recording and acting upon physiological observations in

v6 From: May 19 – To: May 22 Author(s): BRHC Nurse Practice Group of 17

SETTING & PATIENTS EXCLUSIONS

Bristol Royal Hospital for Children (BRHC) All in-patient clinical areas where children are cared for within the Trust and where ward-based or HDU observation charts are used. Children in PICU where a Clinical Informatics system is in use for recording observations.

FOR STAFF This protocol applies to registered and non-registered nurses, medical staff and allied health staff.

_____________________________________________________________________________

PROTOCOL 1 Key Messages

• All children at the time of admission to hospital and whenever observations are undertaken must have the following observations recorded:

o Respiratory rate, oxygen delivery, oxygen saturation level, respiratory distress assessment, heart rate, capillary refill time, blood pressure, conscious level (AVPU) and temperature.

o The above constitutes a full physiological assessment and is required to calculate a meaningful BRHC Paediatric Early Warning (PEW) score.

o A full pain assessment and documentation of the tool used • After the above initial full physiological assessment, a written monitoring plan which specifies

the frequency of the observations to be recorded must be documented on the BRHC Observation chart and in the patient’s health record.

• As a minimum, all in-patient children must receive 12 hourly observations which must include

the full physiological assessment. This is the minimum time period assessment. The only exceptions to this minimum assessment are those children who have entered a palliative care pathway.

• If a child has 2 consecutive sets of observations in any coloured section of the chart, a blood

pressure (BP) must be measured and recorded. Also consider increasing the frequency of the child observations.

• If the BP is abnormal (i.e. reading is in a coloured section), subsequent sets of observations

must also include BP and consider increasing the frequency of the child observations.

• If Heart Rate (HR) and/or Capillary Refill Time (CRT) observations are within the yellow and/or red zones, subsequent sets of observations must also include BP. Also consider increasing the frequency of the child observations.

Clinical Protocol RECORDING AND ESCALATING PHYSIOLOGICAL OBSERVATIONS IN PAEDIATRIC INPATIENT AREAS WITHIN UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST

Extended until November 2022


• Children admitted for a procedure that is supported by a local or national protocol e.g. blood transfusion must have observations recorded at intervals specified by the protocol.

• The PEW Score (PEWS) must be used to monitor all paediatric in-patients and must be

accurately recorded with every set of observations. The only exceptions are those children on a palliative care pathway or those children cared for in paediatric intensive care (PIC).

• The PEW score action / response / escalation response must be used and followed to ensure

a timely response to abnormal observations. • The frequency of observations must be increased in response to abnormal observations and

in line with the PEW score escalation response

• Some children may present acutely unwell and may not reflect the severity of their illness in their PEW score. If there is any concern regarding a child’s condition, senior nursing and, or medical help must be called, or an emergency call (2222) activated.

• All observations must be recorded clearly & legibly. Each entry must be initialled, dated &

timed. Documentation must adhere to ‘UHBristol Clinical Standard – Record Keeping Principles and Standards’ (available on DMS)’

• Consultant to Consultant handover is required if admission to critical care is clinically

indicated. • Transfer from critical care areas to general wards should where possible, be avoided

between 22:00 and 07:00 and must be documented as an adverse incident if it occurs. • Any staff requesting / referring a child for review must use the Situation, Background,

Assessment, Recommendation (SBAR) communication framework to escalate care. • There must be a formal structured handover of care for the child from critical care area staff

to ward staff (including both medical and nursing staff) supported by a written care plan for the child.

• Acutely ill paediatric in-patient transfers must be escorted by an appropriately trained

member of nursing staff who is familiar with the monitoring and equipment being used and, or an appropriately trained member of the medical staff.

2 Background There is increasing evidence to suggest that many patients demonstrate clear physiological abnormalities in the hours leading to cardiopulmonary arrest or intensive care admission (McGloin et al 1999, Vincent et al 2001, NCEPOD 2005, NPSA 2007). By closely monitoring changes in physiological observations, deteriorating patients are more likely to be identified before a serious adverse event occurs. The National Patient Safety (NPSA) report, ‘Safer care for the acutely ill patient: learning from serious incidents’ (2007), identified insufficient observation recording, lack of recognition and delays in treatment as key themes, reporting that observations are seen as a ‘task’ of low priority. A report by the Confidential Enquiry into Maternal and Child Health (CEMACH) ‘Why children die; a pilot study 2006’ (2008), promoted awareness of the lack of recognition in identifying a sick



child & acknowledged the need for health professionals to use a paediatric early warning score. In 2007 the National Institute for Health and Clinical Excellence (NICE) published CG50: ‘Acutely Ill Patients in Hospital’. This document provides key parameters that assisted with the monitoring of physiological observations for adult inpatients. In addition competencies for all staff for the recording and reporting of physiological observations are set out by the Department of Health ‘Competencies for recognising and responding to acutely Ill patients in hospital’ (2008). The use of a validated Paediatric Early Warning (PEWS) score may aid individual and team situation awareness of the children at risk of deterioration, particularly for junior staff or those new to caring for infants, children and young people. However, it is acknowledged that PEWS will not identify all children at risk of deterioration, either due to the speed or the mechanism of deterioration. Therefore, it is essential that all clinical staff are trained to recognise common patterns of deterioration with or without the use of a PEWS and not just use the score for reassurance. Other components of a safe system to recognise and respond to children at risk of deterioration include:

• Succinct communication tools to convey critical information e.g., Situation, Background, Assessment and Recommendation (SBAR) tool. (NHS Institute for Innovation and Improvement, 2008) • A multidisciplinary approach to care (Confidential Enquiry into Maternal and Child Health (CEMACH) 2008,McCabe et al., 2009). • Safety huddles

(RCN 2017 - Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People). 3 Purpose The aim of this protocol is to set the standard for the recording and reporting of observations for all paediatric in-patients. The protocol draws upon information from CG50: ‘Acutely Ill Patients in Hospital’ (NICE 2007) and the Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People (RCN 2017). The protocol outlines the standards by which physiological observations for children should be monitored, recorded and acted upon. This protocol applies to all in-patient children’s wards and departments within the BRHC and any other ward areas caring for in-patient paediatric patients within University Hospitals NHS Foundation Trust, where ward or HDU observation charts, are used. 4 Definitions • Infants, children and young people are referred to as ‘children/child’. • A child is usually defined by age, and includes those up to 16 years. However, there may be

exceptions to this depending on clinical conditions.



• Deteriorating: clinical condition deteriorating and worsening observations. • PEWS - Paediatric Early Warning Score - an early warning score based on children’s

physiological observations. • SBAR - Situation, Background, Assessment and Recommendation - a mnemonic used to

allow a structured framework for communication.

5 Responsibilities within the organisation 5.1 Matrons / Clinical Leads / Ward Sister / Charge Nurse / Consultants Are responsible for: • Dissemination of information regarding this protocol to staff in their clinical areas. • Supporting and ensuring the implementation of this BRHC Clinical Protocol for recording and

escalating physiological parameters. • Ensuring staff have the appropriate competencies to comply with this protocol. • Ensuring that staff are aware of, and adhere to, this protocol and its implementation. • Ensuring children are monitored effectively by staff competent to do so. • Keeping a local nursing staff record of competence though the Paediatric Practitioner Clinical

Competency Document. • Ensuring that the equipment necessary to perform physiological observations is available • Ensuring compliance with this protocol is audited via the Quality in Care Tool (QiCT) within

their clinical areas and fed back to directorate and divisional governance meetings • Ensuring that SBAR is used to communicate information relating to the acutely ill child.

5.2 All Staff All staff undertaking observations and responding to escalated concerns will do so: • In accordance with the standards for physiological observation outlined in section 6 of this

protocol • Using the Paediatric Early Warning Score (PEWS) and escalation response referred to in

section 8 and appendix 1. • Articulate succinctly and clearly when communicating with colleagues about a deteriorating /

unwell child using the SBAR system. • Take into consideration exclusion criteria referred to in section 10. • Complete documentation as set out in section 11. • Meet requirements relating to patients discharge and transfer set out in section’s 12 and 13

6 Standard for physiological observations • All children within BRHC, including Assessment Areas and the Emergency Department

(where the decision has been made to admit the patient) must have a full physiological assessment of observations recorded on the BRHC observation chart – as indicated below.

• If a child’s observations straddle a line between two colour bands e.g. Resps 70/min or a

Heart Rate of 170 in a child 1-4 yrs, then score the higher value i.e. PEW of ‘4’ not ‘2’.

• If a child has 2 consecutive sets of observations in any coloured section of the chart, a blood pressure (BP) must be measured and recorded. Also consider increasing the frequency of the child observations.



• If the BP is abnormal (i.e. reading is in a coloured section), subsequent sets of observations must also include BP and consider increasing the frequency of the child observations.

• If Heart Rate (HR) and/or Capillary Refill Time (CRT) observations are within the yellow and/or red zones, subsequent sets of observations must also include BP. Also consider increasing the frequency of the child observations.

Respiratory rate • Must be recorded every 12 hours as a minimum whilst the child is an inpatient.

• Must not be recorded from monitoring equipment – count the child’s respiratory rate.

• Must be counted for one full minute.

• Mark with a ‘dot’ or a ‘cross’ in the relevant box that indicates the respiratory rate.

• The pattern, effort and rate of breathing must be observed and any increased work of

breathing documented. Mark with a ‘dot’ or ‘cross’ in the relevant box that indicates the effort of breathing.

• Signs of respiratory distress e.g. nasal flaring, grunting, wheezing, dyspnoea, recession,

stridor, use of accessory and intercostal muscles, chest shape and movement should be noted by looking and listening and documented as appropriate.

• Skin colour must be observed and documented if not ‘normal’ for the child. • If apnoea monitoring is in use the nurse must respond immediately when an alarm sounds

and check the child’s respiratory rate.

• Abdominal movements must be counted for children less than seven years of age because they are predominately abdominal breathers.

Oxygen delivery • Record the actual O2% in figures e.g. ‘95%’, ‘91%’ in the appropriate box.

• Use the ‘delivery key’ as a guide to documenting the ‘delivery mode’ of oxygen therapy.

• If a child’s observation span two boxes e.g. 4L/min flow and 55% Oxygen – score them with

whichever scores the higher value i.e. PEW ‘4’, not ‘2’. • Only score the child once in this section i.e. If a child scores in both the ‘yellow’

(PEW ‘2’) and ‘red’ (Pew ‘4’) boxes, ONLY score the higher value of ‘4’. Oxygen saturation monitoring • Must not be used for assessment of heart rates.

• When using continuous oxygen saturation monitoring alarm parameters must be set and

checked each shift. The nurse must respond to an alarm immediately and check to identify the cause.

• Probe sites must be checked for pressure areas and changed at least four hourly if using

continuous oxygen saturation monitoring.



• Record the actual Sp02 % in figures e.g. ‘95%’, ‘91%’ in the appropriate box

Respiratory distress • Place a ‘x’ in the box if ‘none’ is the case

• Place a ‘√’ in the box, as appropriate, if ‘mild’, ‘moderate’ or ‘severe’ is the case Heart rate • Must be recorded every 12 hours as a minimum whilst the child is an inpatient.

• Where possible ensure the child is settled before measuring the heart rate.

• The heart rate can be measured by:

• Palpation of a central or peripheral pulse or • Auscultation of the heart beat with a stethoscope.

• The heart rate must be counted for one minute. • Mark with a ‘dot’ or a ‘cross’ in the relevant box that indicates the heart rate.

• The heart rate must be auscultated:

• In infants and children less than two years of age. • If a peripheral pulse cannot be palpated.

• When using an electrocardiogram (ECG) monitor for continuous heart rate monitoring the

electronic data should be cross checked by auscultation or palpation at least 12 hourly or immediately if the level of consciousness alters.

• Electrodes and leads must be placed in an appropriate position and changed regularly in order to minimise the risk of damage to the child’s skin.

• Alarm limits should be set and checked each shift. A record of this must be made in the patient’s health record.

• Monitoring should not preclude manual heart rate measurement. Blood Pressure (systolic and diastolic mmHg) • Every child must have a blood pressure (BP) recorded on admission to hospital and at

the beginning of each nursing shift. If the blood pressure is within the normal range for the child, the frequency of further recordings will depend on the reason for admission and severity of illness. The frequency of BP recordings will be recorded on the child’s monitoring plan on the Observation Chart.

• Record the child’s BP on the graph with ‘arrows’ indicating the systolic and diastolic

pressures and a ‘x’ indicating the mean BP. Please also write the recording ‘in figures’ in the appropriate box at the top of this section.

• Please note: only the SYSTOLIC BP is scored within the Paediatric Early Warning Score • The right arm should be used for measuring the blood pressure. Where the right arm is not

used the limb used must be documented.



• The arm should be well supported and positioned at the level of the heart. • The correct size of the cuff is necessary for gaining an accurate recording.

• The cuff should be wide enough to cover 2/3 of the length of the upper arm.

• A cuff that is too narrow will result in overestimation. A cuff that is too wide will result in

underestimation.

• The cuff bladder length should cover 80 - 100% of the circumference of the arm. The cuff must be applied so that: • Its lower border is two finger breadth above the elbow crease. This may not be possible in

infants. • The arrow lines up with the brachial pulse.

• Ideally, the first reading of the automated BP machine should be disregarded. Allow one to

two minutes before repeating the measurement and accept the 2nd reading.

PEW Score if BP not taken. • It is appreciate a BP is not routinely undertaken with observations in children and this will

impact on the total PEWS.

• However, remember the PEWS is only one way of assessing the child and staff should use their clinical knowledge, skill and patient assessment to judge the condition of the child. Assessing the child fully is essential to optimising their care.

• BP is the last physiological parameter to alter in children and some children may be

extremely unwell even with a low PEW score. o As such the PEWS helps assessment of the child, but if anyone is concerned , they

must escalate the child’s condition to a senior member of staff.

• Do still record the PEWS total whether a BP has been taken or not – if no BP is recorded, this will be evident on the chart. The issues surrounding recording a child’s BP remains a challenge for all, but evidence still indicates it should be part of the PEW score.

Capillary refill time (CRT) • Should be assessed using the skin of the forehead, or chest (sternum).

• If peripheral digits are used, the practitioner should elevate the limb to the level of the heart.

• Pressure should be applied for five seconds then released.

• The practitioner should count the time in seconds that it takes for the skin to return to its

normal colour.

• The skin normally re-perfuses in less than two seconds in children and less than three seconds in a neonate.

• Please mark with a ‘dot’ in the relevant box that indicates the CRT.



Temperature (oC) • A child’s temperature must be taken on admission to hospital and at least 12 hourly as a

minimum.

• Record the child’s temperature on the graph with a ‘dot’ and write the temperature ‘in figures’ in the appropriate box at the top of this section.

• A child’s temperature should not be recorded in isolation. If there is concern enough to

perform one or two hourly temperature recordings a respiratory rate and a heart rate must be performed as a minimum.

• A child’s temperature should be assessed if the child feels hot or cold to touch.

• The temperature must be measured at least every 4 hours if the child is receiving intra-

venous (IV) therapy (drug or fluid), has a potential site of infection such as a chest drain, wound or other, or has a central or short long line in situ.

• There must be clear guidance for practitioners on the accurate use of the equipment

available in each area for measurement of temperature in children.

• Oral and rectal routes should not be routinely used to measure the body temperature in children aged between 0 – 5 years (NICE 2007). A tympanic membrane thermometer or axillary thermometer or electronic/chemical dot thermometer should routinely be used.

Level of consciousness (AVPU score) • The AVPU is used to assess the level of consciousness. On admission to hospital and as a

minimum every 12 hours whilst the child is an inpatient the practitioner should assess if the child is:

A alert. V responding to verbal stimuli. P responding only to pain. U or unresponsive.

• The child must be woken / be awake to perform the AVPU. • Mark with a ‘dot’ or a ‘cross’ in the relevant box that indicates the child’s AVPU status. • If the child does not respond to verbal stimulation i.e. only respond to ‘P’ - pain or touch in

infants, the practitioner must assess the child’s airway, breathing and circulation and call for assistance. The child must have full and regular neurological observations performed, using the Modified Glasgow coma Score.

• The AVPU does not replace the Glasgow Coma Score where the child has a neurological

problem. A formal Glasgow Coma Score (GCS) must be undertaken for any child who is not ‘alert’ unless there is evidence that this is the child’s normal condition.

• Where neurological assessment (GCS) is required, this must be performed by two nurses at

the handover of each shift and whenever the child is transferred to a ward/organisation to ensure that the level of consciousness has been determined and agreed.

Regularity of observations / observation monitoring plan (Not Relevant for HDU Charts) • On the ward observation charts, the frequency each child’s observations are undertaken

must be document in the ‘observation monitoring plan’. This section must be complete



either by a Registered Nurse or Doctor. One change may be made each ‘monitoring plan’ with appropriate signatures, dates and times being documented. After this a new observation chart will be required.

• Children being monitored on an HDU chart will have hourly observations recorded, unless

explicitly stated and documented in the child’s health record. Parental / nurse concern Having this box has proved valuable in other Hospital’s. Evidence suggests that nursing staff and parents have sometimes voiced their concern about the severity of a child’s condition, but felt no-one has listened. The child has then acutely deteriorated and there has been no documentation of this prior concern. Therefore: • Place a ‘√’ in this box if you or the parent / carer is concerned with the child and the child;

• is not triggering a PEW score that reflects your concern • is triggering a PEW score of concern but you are not receiving the support, guidance

or intervention you feel the child should be having.

• If you place a ‘√’ in this box you must place an SBAR sticky label (as below), in the child’s health record and indicate / document why you have marked this on the chart.

• You must also discuss the chid and the concern patient with the nurse-in-charge, child’s

medical team or CST.

• Consider actioning the SOP – ‘The acutely ill child – parental / patient involvement in escalation of clinical care’ process.

• http://nww.avon.nhs.uk/dms/download.aspx?did=16332 http://nww.avon.nhs.uk/dms/download.aspx?did=19150

SBAR sticky label (kept in all ward areas)

PEW score (see appendix 1) • The ‘total’ PEWS must be written on the observation chart, each time a set of observations is

undertaken.

• All PEWS must be escalated as per the PEW Action / Response / Escalation process on the observation chart or guidance on information sheet under the HDU charts.

• Any child who has a PEW score of ≥7 should have this documented on the back of the

observation chart in the ‘Significant Events’ section and, must have it recorded in the Child’s Health Record where a red SBAR label must be place to clearly identify the concern and action taken.

• Use a red SBAR stick label (as above) and document:

Why the child was generating this score.

Situation Background Assessment Recommendations


http://nww.avon.nhs.uk/dms/download.aspx?did=16332



The escalation process that was undertaken i.e. who escalated the concern, who was it report to and what action was taken.

Additional Observations: • The following scores/levels may also be recorded on the PEWS observation chart but do not

add to the total PEW score: • Optiflow / BiPAP / CPAP parameters • Blood glucose level • Pain assessment and score

• The frequency of observations must be increased in response to a patient’s abnormal

observations & in line with the escalation response set out in appendix 1. • Children’s observations must be reviewed following any procedure or treatment and any

alternate plan for observations documented on the observation chart and in the patient’s health record. This protocol should not replace any existing local guidelines for post procedure observations (i.e. post operative observations, blood transfusion observations)

• There may be some circumstances where the PEWS does not reflect the severity of a

child’s condition. If there is clinical concern about a child, the frequency of observations must be increased, even if the PEWS fails to ‘trigger’, and senior nursing and, or medical help must be called.

• Observations must be carried out by registered or non-registered nursing staff competent to

do so and in-line with the BRHC Paediatric Practitioner Clinical Competency Document. Staff not assessed as competent must be supervised until such a time when they are able to carry out observations without supervision.

• Any suspected faulty monitoring equipment must be reported to the senior nurse and MEMO

department. Refer to the University Hospitals Bristol NHS Foundation Trust (UHBristol) Guidelines for reporting faulty equipment.

Pain assessment • Children’s pain should be assessed, documented and appropriate action taken in line with the

analgesic ladder on the front of the observation chart.

• Every child must have a pain assessment tool to be used by them / carers recorded on their observation chart (FLACC, FACES or VAS age dependent).

• Pain should be scored on admission, and then 12 hourly as long as pain is not a feature of

their care. • Pain assessment should be recorded at more frequent intervals appropriate to the child’s

clinical condition if pain is identified as follows: • Whenever a child appears distressed or complains of pain and again 30 minutes after

analgesic intervention to assess for adequate relief. • More often (in line with clinical guidelines) if opioid infusion, PCA, epidural or

continuous regional analgesia are used. • Four hourly while pain is being managed by oral analgesics. • Continue to monitor and document pain for duration of hospital stay.



7 Escalation of concern linked to a child’s observations. • Escalation any concern regarding your child’s conditions as per the PEWS Action / Response

/ Escalation process (Appendix 1). Record all events fully in the child’s health record. 8 Paediatric Early Warning Score (PEWS) • The PEWS Escalation process referred to in appendix 1 must be used across the Trust for all

paediatric in-patients. Exceptions to the use of the PEWS may be made for children on a palliative care pathway or those children in paediatric intensive care (PIC).

MODIFICATIONS TO PATIENT LIMITS • The ONLY AMENDMENTS that may be made to the PEWS tool are ‘exceptions to the norm’.

Some children have pre-existing abnormalities that make one or more of their observations fall outside of the normal range. The decision that an ‘abnormal observation’ is ‘normal’ for a child must be made by the admitting doctor, child’s specialist medical team or a senior nurse and must be based on their knowledge of the child’s medical problem and physiology, for example a child with cyanotic heart disease will have a low oxygen saturation level .

• Any AMENDMENTS to a child’s accepted physiological parameters MUST be document in

the ‘modifications to physiological parameters’ section on the observation chart (see appendix 3),

• This section is the responsibility of the senior medical staff to complete (i.e. consultant or

registrar) & includes a need for the Drs initials / print name, date and time (See appendix 3).

• Each modification may have one change made to it, which must be initialled and dated. Any further changes require a new observation chart to be commenced.

• Any parameter recorded outside the above amendment(s) must have a PEW score of

‘4’ recorded.

• Non-completion of the ‘Modification to Patient Limits’ box assumes normal physiological ranges for age.

8.1 PEWS Escalation Response • The PEWS and escalation in appendix 1 will be used in all clinical areas covered by this

protocol. The escalation response must be followed to ensure a timely response to abnormal observations.

• If a child’s PEWS is ≥7 urgent action is required. Ensure you follow the escalation process

immediately (see appendix 1).

• Documentation of a child’s PEWS and the ‘action to be taken’ must be as stated in section 6.

• A PEW score of ≥16 = EMERGENCY OR LIFE THREATENING SITUATION, YOU MUST PHONE 2222 AND REQUEST IMMEDIATE ASSISTANCE.

8.2 Communication Process • The staff referring a child for medical review must use the SBAR. system of communication,

and have available all necessary information to fully inform the primary responder of the clinical picture and current set of observations.



SBAR. involves: Situation - state your name and ward, the name of the patient you are calling about, and what the problem is (e.g. “This is staff nurse X on ward 1. I am calling about a patient with a PEW Score of 9”). Background - give brief details of diagnosis, date of admission/operation, relevant history and current treatments (e.g. “Jay is 4 years old, normally fit and well, he was admitted with pyrexia”). Assessment - most recent observations, trends, and parameters triggering an increase in the PEWS (e.g. “His PEWS is 5 because of …[list individual observations]…and it seems like he is tiring”). Recommendation / Readback - what you want the primary responder to do e.g. attend, to review the patient, or give advice and set parameters for further review. (e.g. “Can you come and see him straight away please”). Ensure the referring member of staff requests ‘Readback’ from the clinician, to clarify their understanding of the situation, the response time and plan of care agreed. The content and outcome of this discussion should be documented in the ‘Significant Events’ section of the Observation Chart and, or more fully within the patient’s health record. Staff should initiate prescribed interventions, and assess and document the outcome of these. If the team caring for the child considers that admission to PICU is clinically indicated, then the decision to admit should involve both the consultant caring for the child on the ward and the consultant in PICU. 9 Additional Information On the back of the ward observation chart and in differing areas of the HDU chart there are opportunities to document additional information:

• Additional Observations e.g. respiratory assessment, wound, observations • Significant Events e.g. PEW score ≥7, apnoea’s, convulsions. • Any significant event that occurs with a children being monitored on an HDU

chart should have the event documented across the coloured graphed area of the chart, at the time of the event.

• Blood Gas Analysis Please complete as necessary. 10 Exclusion to standard physiological observations • All children who have been entered into an end of life care pathway. This must be

documented in the patient’s health record. • A child cared for in paediatric intensive care (PIC), where the PIC observation chart is being

used and the child is being physiologically monitored and cared for in a 1:1, or 1:2 nurse:patient ratio.



11 Documentation • All entries must follow the principles of documentation as identified by the relevant

professional body (i.e. Nursing and Midwifery Council & General Medical Council) and written in black ink only.

• Patient demographic details must be completed for each chart. • Observation charts must be kept by the child’s bedside and recorded clearly and legibly.

• All documented observations must be signed or initialled by the practitioner who took them.

If a non-registered practitioner has undertaken the child’s observations these must be counter signed by the registered nurse supervising the non-registered staff member.

• Observations must be documented on one of the 5 colour-banded, age-related charts

printed and provided by the Trust (0-3 mths 4-11 mths, 1-4 yrs, 5-11 yrs and ≥12 yrs) • Observation charts must clearly state when a patient has moved to another clinical area,

making it clear on which ward the physiological observations were taken.

12 Children cared for & seen in BRHC Out-Patient Departments (OPDs) • Children who are seen and, or reviewed in BRHC OPDs, or any outlying OPD staff by BRHC

are likely to have their observations taken by a Band 2-4 Health Care Support Worker.

• These staff have been educate in how to undertake children’s observations, in the recognition of acutely ill children and the required escalation process as identified within this Clinical Protocol. They will follow these processes accordingly.

• These children will not have their observation counter-signed by an RN, but where there are

high risk children e.g. Cardiology OPD, an RN is rostered to be present.

• Agreement for this standard has been supported by Paediatric Patient Safety Team and the BRHC OPD / CIU Governance Teams

13 Children discharged from PICU/PHDU • Children who leave PICU/PHDU must have a discharge plan completed in the patient’s

health record and a verbal medical and nursing handover provided to the receiving Team. • A printout of the child’s last 4hrs of observation from the PIC Critical Care Clinical Informatics

Systems (CICS) will be transferred with the child. This will provide an overview of the child’s condition and recent PEW scores.

• The regularity of a child’s observations once they have been discharged from PIC will be

made by clinical judgement of the child by the nurse / medical team taking over their care and their location i.e. ward or HDU bed.

• Transfer from critical care areas to the general ward between 22.00 and 07.00 should be

avoided whenever possible and should be documented as a patient safety incident.



• The critical care transferring team and the receiving ward team must take shared responsibility for the care of the child being transferred. There must be a formal structured handover of care supported by a written plan.

14 Transferring the acutely ill child • All children transferred internally must have the ‘Children’s Services Clinical Handover Sheet

completed, in addition to any individual ward or unit documentation e.g. BMT transfer sheet. All documentation must accompany the child.

• Children must be escorted by an appropriately trained member of medical or nursing staff who is familiar with the monitoring and equipment being used.

• Any complicated transfers should be discussed with the PICU medical staff. 15 Communication/ Dissemination of this protocol The protocol once approved and ratified by the BRHC Clinical Effectiveness Committee will be disseminated immediately electronically. The protocol will be disseminated to BRHC Matrons, Sisters/Charge Nurses, Lead Children’s Nurse, Medical Consultants, Patient Safety/Governance Team, UHBristol Patient Safety Team and Chief Nurse Team. It is the above individuals’ responsibility to ensure that all staff under their jurisdiction are aware of, and have ready access to the protocol. 16 Implementation of this protocol This protocol will have immediate effect once ratified. Staff directly affected will be informed of the final version being disseminated via email and face to face briefings and teachings. 17 Process for Monitoring Compliance and Effectiveness Compliance and effectiveness will be monitored and reviewed at local level by Ward Sisters/Charge Nurses and via the Patient Safety Thermometer / UHBristol QiCT (Quality in Care Tool), or equivalent. Audits of the protocol will be undertaken at regular agreed timeframes throughout the year, in-line with local and/or national guidance. All audit results will be fed back to clinical areas, and to the Divisional / Trust Patient Safety / Governance Groups. 18 Standards / Key Performance Indicators • On admission 100% of paediatric in-patients must have a respiratory rate, oxygen saturation

level, heart rate, blood pressure, capillary refill time, temperature and AVPU recorded. • As a minimum 100% of paediatric in-patients must have a respiratory rate, heart rate,

temperature and AVPU recorded 12 hourly and a blood pressure recorded 24 hourly. • Each set of observations should be accompanied by an accurate PEW Score, 100% of the

time. If this is not the case, a reason must be documented in the patient’s health record. • All demographic details must be recorded (100% of the time) or patient label attached. • The date and time of the observations must be recorded (100% of the time) • Evidence of PEWS assessment score of ≥9 being appropriately escalated (100% of the time)



There must be consistent implementation of the PEWS and escalation response on all wards and departments covered by this protocol. The escalation response must be followed 100% of the time to ensure a timely response to abnormal observations. 19 References / Bibliography Confidential Enquiry Maternal and Child Health (CEMACH) (2008). Why children die: A pilot study (2006) CEMACH. London Department of Health (2008) Competencies for Recognising and Responding to Acutely Ill Patients in Hospital. DH, London. McGloin H, Adams S, Singer M (1999). Unexpected death and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? Journal of the Royal College of Physicians in London 33 (3):255-59. National Confidential Enquiry into patient outcomes and death (2005) An acute problem. NCEPOD. London. National Institute for health and Clinical Excellence (2007) Acutely Ill Patient in Hospital; recognition of and response to acute illness in adults in hospital. NICE, London. National Patient Safety Agency (2005) Safer care for the acutely ill patient: learning from serious incidents. NPSA. London. National Patient Safety Agency (2007) Safer care for the acutely ill patient: learning from serious incidents. NPSA. London. RCN (2017) Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People http://www.mist-collaborative.net/paediatric-early-warning-systems/ (accessed May 2019) https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration (accessed May 2019)

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RELATED DOCUMENTS

Incident Management Policy

AUTHORISING BODY

Nurse Practice Group

SAFETY To encourage organisational patient safety improvement, failure to accurately observe, record or respond to patient observations or pain assessment should be reported as a patient safety incident.

QUERIES Contact the Consultant Nurse PIC/PHDU or the Paediatric Clinical Site Team on bleep 3217 or 2968


http://www.mist-collaborative.net/paediatric-early-warning-systems/

https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration



Appendix 1 PEW Score Escalation Response

Appendix 2 SBAR



Appendix 3 Modifications to Physiological Parameters


recording and acting upon physiological observations in

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