Policy & Procedure for assessing and measuring vital signs on Paediatric Patients and using the Paediatric Early warning score 1
Procedure Title: Executive Summary: Supersedes: Description Amendment(s): of Policy & Procedure for assessing and measuring vital signs on Paediatric Patients and using the Paediatric Early warning score The purpose of this document is to provide clear and structured guidance to all staff on completing clinical observations and using the Paediatric Early Warning Score System. The aim is to enable the safe and appropriate use of the system for prompt detection of a clinical deterioration of sick children on the Children s ward, Children s observation and assessment ward and in A&E. Guidelines for using Macclesfield Paediatric Early Warning Score (MPEWS) This policy now incorporates all clinical observations and also the use of PEWS. This policy will impact on: The Children s Ward, Emergency Dept, Paediatric Observation and Assessment ward Financial Implications: Non Known Policy Area: Children s Services Document ECT002385 Reference: Version Number: 2 Effective Date: Sept 2015 Issued By: Women s & Children s Review Date: Sept 2018 Services Authors: Joanne Shippey Impact Assessment Date: Sept 2015 APPROVAL RECORD Committees / Group Consultation Phase: Paediatricians, Children s Nurses, Associate Director Women and Children s Service Line, Children s service manager Clinical Lead - Children s Women and Children s Service Dr G Whitehead Line.. Associate Director Mrs S Davies. Date July 2015 Sept 2015 2
POLICY AND PROCEDURE FOR ASSESSING AND MEASURING VITAL SIGNS IN PAEDIATRIC PATIENTS AND THE USE OF THE PAEDIATRIC EARLY WARNING SCORE 1. Introduction The paediatric unit is committed to providing high quality care and assessment of patients. Assessing, measuring and monitoring children s vital signs are essential in the early detection of evolving critical illness. The aim of the Early Warning Score (PEWS) is to assist nurses and medical staff in prompt detection of any deterioration of a child s condition to ensure appropriate care is provided at the earliest opportunity. This policy gives guidance to staff to achieve a consistent standard of care to all patients when measuring and recording vital signs. 2. Roles and Responsibilities 2.1 Chief Executive has overall responsibility for the policies and procedures in use in the Trust. 2.2 Clinical Matron / Ward Manager is responsible for ensuring all staff caring for the patient have access to, and have read this policy. They are also responsible in conjunction with the Paediatric Practice Development Nurse to ensure that staff have appropriate access to training. The senior nursing sister s will promote the guidelines and ensure adherence to them 2.3 All nursing staff are responsible for ensuring that they are familiar with nursing guidelines and policies and that their practice follows nursing guidelines and policies 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 and temperature. 3. Implementation Clinical Observations A complete baseline set of observations (respiratory rate, heart rate, temperature, Oxygen saturations, blood pressure and early warning score) is 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 should include height, weight, glucose, urinalysis (if condition indicates) and assessment of other problems specific to the child s condition. If a child s PEWS score is 0 or 1 a minimum of four hourly observations must be undertaken unless otherwise agreed by the child s medical team and documented in the notes. If the score is above 1 then the frequency of observations must be increased. Appropriate equipment should be used for the age of the child. Observations should be recorded on the appropriate chart for the age of the child, charts available: 0-11 months,1-4,5-12 and 13+. In the unusual event a young person over 16 is admitted to the ward, the adult track and trigger charts should be used and appropriate training should be sought from the senior nurse/night sister for the hospital. Temperature Measurement: Babies under 4 weeks of age should have their temperature measured using a digital axilla thermometer as per NICE recommendation. For all other children an infa-red tympanic thermometer should be used. 3
Blood Pressure Measurement: The arm should be used for measuring BP but when this not possible in infants, the lower leg can be used. The correct size cuff is essential for an accurate reading. The cuff should be sufficient size to ensure overlap to cover 100% of the circumference of the arm and 2/3 of the length of the upper arm or lower leg. If a blood pressure reading is consistently high using an automated monitor over a period of time it should be re-measured using a manual sphygmomanometer. Early Warning Score: It is recognised that the early detection of changes in vital signs and optimal care in acutely unwell children may prevent the admission or transfer to intensive care (Monaghan 2005). The Confidential Enquiry into Maternal and Child Health (CEMACH) produced a report following a pilot study into why Children Die (2007). This report concluded that up to two thirds of childhood deaths may be preventable. One of the key findings from that was that prompt recognition of deterioration of a child s illness was paramount in preventing a child s death. The recommendation from this report is that all areas that care for paediatrics in hospital should have a standardised and rational monitoring system for children developing critical illness- An early warning score. Observations should be completed and plotted on the appropriate aged chart. The PEWS takes into consideration parental/nurse concern, level of consciousness and use of oxygen. Observations that fall into a shaded box on the observation chart scores 1. When the observations have been completed, add all the shaded boxes together to get the PEWS score. This should be documented at the bottom of the chart. The nurse should then take the appropriate action for the score. Score 0-1 Continue monitoring, minimum 4 hourly observations Score 2 Nurse in charge review, repeat observations within 2 hours Score 3 Nurse in charge and medical review. Increase frequency of observations to 1-2 hourly Score 4 Nurse in charge and medical review. Inform consultant Increase frequency of observations to ½ - 1 hourly Score 5-6 Registrar/consultant review, consider crash team. Continuous monitoring in place. Observations to be documented a minimum of every 15 minutes If the score is more than 3, this should be documented on the other side of the chart with the date and time. The reviewer should then document a plan of care on the chart which should include: investigations or interventions ordered, re-evaluation timeframe and acceptable physiological observation parameters. The SBAR tool Situation Background Assessment and Recommendation should be used when discussing a patient s condition with other professionals to ensure clear and appropriate information giving and actions required. The SBAR tool is located on every observation chart. 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 The tool does not replace clinical judgement, if a child is deteriorating acutely or the nurse has concerns about the child s condition, the appropriate medical staff should be informed regardless of their PEWS score. 4
Children Receiving Oxygen: 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 2 for Method of Oxygen Administration key.) Children receiving oxygen therapy must be on continuous oxygen saturation monitoring. 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. Children with a Head Injury: All patients with a head injury must have Neurological Observations recorded as per NICE guidelines on the frequency of observations of patients with a head injury or as the clinician requests. 2 charts are available for this: infant and child. Observation and monitoring of fluid balance: In patients that require fluid balance monitoring (e.g. on IV fluids, In DKA, renal, post surgical, acutely unwell etc), the nurse must chart volume administered (orally, enterally, intravenously) AND measurement of volume lost (urine, drains, nasogastric aspirates). The up to date running fluid balance status of the child must be calculated and documented at every entry on the chart. Entries must be cumulative over the period of monitoring. Patients who do not require full fluid balance but do require feeds to be monitored should have this documented on a daily feed chart Capillary Refill time: This is recommended for measuring circulation in sick infants and children. This should be assessed centrally on the sternum. Pressure should be applied with the fore finger, sufficient to blanch the skin, this pressure should be maintained for 5 seconds and then the time taken for the skin to return to its normal colour is measured. In children this is usually less than 2 seconds and in neonates less than 3 seconds. Level of Consciousness: In children with neurosurgical or neurological conditions this should be assessed using the GCS scoring system. For all other children and young people the AVPU system is sufficient. Post- Operative Care Vital signs can be affected by surgery and the frequency of observations should reflect the child s level of sickness or instability. Following simple procedure vital signs should be recorded every 30 minutes for two hours then hourly for 2-4 hours until the child is fully awake, eating and drinking. A further set of observations should be recorded prior to discharge. In the case of day surgery where children may be discharged more quickly, observations should be undertaken before discharge. Following adeno/tonsillectomy vital signs should be recorded every 30 minutes for 4 hours or more frequently if there is any evidence of bleeding. 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. Children in A&E The child should be triaged following normal procedure. If a child comes into the department with an illness or a head injury, a full set of observations are carried out and a PEWs score is calculated. The PEWs guidelines are followed. Staff education and training 5
For the early warning score, all staff will self-assess and then a competency form will be signed by a more senior nurse (e.g sister or senior sister) It is the responsibility of all staff that will need to use PEWS to make sure that they can use the system competently and confidently in line with the NMC code of professional conduct (NMC 2004), a record of competency will be kept. All new starters will have an introduction to PEWS as well as the competency as part of their induction. All staff using medical equipment for the measuring of vital signs should complete a self assessment competency form. If any training needs are identified from this they should seek the appropriate training from the Paediatric Practice Development Nurse or other senior nurse. A record will be kept of all staffs medical device competencies. 4. Audit The use of the PEWS tool will be audited annually to check adherence. The audit will assess whether: the score is being completed; if it is accurate and whether appropriate management plans are being documented and followed. The findings will be reported to the Clinical Governance Group. The audit findings will be developed into an action plan and this will be used as a tool to guide future teaching and development of the Early Warning Score. It is hoped that through audit, problems and issues surrounding the recording of vital signs and the use of PEWS will be highlighted. 5. Key Performance Indicators All Children admitted to the A&E dept, POBS or the children s ward have an Early Warning Score calculated on initial assessment Appropriate action required is documented / communicated in the medical notes Appropriate action is taken and documented in medical records Documented evidence if any variance on indicated action not being performed Appropriate re-assessment and EWS documented in the timescale indicated depending on the previous score 6. Review This policy will be reviewed on a three yearly basis by the Paediatric Practice Development Nurse in conjunction with the ward manager and Clinical Matron. 7. References Confidential Enquiry into maternal and child health (2008) Why children die? A pilot study London: CEMACH Cronshaw, H., Mcdowell, K., and Yates, R. (2006) Royal Manchester Children s Hospital Audit report: Evaluation of the Manchester Paediatric Early warning Score System, as a predictor of in house emergency admissions to the Paediatric Intensive Care unit, Manchester: RMCH. Department of Health (2000) Comprehensive Critical Care- A review of Adult Critical Care Services, London: DOH. 6
Monaghan, A. (2005) Detecting and managing deterioration in children, Paediatric Nursing Volume 17, No1, Feb 2005. National Institute for Health and Clinical Excellence(2007b) Feverish illness in children: NICE guideline,london: NICE.www.nice.org.uk National Institue for Health and Clinical Excellence (2011)Head injury Triage, assessment, investigation and early management of head injury in infants, children and adults, London: NICE http://www.nice.org.uk/nicemedia/pdf/cg56niceguideline.pdf NHS Institute for Innovation and Improvement (2011) Situation, background, assessment recommendation,london: NIII.http://www.institute.nhs.uk/safer_care/safer_care/Situa tion_background_assessment_recommendation.html Nursing and Midwifery Council (2004) The NMC code of professional conduct: standards for conduct, performance and ethics, London: NMC Royal College of Nursing (2011) Standards for assessing, measuring and monitoring vital signs in infants, children and young people, London: RCN. Appendix 2 Equality and Human Rights Policy Screening Tool 7
Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Procedure for assessing and measuring vital signs on Paediatric Patients and using the Paediatric Early warning score Details of person responsible for completing the assessment: Name: Joanne Shippey Position: Sister Team/service: Paediatric Ward State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) This document outlines guidance for the paediatric unit on assessing and measuring vital signs and using the paediatric early warning score 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document The population of Cheshire as at the 2005 mid year figures (Cohesia Report 2008) is 684,400. Age: 17.8% (30,500) of the population in Cheshire East is over 65 compared with 15.9% nationally. This results in a high old age dependency ratio, i.e. low numbers of working-age people supporting a high non-working dependant older population. The percentage of older or frail old is also considerably higher, with 2.3% (8,200) persons 85 and over compared to 2.1% nationally. Cheshire East has the fastest growing older population in the North West. By 2016, the population aged 65+ will increase by 29.0% (8,845) and the population aged 85+ by 41.5% (3,403). This will have an impact on the number of patients being managed by ECT and the complexity of the health and social care issues that the older person is experiencing. In addition the staffing profile of ECT will change to include an increasing number of staff over 65 in the workforce. Race: 8
The 2005 mid year estimate (Cohesia Report 2008) show that the majority of the population in Cheshire (94.6%) is White British, with 5.4% non White British. The Cheshire 2007-10 Local Area Agreement identified that minority ethnic communities account for around 3% of the population. Issues for BME communities include lack of knowledge of services, access to services, access to translation/interpretation, cultural differences, family values. Many people from BME communities experience poverty, poor housing and unemployment which make it difficult for them to lead healthier lives. 4180 migrant workers registered in Cheshire in 2006/07 and comparison to the mid- year population estimates for Cheshire in 2005 strongly suggests that Cheshire s migrant worker population is larger than every individual BME group other than the White-Other White group. Gypsies and travellers at the last count (July 2006) the highest number was recorded in the Borough of Congleton (125). 42% of gypsies and travellers report limiting long term illness compared to 18% of the settled population, with an average life expectancy 10-12 years less than settled population. 18% of gypsy and traveller mothers have experienced the death of a child compared to 1% in the settled population. Disability: There are over 10 million disabled people in Britain, of whom 5 million are over state pension age. Nearly 1 in 5 people of working age (7 million, or 18.6%) in Great Britain have a disability. Hearing loss: 1 in 4 has a hearing problem. Sight problems: There are 2 million people with sight problems in the UK. Learning disabilities: There is quite a high proportion of people with learning disabilities in the local area due to there being a number of residential homes/institutions in the area. Problems encountered can be lack of staff awareness, communication issues, information requirements. Dementia Approximately six in 100 people aged over 65 develop dementia and this rises to around 20 in 100 people aged 85 or over. Dementia affects 750,000 people in the UK. Carers Around 6 million people (11 per cent of the population aged 5+) provided unpaid care in the UK in April 2001. While 45% of carers were aged between 45 and 64, a number of the very young and very old also provided care. By 2037, it is anticipated that the number of carers will increase to 9 million. Gender On average in Cheshire, 49% of the population are male and 51% are female Transgender: No local data available, national trends show: 1/12,000 males, transgender from male to female 1/33,000 females, transgender from female to male Specific issues around access to services, specific services for men or women, and single sex facilities. In terms of the transgender population, GIRES (Gender Identity Research and Education Society ) gives an estimate of 600 per 100,000. If these figures were applied to the Cheshire East community based on the 2005 mid year estimates, there may be around 2,100 trans people in the area. 9
Religion/Belief In the Cheshire East area: Christian - 80% Sikh - 0.05% Buddhists - 0.16% Other religion - 0.15% Hindu - 0.15% No religion - 11.84% Jewish - 0.12% Not stated - 6.67% Muslim - 0.36% The Muslim population has the highest levels of ill health amongst faith groups this includes higher smoking rates amongst men and higher rates of coronary heart disease and diabetes. Sexual Orientation Lesbians, gay men and bi sexual people (LGB) make up to 5-7% of the UK population (Dept of Trade and Industry, 2003). 13% of Gay men and 31% Lesbian women are parents (Morgan and Bell, First Out: Report of the findings of Beyond the Barriers national survey of LGB people) The experience and health needs of gay men and women will differ. However, both groups are likely to experience discrimination, higher levels of mental ill health and barriers to accessing health care National Health Inequalities data shows that lesbian, gay, bisexual and transgender (LGBT) people are e 2001 census showed: significantly more likely to smoke, to have higher levels of alcohol use and to have used a range of recreational drugs than heterosexual people. They are also at greater risk of deliberate self-harm. Although most LGBT people do not experience poor mental health, research suggests that some are at higher risk of mental health disorder, suicidal behaviour and substance misuse 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) None: It offers guidance for measuring clinical observations on the ward. All patients will have these observations regardless of age, gender, race, religion or sexual orientation 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? No 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No x It offers guidance for checking clinical observations on the ward. All patients will have these observations regardless of race. Any explanations to parents and children whose first language is not English will be carried out using the Trust s interpretation and translation policy. Also, the Unit has a picture communications book in the ward communications aids box. 10
GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No x It offers guidance for checking clinical observations on the ward. All patients will have these observations regardless of gender. DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No x Some children/parents with disability may need further explanation when undertaking these observations and reasonable adjustments may need to be made in order for the procedures to be tolerated by the child. Similarly, patients with disability may have different baseline for the parameters of observations which should be taken into account and identified through discussion with the patient, parent/carer or through their patient passport. If necessary the Trust s interpretation and translation policy and the picture communications aids box can be utilised. For patients with learning disabilities, the health facilitator from CWP can be involved. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No x This guideline is only applicable to children. Age appropriate equipment will be used in taking observations and this is highlighted in the policy. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No x _ It offers guidance for checking clinical observations on the ward. All patients will have these observations regardless of sexual orientation RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No x It offers guidance for checking clinical observations on the ward. All patients will have these observations regardless of religion/belief. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No x It offers guidance for checking clinical observations on the ward. All patients will have these observations regardless of whether they are a young carer. Parents and carers will be involved in explanations about the equipment and decisions about treatment. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No x No other impacts identified 11
4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes x No b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: This guideline offers guidance for the undertaking of clinical observations and the paediatric early warning score for patients on the children s ward. Therefore there is a positive impact on all children and young people on the ward. c. If no please describe why there is considered to be no impact / significant impact on children 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? All relevant staff groups have had the opportunity to read and comment on this policy. Policy has been amended to reflect their opinions 6. Date completed: Review Date: 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 1. Ensure the play team is involved in caring for children with disabilities. 2. Consider involving Learning Disability Health Facilitator during admission. 3. Ensure all staff aware of communications box and contents Management team to encourage staff to consider these things. Ongoing. 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 30.9.15 12