Regular recording and assessment of observations are used to detect any signs of serious illness or deterioration and provide the necessary information of how a child’s illness is responding to treatment.
Combining and monitoring observations over time creates situation awareness of a child’s clinical status that can be shared with other team members.
In addition, using triggers from one parameter, for example; raised heart rate, should promote information seeking from other parameters, e.g. blood pressure and capillary refill time as they both will enhance the clinical picture.
Therefore, if observations trigger an increase in the PEWS score above 0 or there is concern about the patient’s condition, the clinician should assess and measure all parameters to enhance the clinical picture.
Assessment and documentation of observations should continue to be undertaken at a prescribed frequency as clinically appropriate to the child’s needs.
Clinical acumen and judgement remain essential for the detection of deterioration in a child with mild or no abnormal physiological observations.
Clinical observations that should be carried out at the prescribed frequency include:
- Heart rate
- Respiratory rate
- Peripheral oxygen saturation (SpO₂)
- Temperature
- Level of consciousness using the alert, voice, pain, unresponsive (AVPU) scale; please note if patient is asleep
- Blood pressure
- Capillary return time
- Oxygen therapy
Where there are concerns of serious illness and deterioration, or for those children undergoing high risk treatments; for example, chemotherapy, blood transfusion, or for a specific disease pathway, more frequent checks of observations may be required.
A complete set of observations including blood pressure is undertaken on ALL children:
- Within one hour of admission to the ward / department, thereafter serially recorded at a prescribed frequency dependant on the child’s clinical condition
- Where there are concerns of serious illness and deterioration.
- During an acute phase of the child’s hospital admission, a minimum of four hourly observations and more frequently as condition dictates.
- Post-operatively, frequency of observations should reflect the child’s clinical condition or risk of deterioration (RCN, 2017).
- During and after receiving a blood transfusion as per guideline (Blood Component Prescription & Record of Transfusion Document, NHSGGC).
- Chemotherapy or other high risk treatments.
- With a decreased level of consciousness (in addition, Paediatric Neurological observations rather than AVPU should be assessed).
- With an increase in PEWS score.
- Staff and/or carer concern.
Each set of observations taken must be scored using PEWS and the appropriate action taken as set out in the escalation guide on the PEWS chart.
The PEWS chart and score is specifically designed to enhance the identification of changing trends in observations. It is important to watch for declining or no improvement in trends and escalate concerns to the appropriate staff.
Trends are more easily seen if the ‘dots’ on the chart are connected by straight lines.
Recording of observations may be performed by health care support workers, assistant practitioners or nursing students who have received appropriate training; this should be done under the direction and supervision of a registered nurse. These staff must be aware of when they should escalate their concerns.
Abnormal observations recorded by health care support workers, assistant practitioners or nursing students must always be verified by a registered nurse.
When a patient meets the trigger score and the tool is activated, the guidelines regarding frequency of observations and the need for medical assessment should follow the agreed escalation plan.
Parents and guardians can provide information on a child’s normal physiological state; staff caring for them must be aware of this and acknowledge and record any concerns raised.
”Watchers” are children who have clinical indicators which may suggest they are a potential deterioration risk or children for whom there are other clinical concerns, parental concerns, safeguard risk etc. Staff should ensure there is a process in place which allows communication of these concerns to be acknowledged by the clinical teams and locally at the hospital huddles by the Hospital Co-ordinator, which allow discussion of appropriate escalation and plans for identified children and a report/update given to PICU.
Please refer to the ‘watcher criteria’ located in clinical areas (appendix 1).
Some children will transgress the PEWS criteria in their normal state due to chronic illness; where this occurs medical and nursing staff must jointly agree and set alternative parameters to ensure that they can be alerted to potential deterioration.
The PEWS tool does not replace clinical judgment. If a child is deteriorating acutely or is in peri-arrest call the resuscitation team on 2222.
REMEMBER: If the child’s observations score 1 or above on the PEWS chart,
- The child they should be reviewed as per the escalation guide,
- A plan of care agreed and documented, which may include investigations or interventions
- Agree when the child is to be re-assessed
Clinical response to a score may vary from the chart escalation guide in areas such as Emergency Department and Theatre Recovery. In these areas, staff should refer to the agreed local escalation guide.
Regardless of PEWS always escalate if you are concerned about a Child’s condition
Concerns include but are not restricted to:
- Gut feeling
- Looks unwell
- Apnoea
- Airway threat
- Increased work of breathing
- Significant increase in oxygen requirement
- Poor perfusion/blue / mottled/ cool peripheries
- Seizures
- Confusion/ irritability/altered behaviour
- Hypoglycaemia
- High pain score despite appropriate analgesia.
