Clinical Guidelines (Nursing)

Observation and continuous monitoring

  • Introduction

    Aim

    Definition of Terms

    Continuous Monitoring

    Companion Documents

    Evidence Table

    References

    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 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. These charts have been integrated into the Electronic Medical Record (EMR) and the observations are viewed on the ViCTOR graphs.

    These ViCTOR graphs, also known as ‘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 Red). If a child’s observation transgresses the Orange or Red zone an escalation of care response is triggered. The type and urgency of the escalation response depends on the degree of clinical abnormality.

    The ViCTOR graphs are standardised 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 the 12-18 years graph is used for young people older than 18 years. 

    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.

    Definition of terms (abbreviations and acronyms)

    • AUM- Associate Unit Manager
    • CPMS – Children’s Pain Management Service
    • ECG - Electrocardiograph
    • EMR- Electronic Medical Record
    • 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. 

    Guideline details

    Clinical Observations

    Clinical observations may 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
    • pain score. 
    • in certain clinical circumstances further observations (for example, neurological observations or neurovascular observations)

    Clinical observations are recorded by the nurse as part of an admission assessment (Nursing Assessment), at the commencement of each shift and at a frequency determined by the child’s clinical status and/or current treatment. For example, required observations during routine post anaesthetic observations can be found here https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Routine_post_anaesthetic_observation/.

    The frequency of observations and type of observations is ordered within EMR and should be should be documented in flowsheets
    Observations should be performed at least once per hour if the patient:

    • Has previous observations within the shaded orange or red zone (unless modified) 
    • Was transferred from PICU/NICU (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 continuous monitoring as described later in this guideline). 

    A set of observations must be recorded within the hour 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 Red zone, this must be addressed prior to transfer.

    Each set of observations should be documented in flowsheets and then trends should be viewed on the VICTOR graph, to better enable analysis and interpretation of the data. Link: flowsheet learning resources.  For observations entered via Rover the trending of observations on the ViCTOR graph should be viewed as soon as practicable.

    In the event of a “down time” of EMR all treating areas at RCH have a supply of the paper ViCTOR charts for all age groups. This information will later be uploaded to the EMR. On the paper charts the Red Zone is colored purple.

    Coloured zones

    Age-specific ViCTOR parameters are automatically set by the child's age in the EMR and when breached a notification for escalated care is triggered. 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 Red 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 Red zone, an emergency call must be initiated, that is, a Rapid Review or MET call. If the child’s observations transgress into the Orange or Red zone, then further details must be documented, including the Escalation of Care plan and response.

    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.

    Modification of the Orange or Red zone

    Modification of the Emergency response criteria may be ordered by medical staff, in accordance with the Medical Emergency Response Procedure 

    O2 Saturation and oxygen delivery

    Haemoglobin-oxygen saturations (SpO2) are entered numerically in the flowsheet.
    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). Oxygen delivery guidelines.

    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) 

    Standing medical orders for nurse initiated oxygen therapy for PICU patients are linked . 

    Heart rate  

    The heart rate is 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.

    Respiratory rate

    The respiratory rate is checked at least once per shift established by counting the patient’s breaths over 60 seconds.. Further respiratory assessment including the pattern and effort of breathing should also be evaluated at this time. Respiratory distress should be recorded as Nil, Mild, Moderate or Severe based on the assessment.

    Assessment of Respiratory Distress

    Blood Pressure

    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 Red 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 Red zone, BP must be measured and documented. The limb used to measure BP should be documented as should the type of measurement (eg manual, automated). 

    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 (Temperature Management guideline)

    For other age groups, 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 ≥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 ordered for children 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.
    • Those at an increased risk of stoke or bleeding (eg Ventricular Assist Device, altered INR’s)

    Level of Sedation

    Level of Sedation should be assessed 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; 

    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.

    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. Nursing Clinical Guideline Pain Assessment and Measurement. Suggested pain scales include

    • 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.
    • (mPAT) (Neonatal Pain Assessment )
    • COMFORT- B scale (used in PICU).

    Additional Observations

    Further patient specific observations may be required and ordered. 

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

    Adding a comment 

    Comments that help interpret the observations and 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 within flowsheets or as a real time progress notes.  

    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. Some indications include:

    • Potential or actual apnoeic or bradycardic episodes
    • Recent unexplained sudden collapse
    • Abnormalities of heart rate and rhythm or high risk of arrhythmia (e.g. pericardial effusion, altered electrolytes)
    • Temporary pacing
    • Prostaglandin infusion, medications that compromise cardiac function including concentrated electrolyte therapy, administration of pro-arrhythmic drugs with potential to cause QT prolongation or ventricular dysrhythmias, 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)

    Correct electrode placement when utilitsing ECG monitoring is vital. 3 lead ECG monitoring is most common however 5 lead ECG monitoring can also be used with the bedside monitors. 

    5 Lead ECG

    The above image shows the correct lead placement for a 5 lead ECG. When only using 3 leads, place the 3 coloured leads in the appropriate spots as outlined above. Commonly white (RA) , black (LA) and green (RL) are used for 3 lead ECG monitoring.

    Skin preparation and regular changing of electrodes (usually daily) is vital to ensure accurate readings. For further information Cardiac Telemetry Guideline

    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
    • is in the immediate post-operative period  
    • has a decreasing conscious status  

    It is important to neither rely on nor ignore monitors. Whenever continuous monitoring of heart rate, SpO2 or respiratory rate is in use, clinical observations must be documented hourly, at a minimum. The heart rate 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. 

    Alarm settings

    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. 

    By turning the monitor into stand-by mode when not being used, all settings will be saved and available for the next set of observations. If the monitor is turned off by the power button displayed on the front of the monitor, all settings will be lost and need to be re-programed.

    When commencing cardio-respiratory monitoring, make sure that the patient’s name is correctly entered into the monitor. When new patients are added to the monitor it is important that the correct Profile (age group) is selected otherwise alarm settings will default to the 1-4 year age group.

    All alarms must be “enabled” (activated) and audible. 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 by the nursing and medical staff (usually at least once per shift). When no longer necessary the patient can be transitioned to 1-4 hourly observations. 

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

    Companion documents

    Evidence Table

    Click here to view the evidence table.

    References

    • Australian Commission on Safety and Quality in Health Care ACSQHC (2017). National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration (2nd Ed.). 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.
    • Bonafide, C. P., Localio, A. R., Holmes, J. H., Nadkarni, V. M., Stemler, S., MacMurchy, M.,. Keren, R. (2017). Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children's Hospital. JAMA Pediatrics, 171(6), 524-531. 
    • 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.
    • 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.
    • Paine, C. W., Goel, V. V., Ely, E., Stave, C. D., Stemler, S., Zander, M., & Bonafide, C. P. (2016). Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Interventions to Reduce Alarm Frequency. Journal of Hospital Medicine, 11(2), 136-144.
    • Royal College of Nursing (2017). Standards for assessing, measuring and monitoring vital signs in infants, children and young people. RCN: London
    • Victorian Paediatric Clinical Network, Melbourne, Australia, The Victorian Children's Tool for Observation and Response (ViCTOR), available from www.victor.org.au 
    • Winters, B. D., Cvach, M. M., Bonafide, C. P., Xiao, H., Konkani, A., O'Connor, M. F., . . . Hu, X. (2018). Technological Distractions (Part 2): A Summary of Approaches to Manage Clinical Alarms With Intent to Reduce Alarm Fatigue. Critical Care Medicine, 46(1), 130-137.


    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Sarah Sly, Clinical Nurse Specialist, Koala and Sharon Kinney, Nurse Consultant, Nursing Research, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2019.