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Paediatric risk assessment in an adult setting

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VOL: 97, ISSUE: 50, PAGE NO: 40

Sharon McAllister, RGN, DipN, is a senior sister, BUPA Hospital, Leeds

The Department of Health (1991) recommends that two children's nurses should be on duty in any hospital setting in which children are cared for. However, a shortage of paediatric nurses means that it is sometimes not possible to put this into practice.

The Department of Health (1991) recommends that two children's nurses should be on duty in any hospital setting in which children are cared for. However, a shortage of paediatric nurses means that it is sometimes not possible to put this into practice.

I work in an independent sector hospital that offers multispecialty adult surgery. A small number of children aged three and over - about 12 a month - are also admitted for ear, nose and throat surgery. Although a resident doctor holds the Resuscitation Council's Paediatric Advanced Life Support (PALS) and Advanced Life Support qualifications, there are no children's nurses. Some have completed a general child-care module, which covers caring for sick children in hospital, and others have done the PALS course.

Recognising that 'a distinct responsibility of health care staff is to provide a safe environment for children while in hospital' (Stower, 2000), we became concerned about nursing children in this adult environment. The Royal College of Surgeons' report (2000) on paediatric care in hospitals also raised issues that heightened these concerns. Nurses on the ward complained of feeling out of their depth. They began to question whether they had the skills necessary to ensure the best possible care for children.

After talks with the local health authority inspection unit, we decided to introduce a formal risk-assessment tool that the nurses could use when monitoring children. This tool would give nurses a reference point and help them to identify when a child's condition was deteriorating.

Research and development
I asked the RCN to help with a literature search and placed an advertisement in a paediatric nursing journal asking for information on any existing tools. This proved fruitless. I then wrote to specialist paediatric units around the country requesting details of any tool that could be adapted to our needs. Of 40 letters sent, I received 25 replies but none could help. I tried to identify an adult assessment tool that might be adaptable. By widening my literature search I eventually found an article in Nursing Times on identifying and preventing critical illness (Welch, 2000).

Using this as a template, I identified key areas that needed assessment when dealing with children. The aim was to provide a comprehensive assessment that would ensure the early identification of any problems in postoperative children. Prompt recognition is important as, according to Welch (2000), an 'assessment of basic vital signs, such as respiration and tissue perfusion, can identify many patients who are at risk, but staff often fail to recognise the signs soon enough'.

Using the PALS section of the Resuscitation Council's handbook (1997), I selected the necessary observations for inclusion in our tool. If the patient scores above a certain number, medical help is to be sought immediately. Anything in the '0' column is regarded as normal (Fig 1).

It should be noted that all patients are assessed on admission to give baseline readings showing what is 'normal' for each child before surgery. This also provides a benchmark against which to compare the results of the critical-incident assessment.

Assessment tool
The document begins by posing the question: 'Does the child's condition give cause for concern?' If the answer is 'yes', the nurse needs to check the following list and make an informed decision on the best possible course of action to maintain the child's safety and well-being. This includes:

- Level of consciousness;

- Respiratory rate;

- Central and peripheral pulse;

- Oxygen saturation;

- Urine output;

- Core and peripheral temperature;

- Capillary refill time;

- Breathing effort and sound;

- Colour;

- Best verbal response;

- Blood-sugar level.

These are checked in order of airway, breathing and circulation, and level of consciousness, as advised in PALS. The assessment criteria are specific to children aged three and above. (It should be noted that the criteria differ for those children who are under the age of three because certain characteristics are specific to the child's age and developmental stage.)

A draft document was sent to all clinicians with paediatric admitting rights to determine their views on the tool's viability. Most supported the principle and, on their advice, I reduced the critical score from five to three. An amended copy was then sent to the health authority inspection unit and the final document was introduced to the ward. Training sessions were also set up for staff.

Conclusion
As can be seen from the case study, an emergency immediately put the tool to the test - and it passed. The document has improved nurses' confidence in general paediatric care, not merely in emergency situations, although we recognise that children should ideally be cared for by paediatric nurses.

The tool is limited in its use, having been designed for a specific environment, and should never be used on its own. The initial idea was to design something that could be used in conjunction with the existing documentation, which already contains a comprehensive nursing assessment of the patient. We also acknowledge that nurses would benefit from ongoing formal training programmes that focus specifically on paediatric care.

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