Procedure
Standard practice for vital sign and physical assessments in
the Emergency Department HNE LHD
Document Registration Number:
Sites where Procedure applies:
All Emergency Departments HNE LHD
Target audience:
ED Clinical Staff
Description:
This procedure outlines the standardised and
appropriate routine measurement of physiological
parameters that should be performed on all patients
admitted to the ED.
Vital signs, assessment, emergency department,
observations
No
Keywords:
Replaces Existing Procedure:
Registration Number(s) and/or name and
of Superseded Documents:
Relevant or related Documents, Australian Standards, Guidelines etc:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive 2007_077 Medication Handling in NSW Public Hospitals
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_077.pd
 NSW Health Policy Directive PD2009_060 Clinical Handover - Standard Key Principles
 NSW Health Policy Directive 2010_026 Recognition and management of a Patient who is
Clinically Deteriorating
http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_026.pd
 NSW Health Policy Directive 2010_032 Children and adolescents- admission to services
designated level 1-3 Paediatric Medicine & Surgery
http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_032.pd
 HNE LHD Policy Compliance Procedure Recognition and Management of a Patient who is
Clinically Deteriorating PD2010_026:PCP 1
 NSW Ministry of Health Policy Directive 2011_038 Recognition of a Sick Baby or Child in
the Emergency Department
http://www.health.nsw.gov.au/policies/pd/2011/PD2011_038.html
 HNELHD Policy Compliance Procedure; Vital Signs Observations 16 Years and over
PD2010_026:PCP 2
 Local procedure GNAH_0086 Clinical Review and Escalation
 Local procedure GNAH_0085 Vital Sign Observations > 18 years
 BH Emergency Department Drug Guidelines: 02-75-021
http://intranet.hne.health.nsw.gov.au/ppg/gnah/belmont_hospital_procedures_and_guideline
s
Prerequisites (if required):
02-30-005: 02/2011
ED staff must be trained and competent to provide appropriate
assessment and interventions
Page 1 of 6
Procedure Summary:
This procedure sets out the steps to be followed when assessing any
patients being admitted to the ED
Date first authorised:
February 2011
Authorised by:
Contact Person:
Contact Details:
Date Reviewed:
Review due date:
Responsible for review:
Version:
Diana Williamson
Diana.williamson@hnehealth.nsw.gov.au
February 2011
February 2014
Policy, Procedure and Guideline Committee
1
OUTCOMES
1
Safe, standardised and appropriate routine measurements of physiological parameters
in all patients admitted to the Emergency Department.
ABBREVIATIONS & GLOSSARY
Abbreviation/Word
Definition
CVA
Cerebral Vascular Accident
ECG
Electrocardiogram
ED
Emergency Department
GCS
Glasgow Coma Scale
BMI
Body Mass Index
PREAMBLE
A baseline set of observations and physical assessment must be attended and recorded as
clinically indicated and relevant to the patients presenting problem and/or clinical status.
This decision is based on clinical judgement. For elderly and at risk patients allocated to a
waiting area or treatment space observations must be attended as soon as practical to
ensure patient safety and that the patient’s physiological parameters are “Between The
Flags” and not requiring immediate clinical review or a rapid response. At risk patients
include elderly, paediatric, morbidly obese patients Body Mass Index (BMI) greater than 35,
or child BMI greater than 30 and the intoxicated patients.
PROCEDURE
The procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide
informed consent and, that patient identification, correct procedure and correct site process
is completed prior to any procedure.
Staff Preparation
It is mandatory for staff to comply with relevant: “Five moments of hand hygiene”, infection
control, moving safely/safe manual handling, triage assessments and documentation
practices.
02-30-005: 02/2011
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Equipment Requirements
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Alcohol hand gel
Personal Protective Equipment
Vital sign recording equipment
Emergency Department Adult Assessment, Treatment and Observation form and
relevant observation chart.
Procedure steps
Adult presentations (greater than 17years) should include:


An Emergency Department Adult Assessment, Treatment and Observation form and
relevant SAGO chart is mandatory for all patients within the Emergency Department
who have any nursing or medical intervention or assessment. The Emergency
SAGO form will supersede this once introduced by the Ministry Of Health.
Hourly vital sign monitoring (observations) should be carried out and documented
for 4 hours unless clinically indicated by a high triage allocation (ATS 1 or 2),
deterioration of patient’s condition, abnormal vital signs or significant variance in
previous observations. These observations MUST include:
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Temperature
Pulse
Respirations
Blood pressure (BP)
SpO2
Pain Score
AVPU/GCS
Based on these observations the patient may need clinical review if in the Yellow Zone or
an urgent Rapid Response Call if the patient is in the Red Zones

Pupil reaction for patients with depressed levels of consciousness must be
recorded.

A postural BP must be performed for patients with history of giddiness and
dizziness, syncope, history of falls or as clinically indicated. NB: It is taken when
patient is lying flat then sat up and legs placed over the side of bed for 2 minutes
prior to taking the subsequent reading.

Oxygen saturation levels must be recorded for patients with respiratory / airway
compromise or decreased level of consciousness – refer to PD2010_032 (page 4)
regarding respiratory assessment requirements and observations to be recorded

Blood glucose levels must be recorded on all patients who have any alteration in
their level of consciousness, present following a syncopal episode, falls, and seizure
or have a history of diabetes or any other unexplained presentation.

ECG on patients who have chest pain, a syncopal episode, fall or chest trauma,
actual or potential CVA, tachycardia/bradycardia or other unexplained presentation.

Neurovascular observations for any compromised or potentially compromised limb
and any patients suspected of having an abdominal aortic aneurysm.
02-30-005: 02/2011
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
All observations must be recorded and documented in the patient’s health record.
Abnormal vital signs with interventions must be reported to the Team Leader / RN
In-Charge / ED coordinator and medical officer for review.

A weight should be documented as actual, stated or estimated on all patients
entering the emergency department as part of their admission.
Paediatric presentations (0-17 yrs) should include:
NSW Health Policy Directive 2010_032requires all infants and children presenting to the
emergency department must have a full set of observations taken and recorded at the point
of triage based on the presenting symptoms. The minimum data recorded should included
temperature, weight, heart rate (by palpation, auscultation or ECG) respiration rate and
respiratory effort (any patient with a respiratory condition should also have pulse oximetry
with air entry, breath sounds and respiratory effort assessed). A blood pressure must be
recorded at some stage during the presentation and should be taken as soon as practicable
in ATS 1 & 2 patients. The recording of some observations may be deferred if doing so may
compromise the patient’s airway for example in epiglottitis or life threatening croup. In
specific clinical presentations additional observations must be documented. In cases
involving head injuries and altered level of consciousness, a Paediatric Glasgow Coma
Score must be recorded as clinically indicated. A validated age-appropriate pain score must
be documented for all paediatric patients. If a child presents with a suspected fracture then
neurovascular observation must be commenced on the affected limb or digit.
Document all paediatric observations on corresponding age specific BTF observation
chart.

Hourly vital sign monitoring (observations) should be carried out for 4 hours unless
clinically indicated by a high triage allocation (ATS 1 or 2), deterioration of patient’s
condition, abnormal vital signs or significant variance in previous observations.
These observations MUST include:

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Temperature (per axilla for all children equal to or less than 3 years)
Pulse
Respirations
Pulse oximetry
Weight (kg) (bare weight if equal to or less than 12months)
Pain scale as per numerical pain score or faces pain scale (age
appropriate)

Initial Blood Pressures (BP) are to be taken on all children who present with or are:
- Critically ill or injured
- Poisonings, includes alcohol
- Neurological symptoms e.g. head injuries, seizures, meningitis
- Renal disease or renal history
- Cardiac e.g. cardiac history, arrhythmias
- Diabetes
- Obese children
- Syncope
Correlate the blood pressure result with the normal range for age, if abnormal continue
hourly BP monitoring unless more frequent observation is clinically indicated or there is
potential for deterioration. Notify Medical Officer and document in appropriate notes.
Based on these observations the patient may need an increase in the frequency of
observations if in the Blue Zone, a clinical review if in the Yellow Zone or a Rapid
Response Call if the patient is in the Red Zones
02-30-005: 02/2011
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
A physical assessment must be recorded;

The level of consciousness should be assessed and recorded including a paediatric
modified GCS score;

Pupil reaction for patients with depressed levels of consciousness must be
recorded.

Oxygen saturation levels must be recorded for patients with respiratory / airway
compromise or decreased level of consciousness.

Blood glucose levels must be recorded on all patients who have any alteration in
their level of consciousness, present following a syncopal episode, seizure or have
a history of diabetes or any other unexplained presentation.
NB: Any child who is unwell, critically ill or injured should have a baseline BGL
recorded as a minimum

ECG on patients who have chest pain of cardiac origin, a syncopal episode, fall or
chest trauma, CVA, tachycardia/bradycardia or other unexplained presentation.

Neurovascular observations for any compromised or potentially compromised limb
or digit.

Head circumference if child is less than 2 years of age and clinically indicated e.g.
head injury, seizure, meningitis, bulging fontanels or medically requested.

Refer to the Emergency Departments Recognition of a sick child in Emergency
Departments Clinical practice Guidelines to individually evaluate and impose clinical
decisions in order to achieve the best clinical outcomes for the child

All observations must be recorded and documented in the patient’s health record.
Abnormal vital signs with interventions must be reported to the Team Leader / ED
coordinator / RN In-Charge and medical officer for review.
Need to include somewhere that 2 sets of vitals signs need to be recorded as a minimum
on all ED patients
Drug Administration
When administering medications the mandatory observations dictated by the specific
protocols - including Intravenous analgesia, sedation and study protocols – MUST always
be adhered to.
APPENDICES
Nil
02-30-005: 02/2011
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References:
HNE LHD Policy Compliance Procedure Recognition and Management of a Patient who is
Clinically Deteriorating PD2010_026: PCP 1
NSW Health Policy Directive 2011_038 recognition of a Sick Baby or Child in the Emergency
Department
JHH DOEM Policy 2010 / 05 Standard Practice for the measurement of nursing
observations
02-30-005: 02/2011
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