CHILDREN S OBSERVATIONS & SEVERITY TOOL (COAST FORMELY PEWS) & PAEDIATRIC OBSERVATION CHART POLICY Document Author Written By: Paediatric Sister Authorised Authorised By: Chief Executive Date: July 2017 Lead Director: Executive Director of Nursing and Quality Date: 10 th October 2017 Effective Date: 10 th October 2017 Review Date: 9 th October 2020 Approval at: Corporate Governance & Risk Sub-Committee Date Approved: 10 th October 2017 Version No. 3.0 Page 1 of 28
DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue Version No. Date Approved Director Responsible for Change Nature of Change Ratification / Approval 29 Mar 2012 1 29/03/2012 18 Mar 2014 5 Sept 2014 16 Sept 2014 1.1 Executive Director of Nursing and Workforce 1.1 Executive Director of Nursing and Workforce 2 Executive Director of Nursing and Workforce July 2017 2.1 Executive Director of Nursing and Quality 25 Aug 2.1 Executive Director of 2017 Nursing and Quality 11 Sep 3.0 10/10/2017 Executive Director of 2017 Nursing and Quality Updated to reflect COAST tools Policy review Ratified at Approved at Ratified at Clinical Standards Group Approved at Policy Management Group Clinical Standards Group Corporate Governance & Risk Sub-Committee NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust Version No. 3.0 Page 2 of 28
Contents Page 1. Executive Summary... 4 2. Introduction.. 4 3. Definitions 4 4. Scope 4 5. Purpose 4 6. Roles & Responsibilities 5 7. Policy Detail / Course of Action 5 8. Consultation 9 9. Training... 9 10. Monitoring Compliance and Effectiveness 9 11. Links to other Organisational Documents 9 12. References 9 13. Appendices... 10 Coast Forms.. 11 23 Appendix A Financial and Resourcing Impact Assessment on Policy Implementation.. 24 Appendix B Equality Impact Assessment (EIA) Screening Tool 26 Version No. 3.0 Page 3 of 28
1 Executive Summary 1.1 This policy provides guidance to assist both nursing and medical staff on both the Children s Ward/Unit and the Emergency Department in the correct use of the Children s Observation and Severity Tool (COAST) and the Paediatric Observation Charts. 2 Introduction 2.1 It is recognised that the early detection and optimal care in the critically ill adult is associated with improved outcomes (DOH, 2000). These are also equally important in children and may prevent the admission or transfer to Paediatric Intensive Care (Monaghan 2005). 2.2 There are a number of different scoring systems being used to identify adults who are at risk of deteriorating, however a literature search provides very few scoring systems orientated towards paediatrics. It is important to note that an adult scoring system should not be just transferred over for the paediatric population. An appropriate and validated system should be used. 2.3 The aim of an early warning system is to identify sick and/or deteriorating patients at an early stage to allow proactive intervention and management on the ward or in the Emergency Department and therefore reduce the rate of emergency resuscitations and intensive care admissions and transfers (Tune and Bullock 2004). 3 Definitions COAST Children s Observation and Severity Tool 4 Scope This policy applies to all paediatric registered nurses, nursery nurses and doctors working on the Children s Unit as well as all of the Registered Nurses, Emergency Department Assistants and Doctors working within the Emergency Department. Other clinical areas such as the Surgical Day Unit may use this system depending on their patients clinical needs. 5 Purpose The purpose of this policy is to provide clear and unambiguous standards for completing clinical observations on paediatric patients Version No. 3.0 Page 4 of 28
6 Roles and Responsibilities The key staff responsible for the adherence to this policy on the Children s Unit are the Senior Paediatric nurse on duty, the Deputy Sister and the Ward Sister. It is their duty to ensure the correct usage of the Observation Charts by all staff and that the Paediatric Medical staff are kept informed of the patient s condition. The Doctor s responsibility is to respond appropriately and in a timely manner to the COAST score, and document their response to review patient clinical condition according to COAST graded response. The key staff responsible for the adherence to this policy in the Emergency Department are the Senior Nurse on Duty, Deputy Sisters/Charge Nurses and the Senior Sister/Charge Nurse. It is all staff caring for paediatric patient s duty to ensure the correct use of the Observation Charts, calculation of COAST Scores and appropriate actions according to their COAST Score. The Doctor s responsibility is to respond appropriately and in a timely manner to the COAST score, and document their response and review patient clinical condition according to COAST graded response. 7 Policy detail/course of Action 7.1 How COAST Works The child is scored in relation to six parameters: Familial/medical/nursing concerns, Heart Rate, Respiratory Rate, Respiratory Distress, Receiving Oxygen and Conscious level. The child will score either zero (normal) or one (abnormal) for each parameter depending on if their observations fall outside the normal range. The scores are added together to give a COAST score. Blood Pressure, Glasgow Coma Scales / AVPU and pain scores do not contribute to COAST scores. The higher the score, the sicker or more acutely unwell the child is. A COAST score should be calculated every time a set of observations is carried out on a child and clearly documented on the observation chart, with any recommended actions taken appropriately. 7.2 Action After Score Obtained The scores help to assess a child s level of critical illness and deterioration over time. Matching the scores and algorithm at the base of the observation sheet gives a clear pathway for the nurse/doctor to follow. Version No. 3.0 Page 5 of 28
Every time a COAST score is over 3, this will trigger a response which must be recorded with any interventions on the reverse of the chart and in the patient s medical notes on the Children s Unit, or in the Child s Symphony record in the Emergency Department. 7.3 Chart Format The chart is a double sided A4 document, selected on age criteria providing clear details for use. (All charts are available as reference appendices A - H). The COAST criteria are clearly set out, including considerations for the COAST assessment process. Registered nurses and doctors are expected to attend internal departmental COAST training session as part of their professional development. 7.4 Course Of Action On admission to the Children s Unit: All charts will be labelled correctly with the patient s details, including name, date of birth, Isle of Wight number and date chart commenced. All patients will have a complete set of core observations documented on the PPOC upon their admission to hospital. Patient observations on admission will be: a. Respiratory rate b. Respiratory Distress c. Oxygen saturations d. Supplemental Oxygen required e. Blood Pressure f. Heart rate g. Temperature h. GCS/AVPU score (sedation level) A = Alert V = responds to Voice P = responds to Pain U = Unresponsive i. Urinalysis on admission, (urine output during hospital stay, hourly if clinical need is indicated). j. Pain score on 0-10 scale 0 = no pain 1-4 = mild pain 5-7 = moderate pain 8-10 = severe pain NB: if paediatric pain score is used such as Whaley and then the nurse scoring is responsible for recording it appropriately Version No. 3.0 Page 6 of 28
k. If at any time the COAST score is 3 or greater a baseline blood pressure will be recorded and with every subsequent observation. l. Patients who have sustained a head injury should have 15 minute neurological observations for the first hour regardless of COAST score recorded on an age specific neurological chart m. Patients receiving intravenous pain relief should have observations repeated following their administration On admission to the Emergency Department: If required due to clinical presentation, the patients first set of observations will be recorded on Symphony during Triage Assessment, subsequent observations will be recorded on an age appropriate observation chart All charts will be labelled correctly with the patient s details, including name, date of birth, Isle of Wight number and date chart commenced. Patient observations on admission will be: n. Respiratory rate o. Respiratory Distress p. Oxygen saturations q. Supplemental Oxygen required r. Blood Pressure (if appropriate) s. Heart rate t. Temperature u. GCS (if appropriate) v. Urinalysis on admission (if appropriate) w. Pain score on 0-10 scale 0 = no pain 1-4 = mild pain 5-7 = moderate pain 8-10 = severe pain x. If at any time the COAST score is 3 or greater a baseline blood pressure will be recorded and with every subsequent observation. y. Patients who have sustained a head injury should have 15 minute neurological observations for the first hour regardless of COAST score recorded on an age appropriate chart z. Patients receiving intravenous pain relief should have observations repeated following their administration On completing recording the observations, the nurse will date, time and initial the chart. If at any time other observation charts are used, then this information must be recorded in the supplementary charts in use box. This will demonstrate a clear audit trail. Version No. 3.0 Page 7 of 28
The registered nurse responsible for the patient determines the frequency of repeat observations according to the COAST score and the clinical needs of the patient. 7.5 Ongoing Monitoring And Actions Are Required When Any Child s Observations Score more than 2 On The COAST Scoring If at any time the child s condition is obviously of a critical nature then the nurse/doctor must not hesitate to call the Paediatric emergency team. The nurse responsible for the patients care will carry out the initial COAST assessment. If the score triggers a response (i.e. 3 or over) then this must be documented on the back of the chart in the table provided, along with any action taken by the nurse and the name of the doctor subsequently informed of the patient s condition, or in the Symphony notes in the Emergency Department. An SBAR tool is available on the reverse of the observation chart to assist nurses in providing appropriate information to their medical colleagues It is expected that if a doctor is called, they will respond within 15 minutes. This means that they will have contacted the nurse that has put out a call for assistance within 15 minutes. On the Children s ward this would initially be the paediatric trust grade Doctor on duty. If there is no response within 15 minutes, the nurse must not hesitate to call the next level of medical staff escalating if required to consultant level. The same process will be followed in the Emergency Department, escalating to the Middle Grade Doctor then Consultant as necessary. It should be remembered the consultant has ultimate responsibility for the patient s wellbeing. After discussing the patients observations and condition with the attending nurse, the doctor must make a clinical decision, dependant on the information available and the task that he/she may be involved with at that moment, i.e. if the doctor is already dealing with a critical situation, he/she should advice the nurse to contact the next level of medical staff available, offering relevant advice where possible to assist the nurse in the interim period. If the doctor is able to attend, he/she must give the nurse an expected time for his/her arrival at the scene, again giving relevant advice where possible. The nurse should ensure the patient s medical notes; relevant treatment charts and haematology/pathology results are ready for the doctor s arrival. Practitioners should contact the ward/dept. Leader or Matron (in-hours) or Bed Manager/Night Coordinator (out of-hours) if experiencing difficulty accessing medical assistance. Until the patient s condition is stabilised observations should be monitored as specified in the algorithm or more frequently if necessary Once the situation is under the control, the doctor must record all outcomes/interventions in the patient s medical notes, or in Symphony in the Emergency Department. Version No. 3.0 Page 8 of 28
8 Consultation Nationally approved document discussed with Emergency Department and Children s Ward currently in use. 9 Training This (Children s Observation and Severity Tool (COAST Formerly PEWS) and Paediatric Observation Chart Policy) does not have a mandatory training requirement but the following non mandatory training is recommended; in-house training on taking and recording observations. 10 Monitoring Compliance and Effectiveness Yearly audits on COAST are carried out on Children s Ward. These results are reported to the Clinical Business Unit Quality Improvement team on a quarterly basis. An annual audit of PICU and Paediatric emergency resuscitation calls will be carried out in addition by a deputy sister on Children s Ward who will also be responsible for auctioning any amendments to the policy and identifying staff members not adhering to policy in the event of failure. COAST audits will also be completed monthly in the Emergency Department; appropriate action will be taken by the Senior Sister/Charge Nurse on the results/findings of these audits. Results from this will provide evidence of the system s effectiveness and will be reported to Board level on a regular basis. 11 Links to other Organisational Documents Adult Observation Chart Policy (incorporating Modified Early warning Score MEWS) 12 References Akre M, et al. Sensitivity of the Paediatric Early Warning Score to identify patient deterioration. Paediatrics 2010; 125:763-769 APLS The Practical Approach (fifth ed.) ALSG. 2011 Samuels, M and Wietska, S.Wiley-Blackwell. BMJ Books. London. Duncan HP. Survey of early identification systems to identify inpatient children at risk of physiological deterioration. Archives of Diseases in Childhood. 2007; 92 (9):828.doi:10.1136/adc.2006.112094. Goldhill, D.R. (2000). Medical Emergency Teams. Care of the Critically Ill. 16, 209-212 Version No. 3.0 Page 9 of 28
http://www.institute.nhs.uk/safer_care/paediatric_safer_care/pews.html 12/5/14 Viewed Monaghan, A (2005) Detecting and Managing Deterioration in Children. Paediatric Nursing, volume 17, no1, Feb 2005. 13 Appendices Coast Forms Pages 11 23 Appendix A Financial and Resourcing Impact Assessment on Policy Implementation 24 Appendix B Equality Impact Assessment (EIA) Screening Tool 26 Version No. 3.0 Page 10 of 28
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Appendix A Financial and Resourcing Impact Assessment on Policy Implementation NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact. Document title Children s Observation and Severity Tool and Paediatric Observation Chart policy Totals WTE Recurring Non Recurring Manpower Costs 0 0 0 Training Staff 0 0 0 Equipment & Provision of resources 0 0 0 Summary of Impact: Risk Management Issues: Benefits / Savings to the organisation: Equality Impact Assessment Has this been appropriately carried out? YES/NO Are there any reported equality issues? YES/NO If YES please specify: Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Operational running costs 0 0 0 Totals: 0 00 Staff Training Impact Recurring Non-Recurring Totals: Version No. 3.0 Page 24 of 28
Equipment and Provision of Resources Recurring * Non-Recurring * Accommodation / facilities needed 0 0 Building alterations (extensions/new) 0 0 IT Hardware / software / licences 0 0 Medical equipment 0 0 Stationery / publicity 0 0 Travel costs 0 0 Utilities e.g. telephones 0 0 Process change 0 0 Rolling replacement of equipment 0 0 Equipment maintenance 0 0 Marketing booklets/posters/handouts, etc 0 0 Totals: 0 0 Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: 0 Signature & date of financial accountant: 00 Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Version No. 3.0 Page 25 of 28
Appendix B Document Title: Purpose of document Equality Impact Assessment (EIA) Screening Tool Children s Observation and Severity Tool and Paediatric Observation Chart policy To ensure correct, timely observations are performed and acted upon on paediatric patients Target Audience Paediatric staff Person or Committee undertaken the Equality Impact Assessment Emily Mullan 1. To be completed and attached to all procedural/policy documents created within individual services. 2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required. Positive Impact Negative Impact Reasons Gender Race Men Women Asian or Asian British People Black or Black British People Chinese people People of Mixed Race White people (including Irish people) Version No. 3.0 Page 26 of 28
Sexual Orientat ion Age People with Physical Disabilities, Learning Disabilities or Mental Health Issues Transgender Lesbian, Gay men and bisexual Children Older People (60+) Younger People (17 to 25 yrs.) Faith Group Pregnancy & Maternity Equal Opportunities and/or improved relations Notes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts. The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact: Legal (it is not discriminatory under anti-discriminatory law) YES NO Intended If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below: 3.2 Could you improve the strategy, function or policy positive impact? Explain how below: 3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or Version No. 3.0 Page 27 of 28
improves relations could it be adapted so it does? How? If not why not? Scheduled for Full Impact Assessment Name of persons/group completing the full assessment. Date Initial Screening completed Date: Version No. 3.0 Page 28 of 28