days of admission. A simple predictive model that
included the four-hour wRRS, Shock Index and altered mental status had a c-statistic for 7-day in-hospital mortality of 0.843 SE. 0.057.
Conclusion: Four hours of continuously measured respiratory rates was the observation period that best predicted 7-day in-hospital mortality. After
four hours the discrimination of a weighted respiratory rate score deteriorated rapidly.
Keywords: Respiratory rate, Patient monitoring, Physiology, Acute medicine, Technology

However, 9% of deaths within 24-hours occurred in patients who pre-

Introduction sent with a low NEWS value, and many patients who die in hospital
have a low NEWS on admission.1
During the early assessment of patients it is important to be sure that Although vital sign monitoring is key for the prediction of clinical
deterioration is noticed before it is too late to provide time-critical life- deterioration, little is known about the changes and trends of individ-
saving treatment. The National Early Warning Score (NEWS) is ual vital signs during an acute illness in hospital2 or their
widely used to identify patients who need immediate attention and effectiveness in predicting hospital outcomes. It has been suggested
a single measurement is an excellent predictor of imminent mortality. that intermittently measured vital sign changes within the first 4–5 h

Abbreviations: 95% CI, 95% confidence interval, bpm, beats or breaths per minute, NEWS, National Early Warning Score, SD, standard
deviation, SE, standard error, wRRS, weighted respiratory rate score
* Corresponding author at: Department of surgery Fort Portal, Uganda.
E-mail address: [email protected] (F.K. Sikakulya).
https://doi.org/10.1016/j.resplu.2024.100768
Received 28 July 2024; Received in revised form 25 August 2024; Accepted 31 August 2024

2666-5204/Ó 2024 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC license (http://creativecommons.org/
licenses/by-nc/4.0/).
2 R E S U S C I T A T I O N P L U S 20 (2024) 100768

of admission may be of little prognostic value, and only reliably pre- screen.14 The database system automatically calculated and stored
dict outcome after 12 to 24 h.3 the admission National Early Warning Score (NEWS)15 and recorded
Respiratory rate is a component of most early warning systems,4 patient’s status at discharge. All data entries were automatically time
and considered by some to be the most important vital sign.5 Despite and date stamped. Patients who were alert, attentive, calm, and
this, it is often recorded inaccurately or not at all,6–7 and there is no coherent (i.e., normal mental status) provided written informed con-
gold standard for its measurement. Although it is probable that res- sent, all other patients were assessed as having altered mental sta-
piratory rate is the first vital sign to become deranged when patients tus and written informed consent was provided by their next of kin.
deteriorate,8 this hypothesis has been difficult to prove as the accu- The respiratory rate measuring piezoelectric device (Res-
rate continuous measurement of respiratory rate has been techni- piraSenseTM, PMD Solutions, Cork, Ireland) was applied as soon as
cally difficult. However, recently several respiratory rate devices possible after admission to the patient and continuously streamed
using different technical approaches have become available,9 includ- date and time stamped respiratory rate data by wireless to a secure
ing a piezoelectric, non-invasive, wireless, body worn, motion- server. If the device did not have to be removed for clinical or oper-
tolerant and continuous respiratory rate monitor device, which has ational reasons it remained on the patient up to 7 h after admission.
comparable accuracy to the capnograph.10 The hospital’s usual standard of care is to make all patients vital
The aim of this study was to determine the optimal observation signs and calculated NEWS values available to all clinicians. The
time of continuously measured respiratory rate required to predict respiratory rates displayed every 15 min by the piezoelectric device
short term in-hospital mortality (arbitrarily defined as within seven were also made available. However, how to respond to these values
days of admission) of patients admitted to a low-resource hospital was left to each clinician’s clinical judgement. During subsequent
in sub-Saharan Africa, and to compare continuous respiratory mea- analysis the respiratory rates for each hour of observation were aver-
surements with other easily available outcome predictors. aged, yielding an average value for each hour of observation after
admission.

Methods Outcomes
The primary outcome was in-hospital mortality within seven days of
Setting admission. Secondary outcomes were overall in-hospital mortality,
This prospective, observational pilot study was conducted in Kitovu and in-hospital mortality at intervals between admission and seven
Hospital from 18th May 2023 to 31st January 2024 and conforms days.
with STROBE guideline.11 Kitovu Hospital has 248 beds (which
includes 50 medical and 35 surgical) and is located near Masaka, Statistic methods and data analysis
Uganda, 140 km from the capital city of Kampala. It is a private All calculations were performed using Epi-Info version 6.0 (Centre for
not-for-profit hospital, accredited by the Uganda Catholic Medical Disease Control and Prevention, USA) and logistic regression anal-
Bureau. ysis using Logistic software.16 The c-statistic of discrimination for
mortality at different times of after admission was determined by
Participants and study process the method of Hanley and McNeil; values of the c-statistic range from
Participants were a convenience sample of consenting, non- 0 to 1, 0.5 indicates no discrimination and good discrimination is gen-
pregnant, acutely ill patients, aged 18 year of age or older, who were erally considered to be a value >0.8.17 A normal distribution was
admitted to the hospital’s medical ward. Pregnant patients were assumed for all continuous variables,18 which were compared by
excluded because they are never admitted to the medical ward using analysis of variance. Categorical variables were compared
and are always managed in the obstetric unit, which is some distance using Chi squared analysis with Yates’ continuity correction. You-
away. All other patients are admitted through a common emergency den’s J statistic (i.e., sensitivity + specificity – 1) was used to deter-
and out-patient department, which is only a few feet from the medical mine values with the highest association with seven day in-hospital
ward. Therefore, there was no delay to entering the medical ward mortality.19 The p-value for statistical significance was 0.05.
once the decision to admit had been made. Study participants were To capture the mortality risk associated with low respiratory rates,
selected if they were considered sick enough to justify continuous the average respiratory rate for each hour of observation up to seven
monitoring for up to seven hours. The decision to limit the duration hours after admission were weighted according to the NEWS weight-
of observation to seven hours was a pragmatic one, taken to reduce ings for respiratory rates (i.e., rates >=12 and <=20 bpm scored 0
the risk of loss or damage of the piezoelectric devices and to ensure points; rates >=9 and <=11 bpm scored 1 point; rates >=21 and
enough devices were available for new patients. <=24 bpm scored 2 points; and rates <=8 or >=25 scored 3 points).15
The clinical status and vital signs on admission of every partici- These points calculated for each individual hour of observation were
pant were entered at the bedside using tablet computers into a clin- then summed so that after one hour of observation the maximum of
ical database system, which also required variables previously this weighted respiratory rate score (wRRS) was three points, rising
identified to be associated with in-hospital mortality to be entered; to a maximum of 21 points after seven hours.
these included the patient’s mental alertness, gait stability, HIV sta-
tus, mid-upper arm circumference,12 and calculation of the Shock Ethics
Index (i.e., heart rate divided by systolic blood pressure).13 Respira- RespiraSenseTM device is not sold in Uganda, and it required ethical
tory rates were counted using the RRate app, which calculates the approval to use. Ethical approval for the study was obtained from the
respiratory rate from the interval between taps on a smartphone Kampala International University (KIU-2021–45) and the Uganda
 R E S U S C I T A T I O N P L U S 20 (2024) 100768 3

National Council for Science and Technology (UNCST HS2792ES). After one hour of observation 147 (39.0%) patients had an aver-
The study conforms to the principles outlined in the Declaration of age respiratory rate between 12 and 20 bpm (i.e., one-hour wRRS
Helsinki. zero points), and 2 (1.4%) subsequently died within 7 days. In con-
trast, none of the 88 patients with zero four-hour wRRS points
(i.e., their average respiratory rate remained between 12 and
Results 20 bpm throughout four hours of observation) died within 7 days,
compared 10 of the 83 patients (12.0%) with 12 four-hour wRRS
A convenience sample of 402 patients participated in the study; their points (i.e., those whose average respiratory rates were persistently
length of hospital stay was 3.3 SD 3.4 days (median 2.0, IQR 1,5 under 9 or over 24 bpm). The 206 remaining patients, with four-hour
days), their mean age was 55.9 SD 22.9 (IQR 37,74) years, and wRRS points ranging from 1 to 11, had a seven-day mortality
155 (38.6%) of them were men. On admission 161 (40.0%) patients rate of 4.4%; of the nine patients who died within seven days, seven
needed help to walk or were bedbound (i.e., had an unstable gait), 64 had 2 wRRS points throughout their entire four hours of
(15.9%) had altered mental status, and 161 (40.0%) had a NEWS5. observation
Thirty-four patients (8.5%) died while in hospital, 22 within a week of The four-hour wRRS value with the highest Youden J statistic
admission, and 10 during the second week after admission. Only was >9 points, which had an odds ratio for seven-day in-hospital
heart rate, respiratory rate, shock index, NEWS, an unstable gait, mortality of 5.62 (95%CI 1.82 – 18.53, p 0.0008). The Shock Index
and alerted mental status were significantly associated with death with the highest Youden J statistic for seven-day in-hospital mortality
within a week of admission (Table 1). was 1.2 (odds ratio 7.80, 95% CI 2.33 – 25.48, p <0.0001). Of the
All 402 patients had their respiratory rate continuously measured for 377 patients observed for four hours, 63 (16.7%) had a NEWS<5
at least one hour, 399 (99.3%) for two hours, 390 (97.0%) for three and a 4-hour wRRS>9 points; 4 (6.3%) of these patients were among
hours, 377 (93.8%) for four hours, 362 (90.0%) for five hours, 352 the 19 who died within seven days (Fig. 2). Only one of 163 patients
(87.6%) for six hours and 334 (83.1%) for seven hours. The c-statistic with a NEWS<5 and 4-hour wRRS9 died within seven days; she
for the discrimination of 7-day in-hospital mortality of NEWS recorded was 69 years old, had altered mental status and an admission NEWS
on admission was 0.779 SE 0.64. This was compared to the c- of 4.
statistic for the wRRS calculated from first to seventh hour of observa- Logistic regression analysis of altered mental status, unstable
tion, which reached its highest value after 4 h of observation (0.737 SE gait, NEWS >=5, a Shock Index > 1.2 and four-hour wRRS>9 points,
0.078); thereafter it rapidly declined (Fig. 1), so that after seven hours of found only altered mental status, shock index and wRRS remained
observation it was only 0.535 SE 0.078 with only slightly more discrim- significantly associated with seven-day in-hospital mortality (Table 3).
ination than a coin toss (Table 2). The highest c-statistic of the 4-hour A simple score that awarded one point for altered mental status, one
wRRS was for death within 24 h (0.891 SE 0.214), and the lowest for a shock index > 1.2, and one for a wRRS>9 points had a c-
was 0.620 SE 0.059 for in-hospital death. statistic for seven-day in-hospital mortality of 0.843 SE 0.057

Table 1 – Continuous and categorical variables of the study population. NEWS=National early warning score;
SD=standard deviation; bpm = breaths or beats per minute.

Continuous variables

Variable Total Alive Died within 7 days of admission P

Number of patients 402 380 22
Age (years) 55.9 SD 22.9 55.7 SD 23.0 59.5 SD 21.0 0.44
Length of stay (days) 3.3 SD 3.4 3.4 SD 3.5 1.9 SD 1.5 0.04
Heart rate (bpm) 87.9 SD 20.3 82.3 SD 18.9 98.6 SD 32.9 0.01
Systolic blood pressure (mmHg) 118.1 SD 24.8 118.2 SD 24.5 121.0 SD 33.3 0.61
Diastolic blood pressure (mmHg) 74.4 SD 16.9 74.4 SD 16.5 74.5 SD 23.9 0.97
Temperature (°C) 36.2 SD 0.5 36.2 SD 0.4 36.1 SD 0.6 0.61
Oxygen saturation (%) 96.5 SD 6.2 96.5 SD 6.2 96.1 SD 4.5 0.74
Manual respiratory rate (bpm) 22.0 SD 5.3 21.8 SD 5.1 24.2 SD 5.5 0.03
1st hour average respiratory rate by device (bpm) 22.6 SD 5.9 22.2 SD 5.5 28.1 SD 9.2 <0.0001
Shock index 0.78 SD 0.27 0.78 SD 0.25 0.91 SD 0.45 0.02
NEWS (points) 4.3 SD 3.0 4.1 SD 2.8 7.9 SD 4.0 <0.0001
Mid upper arm circumference (cm) 27.0 SD 4.0 26.9 SD 4.0 27.4 SD 2.9 0.57
Categorical variables
No patients Odds ratio 7-day mortality P
Male sex 155 (38.6%) 1.35 (95%CI 0.52–3.45 0.65
HIV positive 36 (9.5%) 1.61 (95%CI 0.35–6.23 0.72
Diabetic 58 (15.4%) 0.91 (95%CI 0.21–3.45) 0.87
Unstable gait 161 (40.0%) 5.57 (95%CI 1.86–17.84) 0.0006
Altered mental status 64 (15.9%) 11.55 (95%CI 4.23–32.23) <0.0001
NEWS >=5 161 (40.0%) 4.32 (95%CI 1.53–12.79) 0.003
Mid upper arm circumference < 20 cm 19 (4.7%) 0.96 (95%CI 0.00–7.48) 0.63
4 R E S U S C I T A T I O N P L U S 20 (2024) 100768

Fig. 1 – C-statistic of discrimination for death with 7 days of hospital admission of weighted respiratory rate scores
(wRRS) according to hours of observation after admission. Solid line = C-statistic; dotted lines = standard error.

Table 2 – C-statistic for death in hospital within a week of admission of weighted Respiratory Rate Score (wRRS)
from first to seventh hour of observation. Each row shows the c-statistic and its standard error (SE) at each hour
of observation for the population that results were available for. Not all patients had their respiratory rate
measured for seven hours i.e., only 344 patients (top row) had their respiratory measured continuously for seven
hours, compared with the entire study population of 402 patients (bottom row) who had their respiratory rate
measured continuously for one hour.

C-statistic for death in hospital within a week of admission of weighted Respiratory Rate Score (wRRS) from first to
seventh hour of observation

Hours observed 1st hour 2nd hour 3rd hour 4th hour 5th hour 6th hour 7th hour
(Maximum points) (3) (6) (9) (12) (15) (18) (21)
Number of patients
Alive Dead Total
319 15 334 0.691 SE 0.705 SE 0.724 SE 0.737 SE 0.729 SE 0.613 SE 0.535 SE
0.077 0.077 0.076 0.078 0.076 0.079 0.078
336 16 352 0.702 SE 0.716 SE 0.735 SE 0.746 SE 0.739 SE 0.620 SE
0.075 0.074 0.073 0.072 0.073 0.076
345 17 362 0.712 SE 0.726 SE 0.744 SE 0.756 SE 0.751 SE
0.072 0.071 0.070 0.069 0.070
358 19 377 0.694 SE 0.706 SE 0.714 SE 0.723 SE
0.069 0.068 0.068 0.068
370 20 390 0.676 SE 0.685 SE 0.690 SE
0.068 0.067 0.067
378 21 399 0.684 SE 0.696 SE
0.066 0.065
380 22 402 0.661 SE
0.065
 R E S U S C I T A T I O N P L U S 20 (2024) 100768 5

Fig. 2 – Seven-day in-hospital mortality of patients according to their admission National Early Warning Score
(NEWS) and their four-hour weighted Respiratory Rate Score (wRRS).

Table 3 – Logistic regression model comparing 5 predictors for 7-day mortality. wRRS=weighted respiratory rate
score. 95% CI=95% confidence interval. NEWS=National early warning score.

Variable Coefficient Odds ratio p

(Standard error) (95% CI)
Constant 4.5236 (0.5912)
NEWS >=5 0.0304 (0.6791) 1.03 (0.27–3.90) 0.96
Unstable gait 0.2793 (0.8072) 0.76 (0.16–3.68) 0.73
Altered mental status 2.4399 (0.7714) 11.47 (2.53–52.04) 0.0016
Shock index > 1.2 1.5689 (0.7029) 4.8 (1.21–19.04) 0.026
wRRS>9 1.2405 (0.5846) 3.46 (1.10–10.87) 0.034

(Fig. 3). Only one of the 207 patients with zero points in this score during hospitalization are more likely to be preventable and, there-
died; he was 54 years old, HIV positive and had an admission NEWS fore, selected death within 7 days as the study’s primary outcome.
of 5. Respiratory rate fluctuates as it is under both voluntary and auto-
nomic control, so that its measurement over time may be interrupted
by speaking, swallowing and coughing. Moreover, it may be tran-
Discussion siently increased by anxiety, movement and other exertions such
as micturition and defecation (see Supplemental figure). Although it
Main findings is quantified in breaths per minute (bpm), it is unlikely that a a single
This pilot study found that when transformed into a weighted respira- measurement captured over a few seconds is the best measurement
tory rate score (wRRS), the best observation period to predict 7-day period Our decision to average respiratory rates over one hour was
in-hospital mortality from continuously measured respiratory rates an arbitrary one, and it may not be the optimal. Drummond20 has
immediately after admission was four hours. After four hours the dis- shown that acutely ill medical patients often have abnormal breathing
crimination of the wRRS deteriorates rapidly. patterns and has argued that these variations over time may explain
the frequently observed discrepancies between respiratory rate
Interpretation measurements.21
Patients with a poor prognosis and multiple comorbid conditions are We found placing respiratory rates into range categories was an
more likely to be too sick to discharge and may, therefore, remain in important insight, and future research may improve on the NEWS
hospital for a longer time. We postulated that deaths that occur early ranges we used. NEWS was devised so that zero points were
6 R E S U S C I T A T I O N P L U S 20 (2024) 100768

Fig. 3 – Seven-day in-hospital mortality according to a simple score that awarded one point for altered mental status,
one for a shock index >1.2, and one for a four-hour weighted Respiratory Rate Score (wRRS) >9 points.

awarded to the range of respiratory rates associated with the lowest respiratory rate over 4 h had a c-statistic for 7-day mortality slightly
risk of death, and that variation within this range might be assumed less than NEWS measured on admission, 20% of the patients who
to be normal physiologic fluctuations.22 Our results confirmed this, as died within seven days did not have an elevated NEWS on admission
no patients who maintained average rates for four hours within this but were identified by four hours of respiratory rate monitoring.
zero-point range (i.e., respiratory rates between 12 and 20 bpm) died
within seven days of admission. However, it is possible that the true
mortality could be as high as 3%.23 Limitations
A possible explanation of our findings is patient fatigue, as
severely ill patients may be unable to sustain the work of breathing. The small number of patients and outcomes, and lack of a validation
Two of our patients with zero wRRS points subsequently died in hos- cohort are the major flaws of this pilot study. Also, we do not know for
pital, one after surgery for intestinal obstruction, and the other was how long patients were severely sick before they presented to hos-
an 88-year-old lady with chronic lung disease who died two weeks pital, and we do not know how many patients died shortly after dis-
after admission from respiratory failure. It is possible that her ‘normal’ charge. The patients enrolled in the study did not present
respiratory rate on admission was because she had already reached consecutively, but were a convenience sample of very sick patients,
the terminal phase of her illness and was no longer able to maintain a many of whom would have been in intensive care in better resourced
higher rate of breathing. The work of breathing is considerable and settings. Therefore, our results may not be applicable to acutely ill
usually accounts for about 5% of the total body oxygen consumption, patients attending emergency departments or admitted to acute
which may rise to 30% in critically ill patients.24 Therefore, a fall in the medical wards elsewhere. For example, only 30% of patients admit-
respiratory rate of a severely ill patients may not indicate improve- ted to UK hospitals have a NEWS >=3,28 compared to 70% of our
ment, but be a sign of serious deterioration and imminent death from patients. We have previously reported that patients with a normal gait
impending respiratory failure. and a NEWS<3 on hospital admission had an in-hospital mortal-
ity <0.4% in Kitovu Hospital and two high-resource European hospi-
Clinical significance tals. However, as we found in this study, immobile patients with a
Although the benefits of continuous monitoring of vital signs by wear- NEWS3 had an in-hospital mortality of 14%, which was much
able devices have yet to be established,25,26 our findings suggest higher than similar patients in the two European hospitals.29
that a four-hour period of respiratory rate monitoring may help The size of this single site study was limited by the resources
improve emergency departments to risk stratify patients and make available and was not large enough to allow what appear to be clin-
safer discharge decisions.27 It is possible that frequent manual spot ically important differences to reach statistical significance. Only 83%
measurements over 4 h may give similar results. Many patients who of our patients were continuously monitored for seven hours; rea-
die in hospital have a low NEWS on admission.1 Although monitoring sons for discontinuing monitoring were numerous and included
 R E S U S C I T A T I O N P L U S 20 (2024) 100768 7

removal by confused patients, anxious relatives, unauthorized or the study and supervised data collection. All authors reviewed the
uninformed personnel, attempted theft, power cuts, and other final manuscript and corrected any errors.
misadventures.
We used the original version of NEWS as it remains comparable
to the new NEWS2 version,30 requires less data, is easier to calcu- Prior publication
late, and is, therefore, more appropriate to a low resource setting.
Although we used the most widely reported NEWS cut-off of 5 There has been no prior publication in any form of this paper or the
points, similar results were obtained with second commonest cut- information it contains.
off values of 3 points.1

Data availability statement

Conclusion
Anonymized data of this study are available to all interested parties
This pilot study shows that the use of continuously measured respi- upon request.
ratory rate as a predictor for mortality and risk stratification may be
more complex than anticipated and may require analysis of unknown
variations, which may not be applicable to all patients, or all clinical CRediT authorship contribution statement
settings. In this study of acutely ill patients just after admission to
hospital, we found four hours of continuously measured respiratory Franck Sikakulya: Data curation, Conceptualization. Immaculate
rates, transformed into a weighted score, was the best observation Nakitende: Data curation. Joan Nabiryo: Data curation. Rezvan
period for the prediction of seven-day in-hospital mortality. After four Pakdel: Formal analysis. Sylivia Namuleme: Project administration.
hours the discrimination of the weighted respiratory rate score dete- Alfred Lumala: Project administration. John Kellett:
riorated rapidly. The risk stratification performance of the four-hour Conceptualization.
weighted respiratory rate score was enhanced by the addition of
mental status assessment and measurement of the Shock Index. Declaration of competing interest

The authors declare that they have no known competing financial

Funding and conflict of interest statement interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
PMD Solutions supplied their RespiraSenseTM devices free of
charge, all other costs were borne by the authors. Dr Rezvan Pakdel Acknowledgements
is an employee of PMD. None of the other authors have any potential
conflicts of interest. The authors wish to acknowledge Mr Pedro Asensio of PMD Solu-
tions for his technical help.

Role of the sponsors / Other contributions

Appendix A. Supplementary material
PMD supplied the piezoelectric devices and extracted the respiratory
rates recorded by them. RD (an employee of PMD) assisted the data Supplementary data to this article can be found online at https://doi.
analysis. PMD played no part in the conceptualisation or design of org/10.1016/j.resplu.2024.100768.
the study, or in drafting the paper.

Author details
Ethics declaration
on behalf of the Kitovu Hospital Study Group aFaculty of Clinical
Ethical approval for the study was obtained from the Kampala Inter- Medicine and Dentistry, Department of Surgery, Kampala
national University (KIU-2021-45) and the Uganda National Council International University Western Campus, Ishaka-Bushenyi,
for Science and Technology (UNCST HS2792ES). The study con- Uganda b Faculty of Medicine, Université Catholique du Graben,
forms to the principles outlined in the Declaration of Helsinki. Butembo, Democratic Republic of the Congo c
Enrolled Nurse
(EN), Emergency and Out-patient Department, Kitovu Hospital,
d
Masaka, Uganda Software Engineer, PMD Solutions, Cork,
Authors contribution e
Ireland Director of Nursing, Diplomate Nursing (DN) Kitovu
f
Hospital, Masaka, Uganda Medical Director, Kitouv Hospital,
FS and JK conceptualisation, data analysis and drafting of the paper, g
Masaka, Uganda School of Clinical and Biomedical Sciences,
IN and JN collected data, RP data analysis, SN and AL administered
University of Bolton, United Kingdom
8 R E S U S C I T A T I O N P L U S 20 (2024) 100768

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