Paediatric Inpatient Observation Policy
Classification: Policy
Lead Author: Nathan Griffiths, Consultant Nurse – Paediatric
Emergency Medicine
Additional author(s): N/A
Authors Division: Salford Healthcare
Unique ID: DDCPan04(14)
Issue number: 2
Expiry Date: 1st February 2018
Contents
Intro
1
2
3
4
5
Section
Page
Who should read this document
Key Messages
Background
2
2
2
Protocol
Standards
Roles & Responsibilities
Explanation of terms
References
3
4-5
5
6
6
Appendix
Age specific PEWS charts in use
Newborn (<28 days)
Infant (<1 year)
Pre-school (1-5 years)
School child (5-11 years)
Age 12-16 years
7
7
8
9
10
11
Document control information (Published as separate document)
Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis
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Who should read this document?


PANDA Medical & Nursing Staff
Emergency Department staff managing and transferring paediatric patients to
PANDA
Key Messages
This document is to ensure all Trust employees dealing with infant and child
assessment and admission are aware of their responsibilities and actions in relation
to recording and documenting clinical observations.
 Physiological observations must be documented on an AGE APPROPRIATE
PEWS Chart.
 A score of 3 should trigger a clinician review within 10 minutes.
 A score of 4 or more should trigger immediate clinician review.
Background
The Confidential Enquiry into Maternal and Child Health (CEMACH) ‘Why Children
Die’ report (2008) concluded that up to two thirds of childhood deaths may be
preventable. One of the key findings from the study was that prompt recognition of
deterioration of a child’s illness was paramount in preventing a child’s death and
thereby recommendation made for areas caring for paediatrics patients to have a
‘standardised and rational monitoring system for children developing critical illness’.
The assessment, measuring and monitoring of a child’s vital signs are an essential
and fundamental part of the monitoring process to early detection thus the Trust
operates a Paediatric Early Warning System (PEWS) to assist medical and nursing
staff in the prompt detection of any deterioration of a child’s condition to ensure
appropriate care is provided at the earliest opportunity.
Within the United Kingdom a variety of PEWS trigger tools have been devised and
adopted. SRFT have adopted and adapted the initial PEWS devised by Monaghan
(2005).
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Protocol
Using the PEWS
A complete baseline set of observations (Temperature, Heart Rate, Respiratory
Rate, Oxygen Saturations, Blood Pressure and Pain Score) should be performed on
every child admitted to the hospital within one hour of attendance. Justification for
non compliance must be clearly documented within the patient’s notes.
The assessing clinician must identify an initial frequency of required observations,
which should be documented on the PEWS chart. This initial frequency may alter
dependent upon subsequent recordings as dictated by the scoring system.
Each set of physiological observations must be documented on the AGE
APPROPRIATE PEWS Chart.
Abnormal observations recorded by a student nurse or non registered nurse must be
verified by a qualified nurse.
A total paediatric early warning score must be clearly documented on the
observation chart to coincide with each set of observations.
This score will dictate further actions possibly including a change in the frequency of
subsequent observations. Such a change in frequency must be documented on the
chart.
When a patient’s EWS score triggers, nursing staff must ensure that a medical
review is undertaken. Medical staff responsible for undertaking the review must do
so in timely manner, as indictated upone the PEWS charts (see appendix). Any
deviation from the suggested actions must be clearly justified and documented both
in the appropriate section on the chart and also the patient’s notes.
Some children with chronic illness may trigger their PEWS despite being well. In this
instance the PEWS parameter values should be reviewed and an alternative range
of trigger parameters jointly agree upon by medical and nursing staff must be set.
The tool does not replace the clinical judgement of either the nursing or medical
team. If a child is deteriorating or if concerns are raised despite the presence of a
low early warning score, the alert process should be activated regardless.
When a review is triggered by the early warning score and examination has taken
place, a clear plan of care must be documented in the patient notes including; time of
review, examination findings, investigations or interventions requested and any
deviation from the scoring tool with regards to frequency of subsequent
observations. A summary of this must be included on the appropriate section of the
observation chart
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Standards
Summary Table of Standards
No
Care (Standard)
Responsibility
Standard
Exceptions
Target
Children admitted to the
PANDA unit will have an
PEWS observation chart
commenced and their
clinical observations
recorded within
approximately 1hrs from
time of admission
All patients to have
observations undertaken
4 hourly as a minimum
standard.
Registered
Nurse
Observation chart is
present at the
patient’s bedside.
None
100%
Named Nurse
Documented
evidence on the
Observation Chart.
Frequency of
observations to be
determined by PEWS
Score
(Green, Yellow, Amber,
Red)
Named Nurse
Documented
evidence of planned
frequency of
observations to be
detailed on
Observation Chart.
4
Entries on the
observation chart to be
dated.
All health
professionals
performing
observations
Documented
evidence on the
observation chart
that the date is
entered on the first
set of observations
each day.
5
All entries on observation
chart to specify actual
time observations were
undertaken.
All health
professionals
performing
observations
Documented
evidence on the
observation chart
that all entries
specify time.
None
100%
6
Each set of observations
to include respiratory
rate.
100%
Each set of observations
to include pulse
Recorded evidence
on the observation
chart that respiratory
rate has been taken.
Recorded evidence
on the observation
chart that pulse has
been taken.
None
7
All health
professionals
performing
observations
All health
professionals
performing
observations
None
100%
1
2
3
A manual pulse should
be taken every time a
set of observations is
undertaken to assess
the pulse properties,
and develop and
maintain practitioner
expertise. Readings
from oxygen
saturation monitors
should not be used.
For children under the
age of two years,
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

Where an
infant/child is not for
resuscitation and a
personal
resuscitation plan
(PRP) records so
Patients on blood
transfusion
observations
Patients on drug
infusions requiring
specific
observations.
Clinical judgement
justifies deviation
from PEWS.
None
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100%
100%
100%
heart rate should be
assessed by using a
stethoscope and
auscultating the apex
beat.
8
Each set of observations
to include a recording of
systolic/diastolic blood
pressure. If there is any
RN
concern then a
reading should be
taken using a manual
sphygmomanometer
Recorded evidence
on the observation
chart that blood
pressure has been
monitored.
None
100%
10
Each set of observations
to include Temperature.
Tympanic thermometers
must not be used for
children under the age of
4 weeks.
RN
Recorded evidence
on the observation
chart that
Temperature has
been monitored.
Documented method
of temperature
recording (Tympanic
/ oral/ rectal etc)
None
100%
11
Each set of observations
to include oxygen
saturation.
RN
Recorded evidence
on the observation
chart that oxygen
saturation has been
monitored against
the patients
prescribed oxygen
target saturation
None
100%
Once the observations have been documented on the observation chart the nurse
will then refer to the Paediatric Early Warning Score tool (PEWS tool).
The recorded observations will then be cross-referenced against the child’s
anticipated norm values upon the PEWS Tool. All the values for the clinical
observations are displayed in a traffic light system.
Green Observations are within safe range
Amber Observations are bordering on an unsafe range
Red Observations are abnormal for the age of the child
Roles & Responsibilities
1.1
Medical staff managing infant and child admissions
Must ensure that they are familiar with the Trusts procedures for completion of
PEWS and trigger score procedure. Medical staff of registrar level or above who are
responsible for the supervision and training of junior doctors should ensure that
junior medical staff are aware of their role and that they respond appropriately to
each individual scoring.
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1.2
Nursing Staff
It is the responsibility of the registered nurse to ensure the PEWS Policy is adhered
to when assessing infants and children.
Explanation of terms
PEWS - Paediatric Early Warning System
References
1.
Confidential Enquiry into Maternal and Child Health (2008) Why Children die?
A pilot study. CEMACH. London.
2.
Monaghan, A (2005) Detecting and managing deterioration in children
Paediatric Nursing. vol 17(1) Feb;32-35.
3.
Royal College of Nursing (2013 )Standards for assessing, measuring and
monitoring vital signs in infants, children and young people. RCN. London
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Appendix
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