The paediatric physical assessment research program

About

Professor Marilyn Cruickshank is Professor of Nursing (Research) and Director of Nursing Research, Sydney Children’s Hospitals Network. 

Despite the best efforts of clinicians and the implementation of systems to recognise and respond to patient deterioration, it appears that some hospitalised children continue to deteriorate unnoticed. 

Adult studies have shown strengthening clinical assessment practices can lead to greater nursing empowerment, realignment with professional nursing values, and improved patient safety (Douglas et al., 2016a, Osborne et al., 2015). 

Little is known about how to improve patient surveillance within the paediatric context. The paediatric physical assessment research program is a vital piece of work. 

This is a pilot study to gain an understanding of what is currently happening at in the paediatric context with respect to vital signs and physiological monitoring. This project is the foundational work for a 5-year plan to develop core paediatric nursing skills and integrate them into clinical practice.

A mixed methods study was undertaken across two Australian tertiary children’s hospitals and paediatric wards in 2 LHDs:

1. A systematic scoping literature review (Arksey and O’Malley, 2005)
2. Quantitative retrospective chart review of 512 patients aged 0-17 years
3. Observational study of 50 episodes of vital signs undertaken in 10 acute paediatric wards

Impact

A framework is being developed that combines the 3 approaches currently operating independently in responding to clinical deterioration (i) thus Paediatric Early Warning Signs (PEWS) based on vital signs; (ii) the situational awareness of nurses, and (iii) parental escalation program (REACH).  

The Framework is based on the findings from the pilot studies:

• Vital sign parameters in children are ill-defined and not based on evidence.
• Early signs of deterioration in children such as colour, skin tone, movement patterns and behaviour are often subtle, nuanced, are difficult to quantify.
• Non-measurable signs, using clinical judgement, are neither weighted equally, nor well-articulated
• Changes in vital signs can be a late sign of deterioration, thus Paediatric Early Warning Signs (PEWS) may be poor indicator, especially in early stages when action could make a difference to outcome.