The full initial Observation and Monitoring Policy 2008 (Appendix 1) and current Observation, Monitoring and Escalation Policy 2019 (Appendix 2) are attached to provide detail. The guidance included hyperlinks to current clinical guidelines and references the source literature when available.
a) Change of guidance content
The changes in content of the guidance reflected new published standards and guidance, feedback from the reviewed cases, the need to incorporate parental concern and escalation, changes to governance structures and the addition of Nursing Care Quality Indicators.
A full comparison is presented in Appendix 3. The main changes included:
i) Parental concern has been integrated into each set of routine observations. A leaflet called ‘Listening to you’ is given to parents to help them communicate their concerns.
ii) Quick tips to answer frequent questions.
iii) Continuous and intermittent cardiorespiratory monitoring is detailed for certain conditions and medications.
iv) The documentation on the chart is clarified with pictures.
v) Alarm management
vi) The use of extension charts for respiratory support, neurological and cardiac catheter observations.
vii) Indications for continuous pulse oximetry and sensor positioning.
viii) Oxygen is a medication and therefore must be prescribed or administered via a patient group directive, and each set of observations requires a signature.
ix) Fluid balance observations, target fluid volumes and hydration risk assessment.
x) Sepsis 6 identification and treatment is included10
xi) Conditions to omit and de-escalate observations.
xii) Documentation of significant clinical events contemporaneously on the observation chart.
xiii) Department- and condition-specific observations.
xiv) Guidance and chart design incorporate ergonomic design.
b) The use of the PEW score chart influences guidance
The guidance is closely linked to the observation chart and how it is used. Our current revision of the chart has incorporated ergonomic recommendations, including altering the layout to improve the process flow, completeness of documentation and specific questions for parental concern. The guidance has therefore been updated with these recommendations to support practice change and clinical decision-making. Similarly, when we introduced the Paediatric Sepsis 6 initiative10 and included ideas from other hospitals (e.g., Parental/Nurse concern, planned observation frequency, patient-specific risk factors and a signature for each set of observations), the guidance was updated accordingly.
c) Enhanced scoring
The guidance provides clear instructions for these situations to ensure consistency in practice. In our aggregate PEW score deviations from “normal physiology for age” accrue scores of one, two or four. There are some “at risk” patient groups that we score higher to reflect their additional risk. For example, all patients on enhanced respiratory support, such as humidified high flow oxygen or continuous positive airway pressure, will be scored four for oxygen delivery (in the category >4 l/min/ >50%), for the gas flow even though they may be in air (usually zero), because this reflects the higher risk we see in patients on respiratory support. Similarly, cyanotic patients are still scored four for pulse oximetry £91%, even though it is normal for them. Their own normal pulse oximetry range will be documented in the patient-specific parameters.
d) Ownership and Governance
The PEW system, including observation and monitoring guidance, is managed by the Director of Nursing for Quality & Safety. Revisions are multi-professional and systematic and include information from risk reporting through the governance department.
The guidance is used as part of the Morbidity and Mortality review process to determine whether there were avoidable factors associated with patient harm. The results of these reviews are reported quarterly at the Executive Board level in the Trust Quality Report and to our Commissioners. The guidance is a very important template and keeps potential avoidable harm visible to senior decision-makers. Because our guidance is used in serious incident reviews, it has also been used in coronial and civil courts to determine acceptable standards of care.
Charts and guidance need careful version control when they are revised. Printers have simply switched out the age group on a chart resulting in incorrect thresholds, with a resultant increase in clinical risk. Each change requires clear responsibility for updating the intranet and introducing it into the education and training of existing and new starters to the organisation.
e) Differences between Birmingham Children’s Hospital (BCH) and RCN guidance.
The purpose of the RCN guidance is to standardise the performance of vital sign measurement. The purpose of BCH guidance is the performance of observations, monitoring, documenting and communicating that information to detect, evaluate and manage clinical deterioration. The BCH guidance includes similar information to the RCN guidance but is broader, context-specific and provides standards for monitoring a wide range of situations and conditions appropriate to our resources. There is guidance on triage and the transition to admission observations, planning the normal frequency of observations, continuous monitoring, escalation and de-escalation of observations for stable children. It also extends to fluid balance monitoring as well monitoring for sedation and procedures. At BCH, a PEW score is required with each set of observations rather than being optional. Learning from events can be seen in the advice about what to do if your concerns are not adequately addressed, a warning about looking for (and so not missing) deterioration when starting a new chart and listening to parental concern. The RCN guidance provides an interesting section on teaching children and families about observations not included in the BCH guidance. They are complimentary, both useful in their different areas of focus and should be adapted to the local context of patients and resources.