Patient Observation and Monitoring - Paediatrics and

Patient Observation and Monitoring - Paediatrics and Neonatal Unit V4.0

Patient Observation and Monitoring - Paediatrics and Neonatal Unit V4.0

October 2018

Patient Observation And Monitoring - Paediatrics And Neonatal Unit V4.0 Page 2 of 23

Table of Contents

1. Introduction ................................................................................................................. 3

2. Purpose of this Policy/Procedure ............................................................................. 3

3. Scope ........................................................................................................................... 3

4. Definitions / Glossary ................................................................................................. 3

5. Ownership and Responsibilities ............................................................................... 3

6. Standards and Practice .............................................................................................. 5

7. Dissemination and Implementation .......................................................................... 9

8. Monitoring compliance and effectiveness ............................................................... 9

9. Updating and Review ................................................................................................. 9

10. Equality and Diversity ............................................................................................. 9

Appendix 1. Governance Information ............................................................................ 10

Appendix 2.Initial Equality Impact Assessment Form .................................................. 14

Appendix 3 –Paediatric Early Warning tool- identifying children at risk of deterioration. .................................................................................................................... 17

Appendix 4:Example of additional information on the front and back of PEWS chart. ........................................................................................................................................... 19

Appendix 5: Method of oxygen administration. ............................................................ 21

Appendix 6: Neurological Observation Chart- CHA2826 .............................................. 22


1. Introduction 1.1. This policy has been drawn up to ensure that all Paediatric and Neonatal patients within the Trust receive an appropriate level and type of observation and monitoring, according to their clinical condition and therapies delivered. Routine observations may not be appropriate during end of life care. In such circumstances the decision to discontinue routine observations will be discussed with the child’s consultant by the child’s nurse and the decision documented in writing in the medical and nursing notes. The appropriate level of monitoring in these circumstances: the type of observations to be made, their frequency, acceptable parameters and any actions to be taken if the observations fall outside these parameters will need to be discussed between the child’s nursing and medical teams and with the child and family. The child’s safety however, whilst an inpatient must be ensured. If the child’s condition subsequently improves the re-instigation of routine observations in line with hospital policy should be discussed with the child’s consultant and with the child and family.

1.2. This version supersedes any previous versions of this document.

2. Purpose of this Policy/Procedure The purpose of this policy is to give all staff guidance in the observation and monitoring of children in Child Health. It is the policy of Royal Cornwall Hospitals NHS Trust that all children admitted to this hospital receive an appropriate level and type of observation and monitoring.

3. Scope This policy applies to all staff who undertake the practice of obtaining patient observations and monitoring.

4. Definitions / Glossary ECG Electrocardiography PEWS Paediatric Early Warning Score SBARD Situation, background, assessment, recommendation, decision NMC Nursing and Midwifery Council HCSW Health care support worker STAMP Screening tool for the assessment of malnutrition in paediatrics Spo2 Peripheral capillary oxygen saturations NICE National guidelines for health and clinical excellence PERT Paediatric Emergency Response Team

5. Ownership and Responsibilities

5.1. Role of the Managers

Line managers are responsible for ensuring that:

Qualified nurses, student nurses & healthcare assistants are familiar with and follow the current Clinical Practice Guidelines in section 6.0 and the Paediatric Early Warning tool guidelines (Appendix 3).


All nurses, students and healthcare support workers (who undertake observation and monitoring) are trained and competent in the accurate recording of all vital signs: blood pressure, pulse rate, respiratory rate, temperature and pain assessment.

PEWS and observation learning pack is available and must be completed by Health Care Support Workers during their first three months in post.

Staff who use continuous ECG and/or pulse oximetry are trained in the use of this equipment and appreciate the equipment’s limitations.

Varying sizes of age appropriate equipment (including disposables) are readily available for the above.

Monitors and equipment are kept in good condition, with regular planned servicing by the medical physics department.

Defective equipment is withdrawn immediately from patient use and sent to medical physics (Trusts Medical Device Policy )

Age appropriate observation charts incorporating the Paediatric Early Warning tool are readily available to record the observations.

An appropriate level of staffing is in place to ensure that an adequate level of observation is facilitated (determined by the child’s clinical status). In children requiring higher frequency of observations, the patient caseload of the nurse caring for these child/children may need to be reorganised to enable him/her to undertake this level of monitoring effectively.

If staffing is not adequate to meet this need, the matron/senior nurse bleep-holder must be notified immediately.

5.2. Role of Individual Staff

All staff members working in Child Health are responsible for ensuring that:

They follow the Current Practice Guidelines-monitoring and observation. Section 6 and the Paediatric Early Warning Tool Guidelines (Appendix 3) and are familiar with Normal Parameters.

They have the appropriate level of knowledge and skill in the use of any monitoring equipment and therapies being used for his/her assigned patient/s. The nurse must

make known any practice limitations they have to the nurse in charge in order to remain accountable for his/her own practice (NMC Code of Professional Practice)

The exact time and date of observations are recorded on the observation chart.

The vital signs are recorded accurately , various factors that may affect vital signs e.g. state of wakefulness of the child, pain level, irritability of the child etc. must be documented.


Escalate concerns appropriately in accordance with guidance on the front of the PEWS chart where clear actions are detailed.

6. Standards and Practice

6.1. Training.

6.1.1 All staff are required to be competent in the use of E Observations and related devices. Most areas where paediatric patient are cared for use the EObs system provided by nervecentre, with a plan to introduce to all areas. If there are system failures within Eobs all areas must revert to the paper PEWS charts.

6.1.2 All staff using equipment must be trained in its use (ECG, pulse oximetry, manual sphygmomanometers, electronic blood pressure monitors etc.)

6.1.3 During the local induction period of new staff, mentors must ensure that all new registered nurses and HCSWs (if undertaking observation monitoring) are competent in undertaking basic observations (heart rate, respiratory rate, blood pressure, pulse oximetry). Deficiency in capability/competence must be dealt with by the Ward Manager/Deputy Ward Manager in line with Trust Capability policy.

6.1.4 Student nurses undertaking observations must be assessed by their mentor using the university practice competency document. Deficiencies must be fed back to the university link tutor and recorded in their practice book.

6.1.5 A database of all training undertaken re: equipment for observations is

maintained by senior nurse (or deputy) at ward level. 6.2. Clinical Practice Guideline- Patient Assessment and Monitoring.

6.2.1 A complete baseline set of observations (respiratory rate, heart rate, temperature, oxygen saturations, CRT, blood pressure and pain assessment) are undertaken on ALL children within one hour of admission onto the Paediatric Observation Unit or the ward area. This will usually coincide with the detailed patient assessment process which MUST include height, weight, age related developmental assessment and STAMP score, glucose level in all neonatal admissions, urinalysis (in some ward areas) and assessment of other problems specific to the child’s condition.

6.2.2 All children admitted to any observation or ward area must have a BP included in their initial observations. If this is difficult to obtain initially, go back and try again, hand over to ward staff if patient is transferred or speak to a senior member of staff.

6.2.3 Blood Pressure must be done at every episode of full observation taking.

6.2.4 A newly occurring low or abnormal BP must be alerted to medical staff.


6.2.5 lf at any intervention you are unable to obtain an observation and are

concerned about a child you must use the ‘refused-concerned’ function on E-Obs, document in the medical notes and inform a doctor.

6.2.6 Please remember to ask parents/carers if they are concerned about their child. Do not wait for them to tell you. This must be documented using the E-Obs function. This function can be used for parental/carer/nurse or medical concern. It contributes to the overall PEW score, therefore is vital in giving a correct score. If this is not used it could potentially give a falsely low score and change a treatment plan.

6.2.7 Patient’s weight must be documented on arrival, if a child has had a

previously estimated weight this must be replaced with an actual weight as soon as the child is well enough to be weighed. All patients that have been transferred to a paediatric ward from another area (i.e. ED or another Hospital) must be re weighed. ALL patients’ weights must be double checked and signed for on the admission proforma by two members of staff.

6.2.8 The respiratory rate must be observed for a full minute. The assessment of severity of respiratory distress/breathing difficulty must be assessed and documented. The appropriate tool is embedded within E obs.

6.2.9 Capillary Refill Time (CRT) is the rate at which blood returns to the capillary

bed after it has been compressed digitally.

6.2.10 Important elements to practice include the following:

1. The skin on the forehead or chest (sternum) are better for estimating CRT. 2. Where fingers are used, elevate the hand to the level of the heart. 3. Apply pressure with a forefinger, sufficient to blanch the skin. 4. Maintain pressure for five seconds, then release. 5. Count in seconds how long it takes for the skin to return to its normal colour. 6. The skin generally perfuses in less than two seconds in children and less

than three in neonates. 7. Record the site used. 8. Consider any factors that may affect CRT eg. a cold environment.

Based on:

1. The results of previous observations 2. The initial PEWS score 3. Recommended action 4. The clinical condition of the child

6.2.11 The registered nurse accountable for the child must decide along with the

medical team, the frequency of observations to be undertaken. This frequency must be recorded in the medical notes. A minimum of four hourly observations must be undertaken unless otherwise agreed by the child’s medical team and documented in the notes.


6.2.12 The frequency of observation monitoring and the observation trends for the

individual child will be reviewed at least once each shift by a registered nurse and medical staff, preferably at handover with the on-coming nurse. The nurse in charge must review all observations which have been escalated via E obs.

6.2.13 The level of monitoring MUST reflect the therapies being delivered to the child.

Consider whether the child is receiving any of the following and discuss with medical staff, in addition refer to patient care plans and Trust policies and procedures.

i. Oxygen therapy, pain assessment, narcotic/sedative infusion, epidural, blood transfusion, chemotherapy, chest drains.

6.2.14 All alarms must be enabled and audible to the nurse responsible for the

child’s care. Nurses must not allow children or parents/carers to disable alarms at any time and must discuss alarms and limits with children if appropriate, and with parents/carers.

6.2.15 If a child is receiving oxygen then the method of oxygen administration and the amount of oxygen being administered must be recorded along with oxygen saturation and the child’s respiratory rate. (See Appendix 4 for Method of Oxygen Administration key.) Children receiving oxygen therapy must be on continuous oxygen saturation monitoring. Please refer to the Child Health Oxygen Policy for full guidance regarding patients receiving oxygen therapy.

6.2.16 Children with tracheostomies should be nursed in an area where they can

be easily accessed by healthcare staff. If the child is not being directly observed by a health care professional, parent/guardian, careful consideration should be given to the level of monitoring required, particularly for neonates and infants (<1 year), or those with specific clinical concerns (e.g. children with poor head control or at risk of self-decannulation).Pulse oximetry must be used if clinically indicated.

6.2.17 Heart rate should be palpated manually/or listened to using a stethoscope if

possible in addition to being recorded from the oximetry pleth or ECG. If the pulse is irregular when palpated then palpate it manually for a full minute, inform the child’s medical team and consider ECG monitoring.

6.2.18 If the child is on continuous electronic monitoring of ECG and/or oximetry

then appropriate alarm limits MUST be set on the monitor. (SpO2 alarm set < 92% unless otherwise agreed with medical team due to child’s condition.) The alarm should NOT be silenced without first assessing the child. Condition specific parameters for oxygen saturation will be determined locally (cardiac patients for example) and recorded in the patient notes.

6.2.19 At the time of undertaking the observations the nurse must assess the child holistically, and decide whether the child is stable or whether a more detailed assessment needs to be undertaken (e.g. neurological observations, fluid balance).


6.2.20 Pain assessment must be completed on admission and continued regularly if child appears to be in pain or is showing any clinical signs of pain. A full and age appropriate pain assessment must be completed, scored and documented alongside any treatment given. A time for reassessment should also be stated and the result of that reassessment, documented. Any concerns or issues in relation to pain must be escalated and discussed with medical staff.

6.2.21 All patients with a head injury must have Neurological Observations as per

NICE guidelines on the frequency of observations of patients with a head injury. These guidelines are printed on the Trust Neurological Observation Chart and must be adhered to in full. See appendix 10. Any patient reporting a headache on assessment or displaying clinical indications of a head injury or neurological deficit must have baseline neurological observations performed and documented. Continuing neurological observations must be discussed and agreed with medical staff.

6.2.22 Neurovascular observations:

To apply to all limb injuries distal to the neck of humerus and femoral inter-trochanteric region. Both limbs should be assessed simultaneously, although it is only required that the injured/affected limb be recorded. It is essential to record a baseline of both limbs as a reference point to identify any anomalies such as absent pulses in the feet or altered movement or sensation from previous injury or condition. Any concerns, issues or deterioration must be reported to orthopaedic medical staff immediately.

6.2.23 If the child is in hospital longer than 7 days then their weight should be re-

assessed at least every 7 days.

6.2.24 A daily weight should be recorded (at the same time of day) to assess fluid balance where this is appropriate. E.g. Cardiac children on the wards receiving diuretic therapy, or children with renal failure and children in DKA.

6.2.25 In patients that require fluid balance monitoring (e.g. cardiac, renal, post surgical, trauma –if clinically indicated, acutely unwell, severe sepsis, gastroenteritis) the nurse must chart volume administered (orally, enterally, intravenously) AND measurement of volume lost (urine, drains, nasogastric aspirates). Urine mls/kg/hr must be calculated and documented at every entry on the chart. The up to date running fluid balance status of the child must be calculated and documented at every entry on the chart.12 and 24 hour totals must be completed. Entries must be cumulative over the period of monitoring. Patients who do not require full fluid balance but do require feeds/meals to be monitored should have this documented on a daily feed chart (CHA2858) There are separate Nutritional care plans for neonatal and non neonatal patients, staff must ensure they are using the right chart.

6.2.26 If clinically indicated in neonates and children less than 1 year, head

circumference should be measured on admission. This should be repeated weekly while the child remains in hospital and appropriate care plan must be in place.


6.3. Liability.

6.3.1 Registered nurses are individually accountable for their actions and their standard of practice. Health care assistants and student nurses must act under the direct supervision of a registered nurse.

6.3.2 The Trust is vicariously liable for the actions of staff in respect of civil claims for compensation.

6.3.3 Registered nurses are under a contractual obligation to operate within this

policy and associated guidance.

7. Dissemination and Implementation This policy will be disseminated to all staff via email and publication on the Document Library. Any new version of this policy will be re circulated and all relevant staff made aware of the updates.

8. Monitoring compliance and effectiveness

Element to be monitored

Compliance with the observation and monitoring of patients within the child health directorate. Compliance with use of the PEWS tool.

Lead Ward managers and Clinical Matron Child Health.

Tool Monthly quality nursing matrix. Audit.

Frequency Monthly. At time of policy review.

Reporting arrangements

Reported to Lead Nurse, Ward managers, Practice Development Forum, Audit and Guidelines.

Acting on recommendations and Lead(s)

All staff.

Change in practice and lessons to be shared

Via all staff communication and relevant training. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders.

9. Updating and Review This document will be reviewed in June 2021 and discussed at the Paediatric Practice Development Group.

10. Equality and Diversity This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement.

10.1. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.


Appendix 1. Governance Information

Document Title Patient Observation and Monitoring -

Paediatrics and Neonatal Unit V4.0

Date Issued/Approved: September 2018

Date Valid From: 17 October 2018

Date Valid To: 17 October 2021

Directorate / Department responsible (author/owner):

Melanie Gilbert – Matron Child health

Contact details: 01872 25 2411

Brief summary of contents

This policy has been drawn up to ensure that all Paediatric and Neonatal patients within the Trust receive an appropriate level and type of observation and monitoring, according to their clinical condition and therapies delivered.

Suggested Keywords:

Observation Monitoring Documentation PEWS

Target Audience RCHT CFT PCT

Executive Director responsible for Policy:

Tunde Adewopo

Date revised: September 2018

This document replaces (exact title of previous version):

POLICY FOR PATIENT OBSERVATION AND MONITORING IN CHILD HEALTH V3

Approval route (names of committees)/consultation:

Child Health Directorate. Consultants and senior staff. Lead Nurse Matron- Neonatal unit Ward Managers Paediatric Practice development Forum Audit and Guidelines meeting – September 2018

Divisional Manager confirming approval processes

Tunde Adewopo

Name and Post Title of additional signatories

None

Name and Signature of {Original Copy Signed}


Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

Name: Caroline Amukusana

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Paediatrics Neonatal

Links to key external standards

Related Documents:

Advanced Paediatric Life Support (3rd Edn) Recognition of the seriously Ill Child (Chapter 3) p. 17 -18. Andrews T, Waterman H (2005) Packaging: a grounded theory of how to report physiological deterioration effectively J Adv Nursing; 52(5): 473-481. Buist M, Bernanrd S, Nguyen T, Moore G and Anderson J (2004) Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 62. Derrico D (1993) Comparison of blood pressure measurement methods in critically ill children. Dimensions of critical care nursing vol 12(1) Jan-Feb. DoH (2003) Getting the right start: The Children’s National Service Framework – Standards for Hospital services. Haines C, Perrott, M & Weir P (2005) Promoting Care for Acutely Ill Children – Development and evaluation of a Paediatric Early Warning Tool Intensive & Critical care Nursing Dec. Haines C (2005) Acutely Ill Children within ward areas – care provision and possible development strategies Nursing in Critical care vol 10(2): 98-102. Harrison GA, Jacques TC, Kilborn G et al (2005) The prevalence of recordings of the signs of critical conditions and emergency responses in hospital wards – the SOCCER study. Resuscitation 65; 149-157 Mackay C., Burke D., Burke J., Porter K., Bowden D., Gorman D. Association between the assessment of conscious level using the AVPU system and the Glasgow coma scale. Pre-Hospital Immediate Care


2000;4:17-19 McBride J, Knight D, Piper J & Smith G (2005) Long-term effect of introducing an early warning score on respiratory rate charting on general wards Resuscitation 65; 41-44. Monaghan, A (2005) Detecting and managing deterioration in children Paediatric Nursing vol 17(1) Feb; 32-35. Morley, Thornton, Fowler, Cole and Hewson (1990) Respiratory rate and severity of illness in babies under 6 months old. Archives of diseases in childhood 65. Naeem N & Montenegro H (2005) Beyond the intensive care unit: A review of interventions aimed at anticipating and preventing in-hospital cardiopulmonary arrest. Resuscitation 67; 13-23 NCEPOD (2005) An acute problem – a report of the national confidential enquiry into patient outcome and death. NMC (2004) Standards of proficiency for pre-registration nursing education. Patient Observations and Monitoring on Ward Areas Policy Page 6 of 9 - 05/07/2010

Park & Menard (1987) Accuracy of blood pressure measurement by the Dinamap monitor in infants and children. Paediatrics vol 79(6) 6 June. RCN guidelines for staffing on Paediatric wards (2000) Ryan, Cadman & Hann (2004) Setting standards for assessment of ward patients at risk of deterioration. British Journal of Nursing vol 13(20). Tibballs J, Kinney S, Duke T, Oakley E, Hennessey M (2005) Reduction of Paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Archives of Diseases in Childhood: 90; 1148-1152. Tume L (2005) A 3 year review of emergency PICU admissions from the ward in a specialist cardio-respiratory centre. Care of the Critically Ill vol 21 (1) 4-7. Tume & Bullock (2004) Early warning tools to identify children at risk of deterioration: a discussion. Paediatric Nursing vol 16(8) October Tume, L (2006) The deterioration of children in ward areas in a specialist Children’s Hospital. Standards for assessing, measuring and


monitoring vital signs RCN 2017 Clinical protocol for recording and escalating physiological observations in paediatric in-patient areas within UHBristol NHS Foundation Trust. Sep 2017 Feb) Trust Policies: RCHT Pain service-Paediatrics. Nursing Guidelines for use of Patient Controlled Analgesia (PCA) Or intravenous opioid infusion. RCHT Clinical Record keeping Policy 2009

Training Need Identified? All relevant child health staff to read updated policy.

Version Control Table

Date Version No

Summary of Changes Changes Made by

(Name and Job Title)

1 July 2010 V1 Original document Mary Baulch Tabitha Fergus

17 May 2012

V2 Updated and reviewed. PEWS and SBAR altered to reflect new directorate paperwork.

Tabitha Fergus

May 2016

V3 Updated and reviewed. PEWS and SBAR altered to reflect new directorate paperwork

Tabitha Fergus Mary Baulch

September 2018

V4

Change of title and inclusion of E observations and new sepsis protocol. Paragraph re weighing of children added to section 6.2 . Escalation and CRT information added.

Tabi Fergus Practice development nurse Melanie Gilbert Matron.

All or part of this document can be released under the Freedom of Information

Act 2000 This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2.Initial Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Patient Observation and Monitoring - Paediatrics and Neonatal Unit V4.0

Directorate and service area: Women , children’s and sexual health

Is this a new or existing Policy? exisiting

Name of individual completing assessment:

T.Fergus

Telephone: 01872252596

1. Policy Aim*

Who is the strategy / policy / proposal /

service function aimed at?

To provide information for staff on standard procedure and expectations for patient observation in paediatric and the Neonatal Unit.

2. Policy Objectives*

Standardised best practice.

3. Policy – intended Outcomes*

Standardised best practice.

4. *How will you measure the

outcome?

Audit and review, escalation via EObs system.

5. Who is intended to benefit from the

policy?

Children and families, staff.

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x x

Please record specific names of groups Ward managers Nerve centre Practice development group Matron

What was the outcome of the consultation?

Policy agreed


Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age x No areas indicated.

Sex (male,

female, trans-gender / gender reassignment)

X No areas indicated.

Race / Ethnic communities /groups


Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.


Religion / other beliefs


Marriage and Civil partnership


Pregnancy and maternity


Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian


You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have

been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

x

9. If you are not recommending a Full Impact assessment please explain why.

No areas indicated.

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


Signature of policy developer / lead manager / director M.Gilbert

Date of completion and submission September 2018

Names and signatures of members carrying out the Screening Assessment

1. M Gilbert 2. Human Rights, Equality & Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust’s web site. Signed __ M.Gilbert_____________ Date _____September 2018___________


Appendix 3 –Paediatric Early Warning tool- identifying children at risk of deterioration. 1. Each set of physiological observations taken must be documented using Paediatric Early Warning tool age appropriate observation charts found on the Eobs system. There are 4 charts for 4 age ranges. 2. Unexpected observations that are outside of normal parameters recorded by student nurses, health care assistants or agency staff will be escalated via the EObs system and must always be investigated, repeated and documented by the nurse caring for the child. 3. Nine clinical parameters are assessed and recorded as part of the child’s routine clinical observations, providing a score between 0-9. (Higher scores are seen in sicker children.) The PEW tool is triggered if one or more of the criteria are met. Criteria are shown clearly by coloured shading on the age appropriate Observations chart, and is embedded in the EObs system. Detailed actions are described according to first PEW score, a persisting score at current level with no evidence of previous action and deterioration to the documented score. These must be actioned and escalated as appropriate and documented in the patients joint nursing and medical notes. Escalation is automatically initiated when using the EObs system. 4. Any PEW score of 3 or more will trigger the sepsis screening tool, please refer to the Paediatric Sepsis Screening & Action Tool, and use the age appropriate tool (under 5 years and 5-18 years). The sepsis audit tool available at http://formic/formicwebforms/ must be completed for every child that meets the criteria for sepsis management. 4. The SBARD tool – Situation Background Assessment Recommendation and Decision should be used when discussing a patient’s condition with other professionals to ensure clear and appropriate information giving and actions required. The SBARD tool is located on the back of every observation chart for reference. 5. Some children will transgress the PEW criteria in their normal state e.g. some severe cyanotic heart defects. The medical teams responsible for these children must set alternative parameters so that they can be alerted of potential deterioration. They must be documented clearly on the Modification to Patient Limits box on the back of the PEWS chart. The ability to modify is also embedded within the EObs system. 6. If the child’s clinical condition deteriorates triggering the PEWs tool the frequency of the observations must increase to the level that the registered nurse feels is appropriate to the child’s condition. This increase in frequency must be documented with the reason for the increase. If initial PEW score is 2 or more then observations must be repeated in 15 minutes and documented hourly until the child is confirmed stable or the PEW score decreases. 7. Once the tool is triggered, and clinical observations have been re checked after 15 minutes - a member of the child's medical team or the on call team will be contacted to review the child within 15 minutes.

http://formic/formicwebforms/


9. The tool does not replace clinical judgement, if a child is deteriorating acutely or is pre-arrest call PERT on 2222. If at any time additional help is required, call for help- regardless of the PEW score. 10. Once the child is reviewed and examined, a plan must be documented which should include: investigations or interventions ordered, re-evaluation timeframe and acceptable physiological observation parameters. 11. If the nurse remains concerned about the child, despite the medical review and following further discussion with the assessing medic they should seek more senior medical advice and alert the Matron/senior nurse bleep holder, if necessary. 12. In the event of problems with Nervecentre and the Eobs system being unavailable staff must revert to the paper PEWS scoring system and observations charts.


Appendix 4:Example of additional information on the front and back of PEWS chart.



Appendix 5: Method of oxygen administration.

Method of Oxygen administration

RBM Re Breath Mask

FM Face Mask

NC Nasal Cannulae

HB Head Box

T Tracheostomy

N Nebuliser

WO Wafting Oxygen

V Vapotherm

CPAP Continuous Positive Airway Pressure

BiPAP Bi Level Positive Airway Pressure


Appendix 6: Neurological Observation Chart- CHA2826
