Analysis

Emergency care staff need new tools to improve child vital signs tests

Children attending emergency departments are not having standardised checks on their vital signs, and just one third of EDs audited hit 15-minute targets  
Vital signs

Worrying gaps in how children are assessed in emergency departments (EDs) have been identified in an audit of emergency services.

The Royal College of Emergency Medicine (RCEM) studied how 191 UK EDs record and act on vital signs, such as temperature and heart rate.

In total, 16,231 cases involving children under 16 with medical illness (as opposed to an injury) were examined.

Variations and gaps

The audit found that for 30.6% of patients there was no formal system used to examine vital signs, despite the fact that large numbers of the children presenting at EDs were below the age of 2 and would therefore have limited communication skills.

Even when formalised systems were used there were variations and gaps in how well doctors and nurses were able to keep to the standards set

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Worrying gaps in how children are assessed in emergency departments (EDs) have been identified in an audit of emergency services.

Vital signs
Assessments of children in emergency departments vary widely. Picture: iStock

The Royal College of Emergency Medicine (RCEM) studied how 191 UK EDs record and act on vital signs, such as temperature and heart rate.

In total, 16,231 cases involving children under 16 with medical illness (as opposed to an injury) were examined.

Variations and gaps

The audit found that for 30.6% of patients there was no formal system used to examine vital signs, despite the fact that large numbers of the children presenting at EDs were below the age of 2 and would therefore have limited communication skills.

Even when formalised systems were used there were variations and gaps in how well doctors and nurses were able to keep to the standards set out by the RCEM.

The college looked at performance against a combination of fundamental standards that every healthcare provider should follow and additional developmental standards. 

15-minute targets

In just over half of cases, temperature, respiratory rate, heart rate and oxygen saturation were taken within the 15-minute goal set out in the RCEM standards, dropping to below 50% for responsiveness. But there was a wide variation between the best and worst performing units with 35% failing to record vital signs in the notes at all.

Another vital sign – capillary refill time – hit the 15-minute target in just over 1 in 3 cases, although this is not classed as a fundamental standard.

Most of the remaining cases saw vital signs recorded, but not within the 15-minute window. Nonetheless, in 1 in 5 cases there was no evidence that responsiveness had been measured and in 1 in 10 there was nothing to suggest that the respiratory rate had been looked at.

Abnormal vital signs

This could be a sign that they were just not recorded rather than not carried out at all, but RCEM president Cliff Mann is still concerned. 

He says the fact that in nearly half of the cases examined there were abnormal vital signs illustrates the importance of using a formal system – and using it properly.

‘Paediatric emergency medicine is particularly challenging because we know there will be a few very sick children among the many children with similar symptoms who have a self-limiting illness – the needles in the haystack,’ he explains.

Early warning systems

He believes there is a ‘clear need’ to agree a standardised system for children as there is for adults. Even in EDs that used a formal scoring system there were a variety of different approaches taken. They included the Paediatric Early Warning Score (PEWS), Paediatric Observation Priority Score (POPS) and Manchester Children’s Early Warning System (ManChEWS).

The most common was PEWS, which was used in more than half of places and is the one the RCEM recommends.

‘In the paediatric population we know that standardised assessment and scoring methods can help clinicians spot the sick children,’ adds Dr Mann.

False positive

However, he is more pleased with how units responded when abnormal signs were detected.

The audit found evidence that action was taken in three quarters of cases where abnormal readings had been taken – and it warned not to read too much into the other quarter as there was no evidence to suggest that children were coming to harm in such numbers.

Instead, it said there were likely to be other factors, such as the abnormal vital sign being a false positive.

Repeat tests

But EDs performed less well on other standards, such as repeating the vital signs recording within an hour of an abnormal result. 

Overall, just 6% had all their vital signs recorded within 60 minutes, rising to 19% of cases having a repeat test at all, 81% not having repeat tests and 1% having no time recorded.

Temperature, oxygen saturation, respiratory rate and heart rate were the ones most likely to be done. Capillary refill was the least likely.

Standardisation

The audit also noted different practices when it came to discharging patients who had persistently abnormal signs during their time in hospital. On average only 60% of cases were reviewed by a
senior doctor before they were discharged.

The RCEM urged all EDs to review practices to see where improvements could be made.

RCN professional lead for children and young people’s nursing Fiona Smith believes this is essential given that a quarter of attendances at ED are children.

Consistent tool

‘There is clearly a need to make improvements. One of the issues is the number of different systems in use across the country. Research is currently under way to identify a consistent tool. That will help.’

But she also believes the wider pressures in the system are playing a part. ‘The volume of attendances is, of course, an issue. During peak times staff are under a lot of pressure and we know that there are not always nurses in EDs with the expertise in assessing and treating children and young people.’

You can read the full report here

The view from the frontline
Janet Youd
Janet Youd

‘The problem with children’s emergency care is that there is no recognised system as there is for adults. It varies from place to place.

So, for example, at my trust we use the Paediatric Advanced Warning Score (PAWS) because our tertiary centre is in Leeds and that is what they use. But in Sheffield it is the Paediatric Early Warning Score (PEWS) and in Manchester it is something else. Some are colour coded, some are numerical and lots of places do not use anything at all.

‘It can make it very confusing, especially for staff such as agency nurses who work across a variety of sites.

‘That is compounded by the fact that the high attrition rate for emergency care nurses means we now have a much less experienced workforce. It is far from ideal.

‘This is no fault of the nurses themselves or the trusts they work for. It is a result of the pressures on the system.’

Results of the Royal College of Emergency Medicine audit

The patient profile  

  • 16,231 cases involving children under 16

  • 19.6% of patients arrived during the night

  • 38% of patients were under the age of 2

What system was used to measure vital signs?

  • 30.6% of EDs used no formal scoring system

  • 54.5% used Paediatric Early Warning Score 

  • 2.1% used Paediatric Observation Priority Score

  • 1.7% used Manchester Children’s Early Warning System

  • 11.2% used another system

Were all the vital signs recorded in the ED notes?

  • 33% recorded in the first 15 minutes

  • 31% recorded after 15 minutes

  • 1% recorded, but no time submitted

  • 35% not recorded

Where abnormal signs were initially recorded was a complete repeat set of vital signs recorded within 60 minutes?

  • 6% recorded in the next 60 minutes

  • 13% recorded after 60 minutes

  • 1% recorded, but no time submitted

  • 81% had no repeat set recorded


Janet Youd, emergency care nurse consultant for paediatric care at Calderdale and Huddersfield NHS Foundation Trust and chair of the RCN Emergency Care Association

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