Clinical Guidelines (Nursing)

Observation and Continuous Monitoring

  • Aspects of this guideline relating to the use of ViCTOR charts are relevant from Jan 7, 2015 (RCH launch of charts.)

    Introduction

    Aim

    Definition of Terms

    Guideline Details

    Companion Documents

    Evidence Table

    References

     

    1. Introduction

    Regular measurement and documentation of physiological observations (i.e. clinical observations) are essential requirements for patient assessment and the recognition of clinical deterioration.

    The Victorian Children’s Tool for Observation and Response (ViCTOR) charts are a set of 5 age-specific ‘track and trigger’ paediatric observation charts for use in Victorian hospitals, and are designed to assist in recognising and responding to clinical deterioration in children.

    An age appropriate ViCTOR chart must be used for all inpatients at RCH. The charts are available for the following 5 age groups: less than 3 months, 3 to 12 months, 1 to 4 years, 5 to 11 years and 12 to 18 years. At RCH there are no adult charts and the 12-18 years chart
    should be used for young people older than 18 years.

    These ‘track and trigger’ charts mandate a response by the clinician once the patient’s observations reach a designated ‘zone’. Concerning changes in any one observation, or vital sign, are indicated by two coloured zones (Orange and Purple). If a child’s observation transgresses the Orange or Purple zone an escalation of care response is triggered. The type and urgency of the escalation response depends on the degree of clinical abnormality.

    2. Aim

    To provide guidance to clinical staff regarding the:

    • Measurement of clinical observations;
    • Use of the Victorian Children’s Tool for Observation and Response; and
    • Role of continuous cardio-respiratory monitoring and pulse oximetry monitoring.

    3. Definition of terms (abbreviations and acronyms)

    • ANUM- Associate Nurse Unit Manager
    • CPMS – Children’s Pain Management Service
    • ECG - Electrocardiograph
    • ED - Emergency Department
    • ICP - Intracranial Pressure
    • MET - Medical Emergency Team
    • PACU - Post Anaesthetic Care Unit
    • PCA - Patient Controlled Analgesia
    • PICU - Paediatric Intensive Care Unit
    • Rapid Review – review of patient by Bed-card doctor within 30 minutes of request.

    4. Guideline details

    A. Clinical Observations

    Clinical observations include estimation of haemoglobin-oxygen saturation (SpO2, pulse oximetry), oxygen delivery, respiratory rate, respiratory distress, heart/pulse rate, blood pressure (systolic, diastolic and mean), temperature, level of consciousness OR level of sedation, and a pain score. In certain clinical circumstances further observations (for example, neurological observations or neurovascular observations) may be required.

     
    Clinical observations will be recorded by the Registered Nurse as part of a full nursing assessment on admission to hospital, at the beginning of each shift and at a frequency determined by the child’s clinical status. Further guidelines about Nursing Assessment can be found here.

     
    The frequency of observations should be documented on the ViCTOR chart, unless they are to be performed routinely, 4 hourly.

     
    The type and frequency of observations must reflect the therapies and interventions being delivered to the child and be consistent with requirements of other individual guidelines and procedures. For example, required observations during blood product transfusions and all fresh blood products can be found here.

     
    Observations should be performed at least once per hour if the patient:

    • Has previous observations within the shaded orange or purple zone (unless modified)
    • Was transferred from PICU/NICU (for 8 hours or as clinically indicated)
    • Is receiving PCA, Epidural, or Opioid infusion
    • Is receiving an Insulin infusion
    • has ICP monitoring
    • is receiving oxygen therapy

    (Note, some children will require hourly observations and continuous monitoring as described later in this guideline).

     
    Clinical observations must be recorded before transfer from one area to another, for example from ED to ward, PICU to ward or PACU to ward. If a child's observations are transgressing the Orange or Purple zone, this must be addressed prior to transfer.

     
    The registered nurse responsible for the child’s care will determine the type and frequency of observations based on the results of previous observations and the child’s clinical condition, and in consultation with others involved in the child’s care.

    B. Observation Charts (ViCTOR)

    See Video explaining ViCTOR charts.

     
    Ensure the correct ‘age-appropriate’ observation chart is used. In addition, ensure that observations are entered onto the correct chart for the patient by identifying the patient and their chart. The patient label is placed on the front of the chart but the patients’ surname, given name, and UR number must also be written on the inside page (observations page).

     
    The child’s actual age and weight are to be recorded at the top of the chart.

    Coloured zones

    There are 3 distinct coloured ‘zones’ within the ViCTOR charts.

     

    The White zone is considered the ‘acceptable zone’. That is, most patients trending in this area are considered to have acceptable age-related vital signs. Nevertheless, it is important to be vigilant – for example, a heart rate that is steadily rising in this White zone should trigger attention before crossing into the Orange zone.


    The Orange zone is the first zone to signal that the patient may be deteriorating. It triggers the clinician to escalate care to the Nurse in Charge (at a minimum) to decide if a medical review or other emergency response is required. The Purple zone is the second and more concerning trigger and signals that the patient may be deteriorating or is seriously ill. If the patient is in the Purple zone, an emergency call must be initiated, that is, a Rapid Review or MET call.


    Appropriate escalation of care must occur as per the Deteriorating Patient: Escalation of Care flow chart and the Medical Emergency Response procedure (to be published as policy and procedure.)

     
    Remember, regardless of what zone the patient is in, if a staff member or parent is very worried about the child’s clinical state, initiate an emergency response.

    O2 Saturation and oxygen delivery

    Haemoglobin-oxygen saturations (SpO2) should be written numerically in the allocated box.


    Oxygen delivery refers to the flow (L/min) or percentage (%) of oxygen that the patient is receiving. If no oxygen is given, write 'RA' (room air).

     

    The device used to deliver oxygen should be noted as follows:

    • Nasal prongs (NP)
    • Hudson Mask (HM)
    • Humidified Nasal Prongs (HNP)
    • High Flow Nasal Prongs (HFNP)
    • Non-rebreather mask (NRM)
    • Tracheostomy (T)


    Oxygen delivery guidelines can be found by clicking on this web-link. Standing medical orders for alteration of oxygen therapy by nurses for patients in PICU can be found by clicking on this web link.

     
    For children on continuous pulse oximetry monitoring, the saturation probe site should normally be re-sited every 4 hours for infants <1year (2 hourly may be necessary for some infants) and 4-6 hourly for >1year. This should be indicated on the chart.

    Respiratory rate and pulse rate

    Respiratory rate and pulse rate (and all remaining observations, except BP) must be indicated on the chart by plotting a dot and joining consecutive observations with a line. In order to enhance the identification of trends in vital signs, numbers must be avoided except for when the parameter trends off the chart. In this instance, a larger box is available for recording the exact number.

     
    If a patient is receiving mandatory mechanical ventilation or cardiac pacing, the rate will be indicated with an 'x'.

    Respiratory Distress

    Respiratory distress should be recorded as Nil, Mild, Moderate or Severe and be determined by assessing the following features.

    Assessment of Respiratory Distress

    Blood Pressure

    Blood pressure must be recorded as systolic (˅) over diastolic (˄) with the mean documented as an 'x'. Only systolic BP triggers an escalation of care response. A measurement in the Orange zone reflects hypertension (upper zone) and in the Purple zone, hypotension (lower zone).

     
    Blood pressure should be assessed at least once on admission, and thereafter at a frequency appropriate for the child’s clinical state. If a child's pulse/heart rate falls in the Orange or Purple zone, blood pressure must be measured and documented.

    Temperature

    For infants less than 3 months, the temperature section contains an Orange zone to escalate care for the infant with a low (≤ 36°C) or high temperature (≥38.5°C).

    For neonates, the temperature should be > 36.5°C (link to Temperature Management Clinical guideline)

    Otherwise, for other age groups, the ‘reportable limits’ section (if applicable) should be used to note when alterations in temperature should be reported to medical staff (e.g. febrile neutropenic patient, temperature rise >1°C and at least 38°C during blood product transfusion).

    Level of Consciousness  

    Level of Consciousness assessment should be made by using the AVPU scale:


    A = child is Alert (opens eyes spontaneously when approached).
    V = child responds to Voice.
    P = child responds to a Painful stimulus.
    U = the child is Unresponsive to any stimulus.

    The AVPU score may be difficult to determine for infants. Some infants may respond to the voice of a parent, but not a clinician.

    Children should be woken before scoring AVPU. Conversely, in an otherwise clinically stable patient, it may not be appropriate to wake a sleeping child to assess the level of consciousness, with every set of observations (e.g an infant with bronchiolitis who is on hourly observations for ongoing evaluation of respiratory distress and has just settled to sleep).

     
    A more comprehensive neurological assessment must be performed for any patient who has, or has the potential, to have an altered neurological state. Neurological observations should be made, including an assessment of the Glasgow Coma Score, limb movements and pupils. These observations should be recorded on a separate Neurological Observation Chart (MR 685/A).

    Children who require neurological observations include those with:

    • Increasing, or potential for increased, intracranial pressure
    • Neurosurgical procedures
    • Encephalopathy (e.g. metabolic disorder, liver failure)
    • Endocrine disorders (e.g. Diabetic ketoacidosis, Diabetes Insipidus)
    • Electrolyte disorders (e.g hyponatraemia)
    • Demyelinating neurological conditions (e.g. Guillain - Barre syndrome)
    • Seizures –consider underlying diagnosis, or new onset. AVPU scoring may be appropriate for children with pre-existing seizure conditions.

    Level of Sedation

    Level of Sedation assessment should be made ONLY for patients receiving sedation (e.g. chloral hydrate, midazolam, nitrous oxide, and opiates at higher doses) and the Level of Sedation score is to be used instead of the AVPU score.

     
    The University of Michigan Sedation Score (UMSS) is used to score the Level of Sedation. 

    0  Awake and alert
    1  Minimally sedated: may appear tired/sleepy, responds to verbal conversation +/- sound
    2  Moderately sedated: somnolent/sleeping, easily roused with tactile stimulation or verbal command
    3  Deep sedation: deep sleep, rousable only with deep or physical stimulation
    4 Unrousable

     

    Guidelines for procedural sedation can be found by clicking on this web-link.

     

    Pain scores

    Pain scores should be calculated by using a Pain Assessment tool appropriate for the age, developmental level and clinical state of the child. Suggested ages are as follows:

    • FLACC scale for infants and toddlers and non-verbal children
    • Wong-Baker Faces Scale for children 5 -17 years (may be used for some children from 3 years)
    • Numeric rating scale for children >8 years.

    Other Pain assessment tools include the neonatal Pain Assessment Tool (PAT) (link to the Neonatal Pain Assessment clinical guideline) and COMFORT- B scale (used in PICU).

     

    Further guidelines for pain scores can be found by clicking on this web-link.


    Children receiving PCA or epidural infusions should have further assessment details recorded on the Pain Observation Chart (MR 87E)

     

    Contact the Children's Pain Management Service (CPMS) for any pain related issues. All children with PCA or epidural must have CPMS involvement.

     

    Additional Observations

    Further observations may be required and should be written in the Additional Observations section at the bottom of the chart.

    These may include:

    • Blood sugar level
    • Capillary refill time
    • Non-invasive ventilation parameters
    • Ventilation parameters
    • Isolette/radiant heater temperature (<1 year only)

    Neurovascular observations should be performed on the Upper Limb Observation Chart (MR947/A) or the Lower Limb Observation Chart (MR 946/A). Further details about neurovascular observations can be found here.

     

    Events /Comments box and section

    At the bottom of the vital sign page there is a larger box to document a letter which refers to a clinical event. Refer to the front page of the chart where the event, or comment, is allocated a corresponding letter and then document this letter in the Events/Comments box.


    Events/Comments should be made on the observation chart if they help interpret the observations and vital sign trends (e.g decreased heart rate observed with administration of procedural sedation, or mother concerned about increased drowsiness of her child, or commencement or completion of blood product transfusion).


    If the child’s observations transgress into the Orange or Purple zone, then further details must be provided in the Events/Comments section on the front page of the chart, including details of the Escalation of Care plan and response.


    Other nursing assessment details, plan of care or real time progress notes should be made on other patient record documents in accordance with the Nursing Documentation clinical guideline.


    Modification of the Orange or Purple zone

    Emergency response criteria may be made by medical staff, in accordance with the Medical Emergency Response Procedure and must be documented on the vital sign page and justified in the Events/Comments section.


    Children with cyanotic congenital heart disease will require at least daily modification of SpO2.

    C. Continuous monitoring

    Continuous monitoring includes either cardio-respiratory monitoring or pulse oximetry monitoring.

     
    Continuous monitoring supplements manually performed intermittent clinical observations. If used appropriately it can assist clinicians to identify rapid changes in condition. Some monitors enable the review of trends in physiological parameters over time.

    Cardio-respiratory monitoring

    Continuous cardio-respiratory monitoring is the technological measurement of heart rate/pulse rate, respiratory rate and SpO2. Children who are clinically unstable or are at risk of sudden changes in condition should have cardio-respiratory monitoring. Indications for continuous cardio-respiratory monitoring include:

    • apnoeic or bradycardic episodes
    • abnormalities of heart rate and rhythm
    • use of temporary pacing
    • prostaglandin infusion, medications that compromise cardiac function including concentrated electrolyte therapy, therapies associated with a high risk of anaphylaxis, administration of toxic medications)
    • high risk of respiratory failure (e.g., infants with severe bronchiolitis)
    • post-operative assessment as ordered by medical staff (e.g. 24-48 hours post spinal surgery)

    Pulse oximetry monitoring

    Continuous pulse oximetry monitoring measures oxygenation (SpO2) and pulse rate. Indications for its use include the child who:

    • is receiving oxygen therapy and clinically unstable
    • is clinically unstable and the need for oxygen therapy is yet to be determined
    • has a nasopharyngeal airway or tracheostomy and requiring acute nursing care
    • is receiving respiratory support (e.g., invasive or non-invasive ventilation)
    • is undergoing a procedure where respiratory depressants are used
    • is a high risk patient receiving an opioid infusion (add web link – pain management CPG’s)
    • is in the immediate post-operative period as ordered by medical staff

    Whenever continuous monitoring of heart rate, SpO2 or respiratory rate is in use, clinical observations must be documented hourly, at a minimum.


    It is important to neither rely on nor ignore monitors. The heart rate indicated by a monitor should be cross checked by palpation of the pulse or auscultation of the heart at least once per shift and whenever there is concern about the child’s physiological condition, a change in heart rhythm or when there is doubt about the accuracy of the monitoring technology. The pulse volume and regularity of heart rate should also be assessed at this time.

    The respiratory rate, usually derived from the ECG monitor, should be cross checked with the patient’s counted rate at least hourly. Further respiratory assessment including the pattern and effort of breathing should also be evaluated at this time.

    Alarm settings

    The alarm limits should be set at the appropriate age related profile selected on the monitor. Subsequent adjustment of the alarms may be required as the patient’s clinical status changes. That is, it may be necessary to set the alarm limits within a narrower range for some patients. Widening of the alarms limits must only be done in accordance with the procedure outlining the modification of emergency response criteria (Orange zone).

    The patient profile and alarm settings should be checked at the beginning of each shift and as otherwise indicated. The key principle is to provide safe alarm settings for the child and minimise the number of false alarms. A high frequency of false alarms has the potential to desensitize staff and decrease their responsiveness, thereby compromising patient safety.

    When commencing cardio-respiratory monitoring, make sure that the patient’s name is correctly entered into the monitor. Similarly, when discontinuing monitoring, it is important to ensure that the previous child’s alarm settings are not inappropriately maintained.

    All alarms must be “enabled” (activated) and audible from the nurses’ station. When an alarm sounds clinicians should respond immediately, assess the child, determine and apply the appropriate intervention and rectify problems with monitoring devices if necessary. Parents are not permitted to disable or alter alarm settings.

     

    Discontinuation of continuous monitoring

    As the condition of the child stabilises and the risk of sudden deterioration lessens, the decision to continuously monitor the child should be reviewed.

    The need for close observation and monitoring should be balanced against unnecessary dependency on the monitors.

     

    5. Companion documents

    Medical Emergency Response procedure
    Deteriorating Patient: Escalation of Care flow chart
    Nursing Assessment Clinical Guideline
    Nursing Documentation Clinical Guideline

    6. Evidence Table

    Click here to view the evidence table.

    7. References

    • Australian Commission on Safety and Quality in Healthcare (2011). National Safety and Quality Health Service Standards. Sydney: ACSQHC.
    • Bonafide CP, Brady PW, Keren R, Conway PH, Marsolo K, Daymont C. (2013). Development of heart and respiratory rate percentile curves for hospitalized children. Pediatrics,131 (4), e1150-e1157.
    • Dionne, J., Abitbol, C., & Flynn, J. (2012). Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, 27(1), 17-32.
    • Dionne, J., Abitbol, C., & Flynn, J. (2012). Erratum to: Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, 27(1), 159-160.
    • Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care. 19(1), 28-34.
    • Haque, I., & Zaritsky, A. (2007). Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatric Critical Care Medicine, 8(2), 138-144.
    • Lawless, S. T. (1994). Crying wolf: false alarms in a pediatric intensive care unit. Critical Care Medicine, 22(6), 981-985.
    • Kinney, S., Sloane, J., & Moulden, A. (2014). Statewide Paediatric Observation and Response Chart (SPORC) Project: Phase One and Phase Two Report. Paediatric Clinical Network: Department of Health, Victoria, Australia.
    • Lurbe et al. (2009).Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. Journal of Hypertension September, 27(9), 1719-1742.
    • National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents (2004). Pediatrics, 114 (2 suppl 4th report), 555– 576.
    • Royal College of Nursing (2007). Standards for assessing, measuring and monitoring vital signs in infants, children and young people. RCN: London
    • Teasdale, D. (2009). Physiological monitoring. In, Dixon, M., Crawford, D., Teasdale, D., & Murphy, J. Nursing the highly dependent child or infant. Chichester: Blackwell Publishing Ltd.
    • Tibballs, J., Kinney, S., Duke, T., Oakley, E., & Hennessy, M. (2005). Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: Preliminary results. Archives of Disease in Childhood, 90(11), 1148-1152.
    • Townley, C., Theisen, E., Stanzel, B., Chang, C., Goddard, J. & Kinney, S. An investigation into the use of MET criteria in setting cardiac monitors and the effect on the rate of false alarms. Master of Nursing Science Presentation Day (27th May, 2011), The University of Melbourne.

     

     Please remember to read the disclaimer.

    The development of this clinical guideline was coordinated by Sharon Kinney, Nurse Consultant, Nursing Research. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. Revision published December 2014.