International Emergency Nursing (2010) 18, 166–168

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Research Review

How well do vital signs identify children withserious infections in paediatric emergency care?Thompson, M., Coad, N., Harnden, A., Mayon-White, R., Perera, R., Mant, D., 2009. Archives ofDisease in Childhood 94, 888–893

Measuring vital signs is standard clinical practice inacute clinical environments, but do their findingsreally tell clinicians what they need to know aboutthe state of their patients? This paper explores thedegree to which recording vital signs identify childrenwith serious infections. It compares their diagnosticvalue with a Manchester Triage Score (MTS) and theTraffic Light clinical risk factors system score (NICE,2007).

Seven hundred children, presenting with suspectedacute infection to an assessment unit at a teachinghospital in England, were utilised in this study. Theyhad a comprehensive set of vital signs recorded andan MTS score allocated. Three hundred and fifty seven(51.0%) came from primary care, 198 (28.3%) wereself-referrals and 116 (16.6%) by emergency ambu-lance transfer. Three hundred and eighty three(54.7%) required admission. The severity of infectionwas characterised as, serious, intermediate, minoror no infection.

Children with serious or intermediate infections(n = 313) were significantly more likely than thosewith minor or no infection (n = 387) to have a temper-ature greater or equal to 39 �C, tachycardia, satura-tions less than or equal to 94% or capillary refilltime (CRT) greater than 2 s. Having one or more ofthe following criteria, temperature greater or equalto 39 �C, saturations less than or equal to 94%, tachy-cardia and tachypnoea, was 80% sensitive and 39%specific for serious or intermediate infection. Thesefindings were comparable to an MTS score, 84% sensi-tive and 38% specific, and the Traffic light system(NICE, 2007), 85% sensitive and 29% specific.

The researchers concluded that a combination ofvital signs can be used to differentiate children withserious infections from those with less serious infec-

doi:10.1016/j.ienj.2009.12.001

tions in child assessment units. Moreover, these mea-sures have comparable sensitivity to morecomplicated triage systems. The diagnostic value ofcombined vital signs and the NICE traffic light systemappeared less conclusive.

Comment: This is an interesting and detailed paperwhich explores not just the relevance of recording vi-tal signs, but assesses the value of individual mea-sures. It is reassuring to find that what is standardclinical practice can be indeed highly effective, butonly if a comprehensive range of measures are uti-lised. The research implicitly cautions practitionersagainst recording vital signs casually and withoutthinking.

A simple intervention improves the recording ofvital signs in children presenting to the emergencydepartment. Bird, C., Shea, A., Michie, C., George,G., 2009. Emergency Medicine Journal 26, 698–700

If the early recording of vital signs in paediatric pa-tients is indeed a valuable clinical exercise then it fol-lows that they must (remove the word ‘‘both’’) becarried out and be documented clearly and consis-tently. This study contends that normal paediatricclinical parameters are often not well understood bypractitioners, are carried out intermittently, and arepoorly documented, particularly at the triage stageof the assessment process.

This study has a very practical aim, to find outwhether the use of a small, laminated aide memoire,based upon recognised criteria, and supported by ashort twenty minute teaching session, might improvethis situation. The process of the study is clearly setout. A preliminary audit of the measurement of vitalsigns in 106 children aged less than 6 years was car-ried out in the emergency department of a districtgeneral hospital. The next stage involved the distribu-tion of small cards, illustrating normal child values toclinical staff. This was supplemented by the provisionof a short teaching session, focusing on the impor-tance of these measures. The audit was then repeatedin a further 106 children. Interrogation of the finding

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concluded that there was a notable improvement inthe recording of all vital signs, and these results werefound to be statistically significant. The results forblood pressure recording and to a lesser extent tem-perature recording were less impressive. The auditorsconcluded that the introduction of a low-cost card to-gether with a short training session offered a usefulstrategy to improve the rate of documentation of vitalsigns of children presenting to the emergencydepartment.

Comment: This is a concise but highly practical pa-per that is realistic in both its aim and recommenda-tions. It raises the significant issue of being vigilant toensure that innovations are maintained and thusembedded in practice. A future audit isrecommended.

‘I can actually talk to them now’: qualitative re-sults of an educational intervention for emergencynurses caring for clients who self-injure’. McAllis-ter, M., Moyle, W., Billett, S., Zimmer-Gembeck,M., 2009. Journal of Clinical Nursing 18, 2838–2845

This qualitative study addressed an area of com-mon concern to emergency nurses, that of managingpatients who have self harmed. The fact that thisstudy was carried out in Australia only goes to demon-strate the international nature of this issue. The con-text of the study was a wider project to increaseconfidence of clinical staff by implementing a specificeducation strategy. The specific objectives of thestudy were to measure the change in knowledge, skillsand professional identity, arising from the solution-focused education intervention and hence its valueas a clinical intervention in emergency practice. Incontrast to most educational interventions which in-crease knowledge, the intervention identified taughtthe value of health promotion strategies, proactiveskills and coping strategies. A mixed method pretestand posttest group design was used and 36 nurseswere interviewed to examine differences in profes-sional identity, subject awareness and clinicalreasoning.

The results demonstrated improvements in knowl-edge and understanding of self harm, and in nurses’self-belief in their ability to positively influence theirpatients. It also produced a positive shift in attitudestowards patients and in an inclination towards moreperson-centred and change oriented practice. Theresearchers conclude that the solution-focused edu-cation intervention demonstrates potential as aneffective intervention to enable nurses to recogniseand appreciate their unique role in providing a healthservice that is more proactive and health-promoting.The utilisation of psychosocial skills by nursing staffbuilds confidence, competence and more person-fo-cused care.

Comment: This interesting paper demonstrates theinternational commonality of problems and issues fac-ing emergency nursing practice. It is particularly help-ful in its emphasis, not just on teaching and deliveryof information to practitioners, but also on the provi-sion of effective tools to do the job. At a time wheneducational opportunities are being squeezed it isessential that when they are provided that they reallywill help practitioners to apply theory to practice. Asin so many areas of practice confidence is the key. Itseems that this project has done just that.

Nurse-patient/visitor communication in theemergency department. Pytel, C., Fielden, N.,Meyer, K., Albert, N., 2009. Journal of EmergencyNursing 35(5), 406–411

Experienced practitioners recognise that communi-cation with patients and carers in emergency depart-ments is often carried out in less than idealcircumstances, often cramped, noisy and chaotic.The result, fractured communication and less thansatisfied customers! The driving purpose underpinningthis pilot study is that patients and visitors must haveenough relevant information so that treatment andrecovery from illness can be optimized. The reportsets out in some detail the research methodology usedto achieve the researchers objectives. They had threequestions they wanted to explore; first, what are thecommunication needs/priorities of patients/visitorstreated in the emergency department prior to dis-charge home or hospital admission; second, how welldo nurses meet patient and visitor communicationneeds; and third, does nursing communication perfor-mance match actual patient and visitor needspriorities?

Utilising a survey design, a convenience sample ofnurses and patients/ visitors were invited to: describepatient/visitor communication needs; and, determineif needs were met during their time in the emergencydepartment. Descriptive statistics were used to ana-lyse the resultant data from 64 nurses and123 pa-tients/visitors. Mantel Haenszelv2 tests used todetermine associations between patient-rated impor-tance of nurse communication needs and nurses com-munication performance. More than 80% of patientsanswered ‘‘excellent’’ or ‘‘very good’’ to 6 of thetop 10 important communication needs. Patient andnurse importance differed significantly on only 2 com-munication needs: calm voice and social status.Nurses rated these needs of higher importance thanpatients (p = .01, p = .006). Nurse and patient/visitorperceptions of important communication were foundto be similar. However, the researchers were by nomeans complacent and emphasised that raisingnurses’ awareness of patient/visitor communicationneeds is the first step in enhancing effectiveness ofmeeting those needs.

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Comment: Patient surveys, such as this one consid-ered here, may be considered to be a tame evenunimaginative attempt to evaluate practice. Certainlythe age of ‘targets’ and outcome measures demandrobust and searching evidence. However, this studyposes highly relevant and challenging questions aboutwhether emergency nurses are meeting patients’needs in this area of practice that is central to nurs-ing. It is important for emergency nurses to take seri-ously the responsibility to find ways of creating

environments of trust, respect, and acceptance. Asthe study makes clear, patients look to nurses forcommunication that reflects caring, listening thatshows concern, compassion and genuine concern.These are the hallmarks of nursing and failures oftenresult in patient/relatives complaints.

Alastair Gray MSc (Advanced Clinical NursingPractice), BSc (Hons), RN, RNT, DPSN

Coventry University, England, UK