Clinical Guidelines (Nursing)

Observation and Continuous Monitoring

  • Introduction

    • Regular measurement and documentation of physiological observations (i.e., clinical observations) are essential requirements for patient assessment and the recognition of clinical deterioration
    • To assist in the recognition of clinical deterioration, ward observation charts contain unshaded zones in which normal observations are expected and shaded zones above and below the normal limits. Clinical observations marked in the shaded zones are MET activation criteria
    • Four different charts are available at RCH and relate to 4 specific age groups: <1 year, 1-4 years, 5-12 years and 12+ years

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    Aim

    This guideline provides guidance for:

    • Measurement of clinical observations
    • Role of continuous cardio-respiratory monitoring and pulse oximetry monitoring
    • Use of the inpatient observation charts
    • The process for escalation of care in response to abnormal physiological observations  

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    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

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    Guideline details

    Clinical Observations 

    • Clinical observations include estimation of haemoglobin-oxygen saturation (SpO2, pulse oximetry), oxygen therapy, respiratory rate, heart/pulse rate, blood pressure (systolic, diastolic and mean), temperature (including measurement method), sedation and pain. In certain clinical circumstances further observations (for example neurological) may be required.
    • Clinical observations will be recorded by the registered nurse as part of a full clinical assessment on admission to hospital.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 transfusion 
    • Observations should be performed at least once per hour if the patient:
      • Has previous observations within the shaded MET criteria
      • Was transferred from PICU (within last 8 hours or as clinically indicated)
      • Is  receiving PCA, Epidural, or Opioid infusion
      • Is receiving an Insulin infusion
      • has ICP monitoring
      • Note, other children will require hourly observations and continuous monitoring as indicated later in this guideline
    • 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, in consultation with others involved in the child's care. The frequency of observations should be documented on the patient care record (MR856/A).
    • 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 MET criteria (i.e., in the shaded zones) this must be addressed prior to transfer. 

    Modification of MET criteria for a specific patient

    • The MET criteria are important triggers for the identification of seriously ill or deteriorating patients.  Inappropriate modification of MET criteria has resulted in some children having unrecognised deterioration and delayed emergency treatment.  For the majority of patients, the MET activation criteria should not be changed.
    • However, occasionally it will be appropriate to modify the MET criteria for a child whose baseline state chronically breaches the vital-sign criteria for age.  This should only be done under the following circumstances:
      • Only medical staff of registrar level and above can alter MET criteria.  The change to MET criterion must be confirmed by a consultant
      • No more than one MET criterion to be changed (e.g., heart rate OR respiratory rate, but not both)
      • The change should be no more than 20% of the existing age-specific criteria.
      • Any change must be communicated to the PICU consultant and bed-card unit consultant
      • Within two hours of changing MET criterion the child must be reviewed by the PICU Outreach team.  It is the responsibility of the person changing the MET criterion to inform the PICU Outreach team.
      • Any change to MET criteria must be documented in the medical record, and the reasons for the change given

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    Continuous monitoring

    • Continuous monitoring may becardio-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
      • evaluation of response to drugs (e.g., inotrope/inodilator infusions, 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
      • has a nasopharyngeal airway or tracheostomy  & 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 
      • 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 MET criteria according to the 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 MET criteria.
    • 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 is 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.

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    Guidelines for Observation Chart

    • The ward observation chart must be used for all clinical inpatients at RCH. 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.
    • All inpatients must have a clinical assessment by their nurse at the commencement of each nursing shift. This will be documented following the ABCD format on the inpatient observation chart in the clinical comments section. For example: A; clear, B; bilateral air entry, C; pink and warm peripherally, D; awake & appropriate
    • Haemoglobin-oxygen saturations (SpO2) should be written numerically in the allocated box. Note that separate boxes pertain to children with congenital cyanotic heart disease.
    • The saturation probe site must be re-sited every 2 hours for children <1year and 2-4 hours for/>1year. This should be indicated on the chart.
    • Oxygen (therapy) refers to the flow (litres/min) of oxygen that the patient is receiving. If no oxygen is given, write 'RA' (room air).
    • Oxygen delivery refers to:
      • Mask (M),
      • Nasal prongs (NP), 
      • Humidified nasal prongs (HNP)
      • Non-rebreather mask (NRM)
      • Tracheostomy (T)
    • Please also refer to the following
    • Respiratory rate and pulse rate must be indicated on the chart with a dot. If a patient is receiving mandatory mechanical ventilation or cardiac pacing, the rate will be indicated with an 'x'.
    • If a child's pulse rate falls in the shaded zones (MET criteria), blood pressure must be measured and documented.
    • Blood pressure must be recorded as systolic over diastolic with the mean documented as an 'x'. Since only systolic BP triggers MET, a measurement in a shaded zone may reflect either hypertension (upper zone) or hypotension (lower zone).
    • Temperature, note the method of measurement:
      • per axilla (PA)
      • tympanic (T)
    • Contact the Children's Pain Management Service (CPMS) for any pain related issues. All children with PCA or epidural must have CPMS involvement
    • Neurological observations must be performed for any patient who has or has the potential to have an altered neurological state.

    Guidelines for neurological observations

    • The chart below provides a guide for performing neurological observations

    neuro_obs_chart_pic

    Additional observations

    • Additional observation as listed on the reverse side of the Clinical Observation Chart should be transcribed onto the blank lines at the base of the physiological measurements. These include:
      • Non invasive ventilation
      • Ventilation
      • Humidified oxygen prongs
      • Asthma assessment*
      • Epidural
      • PCA
      • Limb observations
      • Isolette/radiant heater (<1 year only)
    • Asthma
      • Clinical assessment of asthma tool should be used for children with asthma

    Clinical Assessment of Asthma

     Code

     0

     1

     2

     3

    Accessory Muscle Use

    Noaccessory Muscle Use

    Mildintercostal and suprasternal recession

    Moderate intercostal and suprasternal recession

    Marked intercostal and suprasternal recession

    Mental State

     Normal

     

     Agitated / Confused

     Severe

    Limitation of Activity

     No

     Mild

     Moderate

     Severe

     

     Wheeze Code

     0

     1

     2

     3

    Wheeze audibility with Stethoscope

     Nil

    On expiration

    Throughout expiration and inspiration

    Audible without Stethoscope or silent chest

     

    • Additional observations required for an individual patient can also be documented within these lines and further lines can be added if required.
    • Clinical assessments, comments or interventions will be documented in the vertical spaces at the base of the chart in a time-relevant manner (e.g., initial assessment of the child at the commencement of nursing shift, commencement of a therapy).
    • MET activation criteria are documented on the observation chart as shaded zones
    • There may be variations in the requirement for observations if witholding or withdrawal of life-sustaining treatment

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    Escalation of Care

    • There are three main ways to escalate care for a child whom you are concerned about.
    • If immediate review is required in a deteriorating child, call a MET (dial 777 and state building, level, ward and room number).
    • Otherwise, if any staff member or parent is concerned about a patient but considers that MET activation is not necessary, the treating medical team should be contacted.

    Level 1: The treating medical team and/or other specialty teams (e.g., Pain management services)

    1. Bedside nurse must notify their ANUM.
    2. If ongoing concern, the Bedside nurse or ANUM must notify the attending bed card or covering medical resident/registrar/fellow
    3. A parent should contact the bedside nurse or ANUM
    • When contacting medical staff ensure that communication is clear and a response time frame is agreed.
    • The ANUM has the right to ask the registrar to contact the bed card consultant about a patient and call themselves if deemed necessary.

    Level 2: PICU Outreach Review

    • Requesting PICU involvement in the management of a patient outside PICU can occur via the PICU outreach registrar or the PICU liaison nurse.
    • PICU outreach registrar is available 08:00-17:00, 7 days a week. Outside of these hours call PICU directly.
    1. Referrals for advice or review by the PICU outreach registrar should only be made by senior medical staff (Registrar, Fellow, or Consultant). Junior medical staff and ward nursing staff should seek input from senior staff first.
    2. When requesting a PICU medical review, the doctor should agree on a 'time frame' required, for example, within 15 minutes, 30 minutes. PICU staff will try to respond within an agreed time period, but this must be balanced by PICU workload. If a commitment cannot be fulfilled, the PICU doctor should inform the requesting staff member.
    3. The bedcard medical consultant must be informed of any request for PICU review of a patient under their care.
    4. The PICU outreach team must be informed of any MET modification for further follow up.
    5. Referral to the PICU Liaison Nurse can be made by ward nursing staff and junior medical staff for support of patients who are not clinically deteriorating but when clinical assistance or advice is required. The PICU liaison nurse is available 08:00 -18:00, 7 days a week.

    Level 3: MET

    1. If immediate review is required in a deteriorating child, call a MET (dial 777 and state building, level, ward and room number)
    2. The bedcard medical consultant must be informed of any MET call or request for PICU review of a patient under their care.

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    Companion documents

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    References

    1. Australian Commission on Safety and Quality in Healthcare (2010). National consensus statement: Essential elements for recognising & responding to clinical deterioration. Sydney: ACSQHC.
    2. Chapman, S. M., Grocott, M. P. W., & Franck, L. S. (2009). Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration. Intensive Care Med, 36(4), 600-611.
    3. 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.
    4. Harley, S., & Timmons, S. (2010). Clinical assessment skills and the use of monitoring equipment. Paediatric Nursing, 22(8), 14-18.
    5. Lawless, S. T. (1994). Crying wolf: false alarms in a pediatric intensive care unit. Critical Care Medicine, 22(6), 981-985.
    6. 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.
    7. Parshuram, C.P., Hutchison J., Middaugh, K.   (2009). Development and initial validation of the Bedside Paediatric Early Warning System score. Critical Care 13(4): R135.
    8. Royal Collegeof Nursing (2007). Standards for assessing, measuring and monitoring vital signs in infants, children and young people. RCN: London
    9. Singh, J. K. S. B., Kamlin, C. O. F., Morley, C. J., O'Donnell, C. P. F., Donath, S. M., & Davis, P. G. (2008). Accuracy of pulse oximetry in assessing heart rate of infants in the neonatal intensive care unit. Journal of Paediatrics and Child health, 44(5), 273-275.
    10. 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.
    11. Tibballs J. (2011). Systems to prevent in-hospital cardiac arrest. Paediatrics and Child Health 21(7): 322-328.
    12. 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.
    13. 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.

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    Evidence Table

    Observations and Continuous Monitoring Evidence Table

    Please remember to read the disclaimer

    The development of this clinical guideline was coordinated by Sharon Kinney, Nursing Research. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published February 2012 (replacing Clinical Observations Procedure published November 2010).