In this section
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.
Electronic Medical Record (EMR): In the electronic medical record at RCH (EMR), observations are to be entered numerically in the Flowsheets activity. Trending of observations can be viewed via the ViCTOR graph. In EMR, age-specific ViCTOR parameters are automatically set by the child's age in the system and when breached a notification for escalated care is triggered. The orange and purple zones in EMR will appear as below:
Information regarding the documentation of observations and viewing the ViCTOR graph in the EMR can be found in flowsheet learning resources.
To provide guidance to clinical staff regarding the:
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 nurse as part of an admission assessment, at the commencement 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, 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:
(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 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 treatment.
Ensure that observations are entered onto the correct medical record by checking the patient's identification.
There are 3 distinct coloured ‘zones’ within the ViCTOR graph.
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 (
Normal Ranges for Physiological Variables.) 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 AUM (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.
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.
Haemoglobin-oxygen saturations (SpO2) should be entered 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:
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.
Note: It is not recommended to secure oxygen saturation probes with CombanTM stretch compression bandage.
Respiratory rate and pulse rate must be entered on the flowsheet activity in EMR. In EMR, ViCTOR graphs will be automatically populated to enable review of trends.
Respiratory distress should be recorded as Nil, Mild, Moderate or Severe and be determined by assessing the following features (see www.victor.org.au)
Blood pressure (BP) must be recorded as systolic, diastolic and mean BP. 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).
BP 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, BP must be measured and documented.
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)
For other age groups, in the observation frequency section (EMR), an order can be placed when, and if an alteration 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 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.
Children who require neurological observations include those with:
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.
procedural sedation can be found by clicking on this web-link.
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:
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).
Contact the Children's Pain Management Service (CPMS) for any pain related issues, including all children with PCA and epidural infusions.
Further observations may be required.
These may include:
Neurovascular observations should be performed in the Neurovascular section. Further details about
neurovascular observations can be found here.
Comments that 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) can be made in the Notes Activity or Progress Notes.
If the child’s observations transgress into the Orange or Purple zone, then further details must be provided, including details of the Escalation of Care plan and response.
Other nursing assessment details, plan of care and real time progress notes should be made in accordance with the
Nursing Documentation clinical guideline.
Emergency response criteria may be made by medical staff, in accordance with the Medical Emergency Response Procedure and must be ordered by medical staff. A ViCTOR modification order can be viewed through the flowsheet activity sidebar.
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.
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:
Continuous pulse oximetry monitoring measures oxygenation (SpO2) and pulse rate. Indications for its use include the child who:
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.
The alarm limits should be set at the appropriate age related profile selected on the monitor, where the default settings reflect the ViCTOR escalation of care parameters. 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.
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.
Click here to view the evidence table.
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.