Observation chart (obs chart) is a chart used to quickly determine the degree of illness of a Pt. Being between the flags (aka early warning score, EWS) means that the observations are within an appropriate range.

It is derived from:

• 4 vital signs (aka vitals), which are physiological readings assessing general physical health of a Pt, giving clues to possible diseases, and show progress towards recovery. The SPOC chart is drawn in the order of ABCDE, as you go from the LHS to RHS. Normal ranges vary with age, weight, gender, and overall help. These include:
  • Systolic BP [or even, BP generally]
  • HR [which can be measured by pulse]
  • RR
  • Body temperature
• 1 observation:
  • LOC, via AVPU

• Notice anything outside the flags, i.e. in the yellow or red zones. Rapid response should be initiated as soon as any of the obs enters the red zone
• Trend in obs
• Altered calling criteria
• Check for patients in a high risk group, e.g. <3mo, chronic conditions, post op, pre-existing respiratory/cardiac conditions, or opioid transfusions

Paperwork for Standard pediatric observation chart (SPOC) depends on age, with different charts for Under 3 months, 3-12 months, 1-4 yo, 5-11yo, 12+ yo. It includes (sampling 12yo+):

• Indicates the Age applicable (eg. 12 Years and over)
• Tick, for Altered calling criteria
• ALL OBSERVATIONS MUST BE GRAPHED
• Other charts in use, ticks for Fluid balance, Insulin infusion, Neurological observatino, Pain/epidural/Pt control analgesia, Neurovascular, Resuscitation plan, and several Other ___
• Prescribed frequency of observations, Observations must be performed routinely at least 4th hourly, unless advised below. Various columns, for the rows DATE dd/MM/yy, TIME hh:mm, Frequency required, Medical office name (BLOCK letters), Medical officer signature, Attending medical officer signature
• Alterations to calling criteria must be reviewed within 48 hours or earlier if clinically indicated. Any alterations MUST be signed by a medical officer and confirmed by attending medical officer. Document rationale for altering calling criteria in the Pt's health care record. Various columns, for the rows DATE dd/MM/yy, TIME hh:mm, next review due date & time dd/MM/yy hh:mm
• Section for Vital sign, with various columns, for the rows Respiratory rate which in its Yellow Zone is 5-10, 30-40; or for the Red Zone is <5 > 40. SpO2, which in its Yellow Zone is 90-95; or for Red Zone is <90. Heart Rate, which for yellow zone is 40-50, 130-150; or Red zone <40 or >150. Other, which is subdivided into Yellow Zone and Red Zone
• Authentication, including Medical Officer Name (BLOCK letters), Medical officer signature, Attending medical officer signature
• Various rows, with rows 1 to 4, and column titles Date, Time, INTERVENTIONS/COMMENTS/ACTIONS
• Inside page, which is colored with white, blue, yellow, and red. There is a table, which has various columns for the time series. The top row includes the Date, and for each individual column, the Time. The sections include:
  • Airway/breathing, which includes Respiratory rate (breaths per minute), which ranges from 5-60; Respiratory distress, which ranges from normal, mild, moderate to severe; SpO2 %, which ranges from <70 to 100, with an additional box for Probe change; Oxygen, which is subdivided into L/min or %, and Device
  • Circulation, which includes Heart rate (beats per minute), which ranges from 40 to 180; Capillary refill, which is either < 3 seconds or >=3 seconds; Blood pressure (mmHg) > < SBP is the trigger, which ranges from 20 to 200
  • Disability, which includes Level of consciousness, which ranges from Alert, Verbal, Pain, Unresponsive, which in the under row is to be followed by Enter appropriate letter A=Alert, V=Rousable only by voice (consider GCS), P=Rousable only by central pain (conduct GCS), U=Unresponsive; Pain score, ranging from Nil, Mild (1-3), Moderate (4-6), Severe (7-10)
  • Exposure, which includes Temperature (degrees C) (check unit policy), which ranges from 34 to 41
  • Row for BGL
  • Row for Weight, which extends over 2 columns
  • The last row is Initials, for authentication
• Consider earlier escalation of Pt's with Chronic or complex conditions, Postoperative, Pre-existing cardiac or respiratory conditions, Opioid infusions. Note that Additional criteria for escalation on back page
• Assessment of respiratory distress, with the rows Airway, Behavior and feeding, Respiratory rate, Accessory muscle use, Apneic episodes, Oxygen. Mild is Stridor on exertion; Normal, talks in sentences; Mildly increased; Non/minimal; None; No oxygen requirement. Moderate is Stridor at rest, Partial airway obstruction; Some/intermittent irritability, Difficulty talking or crying, Difficulty feeding or eating; Respiratory rate in the Yellow Zone; Moderate recession, Tracheal tug, Nasal flaring; Abnormal pauses in breathing; Mild hypoxemia, corrected by oxygen, Increasing oxygen requirement. Severe is New onset of stridor, Imminent airway obstruction; Agitated/confused, Drowsy, Unable to talk or cry, Unable to feed or eat; Respiratory rate in the Red Zone, Decreasing (exhaustion); Severe recession, Gasping, Grunting, Extreme pallor, Cyanosis, Absent breath sounds; Apneic episodes; Hypoxemia, may not be corrected by oxygen
• Refer to your local clinical emergency response system (CERS) protocol for instructions on how to make a call to escalate care for your Pt. Check the health care record for an end of life care plan which may alter the Mx of your Pt:
  • Blue zone response: If your Pt has any blue zone observations you MUST (1) Initiate appropriate clinical care. (2) Increase the frequency of observations, as indicated by your Pt's condition. (3) Manage anxiety, pain and review oxygenation in consultation with the NURSE IN CHARGE. (4) You can make a call to escalate the care of your Pt at any time if you are worried or unsure whether to call. Consider the following: (1) What is usual for your Pt and are there documented "ALTERATIONS TO CALLING CRITERIA"? (2) Does the abnormal observation reflect deterioration in your Pt? (3) Is there an adverse trend in observations?
  • Yellow zone response: If your Pt has any yellow zone observations or additional criteria* you MUST (1) Initiate appropriate clinical care. (2) Repeat and increase the frequency of observations, as indicated by your Pt's condition. (3) Consult promptly with the NURSE IN CHARGE to decide whether a CLINCAL REVIEW (or other CERS) call should be made. Consider the following: WHat is the usual for your Pt and are there documented "ALTERATIONS TO CALLING CRITERIA"? Does the trend in observations suggest deterioration? Is there more than one Yellow Zone observation or additional criteria? Are you concerned about your Pt? If a clinical review is called, (1) Reassess your Pt and escalate according to your local CERS if the call is not attended within 30 minutes or you are becoming more concerned. (2) Document an A-G assessment, reason for escalation, Tx and outcome in your Pt's health care record. (3) Inform the Attending Medical Officer that a call was made as soon as it is practicable. *Additional YELOW ZONE criteria, include Increasing oxygen requirement; Poor peripheral circulation; Greater than expected fluid loss; Reduced urine output or anuria (< 1mL/kg/hr); Altered mental state: Agitation, Combative or Incosolable; New, increasing or uncontrolled pain; New onset of fever > 38.5 degrees C; BGL 2-3 mmol/; concern by you or any staff or family member
  • Consider if your Pt's deterioration could be due to sepsis, dehydration/hypovolemia/hemorrhage, or an overdose/over sedation
  • Red zone response: If your Pt has any red zone observations or addtional criteria# you MUST call for a rapid response (as per local CERS) AND, (1) Initiate appropriate clinical care; (2) Inform the NURSE IN CHARGE that you have called for a Rapid Response; 93) Repeat and increase the frequency of observations, as indicated by your Pt's condition: (4) Document an A-G assessment, reason for escalation, Tx and outcome in your Pt's health care record; (5) Inform the Attending Medical Officer that a call was made as soon as it is practicable. #Additional Red zone criteria are, especially highlighted, Cardiac or respiratory arrest; Circulatory collapse; Pt unresponsive; New onset of stridor. Also includes Deterioration not reversed within 1 hour of Clinical review; 3 or more simultaneous "Yellow Zone" observations; Significant bleeding; Sudden decrease in Level of Consciousness (a drop of 2 or more points on the GCS); New or prolonged seizure activity; BGL <2mmol/L or symptomatic; Lactate >=4 mmol/L; serious concern by you or any staff or family member

• Medical record (category)