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Variation in A&E scoring system for vital signs in children

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Almost a third of emergency departments in the UK are not using a formalised scoring system for recording vital signs in children, leading to variations in assessment and potentially undetected illness, an audit has revealed.

The Royal College of Emergency Medicine, which carried out the analysis of 191 accident and emergency departments, called for a national standardised scoring system to be developed to ensure sick children were identified. It recommended the paediatric early warning score (PEWS) system or an equivalent.

“To enable sick children to be identified, there is a clear need to agree a standardised scoring method that all clinicians can use”

Dr Cliff Mann

In addition, it highlighted the need for strong multi-disciplinary working and particularly emphasised the “vital role” of nursing staff in the assessment of vital signs.

Paediatric attendances make up a quarter of A&E attendances and the timely and accurate recording of vital signs can ensure a disease or underlying health problem is detected, said the college.

The audit, which looked at vital signs in children under the age of 16 years with a medical illness – as opposed to injury – found more than a third were below the age of two and, therefore, less able to communicate their symptoms, making them a more challenging patient group to assess.

It also looked at how many children were being assessed within recommended timeframes.

Around a half of children with a medical illness had a basic set of vital signs – temperature, respiratory rate, heart rate, oxygen saturation, Glasgow Come Scale or AVPU score – all taken and recorded within the recommended 15 minutes of arrival or triage.

While this could be better, said the report, it was “gratifying” that the vast majority – around 80% – were having their vital signs recorded at some point.

It also noted that in around 75% of cases, clinicians took action to address patients with abnormal vital signs. In the 25% of cases in which abnormal signs were not acted upon, it called for emergency departments to investigate the reasons.

However, due to low numbers of children coming to harm in A&E, this result could be down to “false positives” – such as when someone’s heart rate is taken while they are distressed – said the report, called  Vital Signs in Children Clinical Audit 2015-16 (see PDF attached).

“There is much good practice demonstrated in this audit, with high numbers of patients being assessed by more experienced ED staff,” concluded the report.


Dr Clifford Mann

Clifford Mann

“Strong multidisciplinary working in the ED team is important for timely and effective monitoring of vital signs in children, particularly the vital role of nursing staff who are often responsible for the assessment of vital signs,” it added.

RCEM president Dr Cliff Mann said: “In the paediatric population we know that standardised assessment and scoring methods can help clinicians spot the sick children but no tool is currently sufficiently sensitive or specific.

“To enable sick children to be identified, there is a clear need to agree a standardised scoring method that all clinicians can use,” he added.

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