Intro Who should read this document 2 Key Messages 2 Background 2

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: 1 st February 2018 Contents Section Page Intro Who should read this document 2 Key Messages 2 Background 2 1 Protocol 3 2 Standards 4-5 3 Roles & Responsibilities 5 4 Explanation of terms 6 5 References 6 Appendix 7 Age specific PEWS charts in use Newborn (<28 days) 7 Infant (<1 year) 8 Pre-school (1-5 years) 9 School child (5-11 years) 10 Age 12-16 years 11 Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 12

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). Page 2 of 12

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 Page 3 of 12

Standards Summary Table of Standards No Care (Standard) Responsibility Standard Exceptions Target 1 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 2 All patients to have observations undertaken 4 hourly as a minimum standard. 3 Frequency of observations to be determined by PEWS Score (Green, Yellow, Amber, Red) 4 Entries on the observation chart to be dated. Registered Nurse Named Nurse Named Nurse All health professionals performing observations Observation chart is present at the patient s bedside. Documented evidence on the Observation Chart. Documented evidence of planned frequency of observations to be detailed on Observation Chart. Documented evidence on the observation chart that the date is entered on the first set of observations each day. Where an 100% infant/child is not for resuscitation and a personal resuscitation plan (PRP) records so Patients on blood 100% transfusion observations Patients on drug infusions requiring specific observations. Clinical judgement justifies deviation from PEWS. 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. 6 Each set of observations to include respiratory rate. 7 Each set of observations to include pulse 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, All health professionals performing observations All health professionals performing observations Recorded evidence on the observation chart that respiratory rate has been taken. Recorded evidence on the observation chart that pulse has been taken. Page 4 of 12

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 concern then a reading should be taken using a manual sphygmomanometer 10 Each set of observations to include Temperature. Tympanic thermometers must not be used for children under the age of 4 weeks. RN RN Recorded evidence on the observation chart that blood pressure has been monitored. Recorded evidence on the observation chart that Temperature has been monitored. Documented method of temperature recording (Tympanic / oral/ rectal etc) 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 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. Page 5 of 12

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 Page 6 of 12

Appendix Page 7 of 12