Abnormal Vital Signs: Intervention Bundle

This intervention bundle is designed to help EMSC NPRQI teams improve the identification and reassessment of abnormal vital signs in children presenting to the ED. These actions align with the National Pediatric Readiness Quality Initiative (NPRQI) quality measures, which participants will aim to improve upon over the collaborative. Please see here to learn more about quality measures development.

The quality measures related to abnormal vital signs are:

Assessment

• Percentage of pediatric patients with vital signs re-assessed

Intervention

• Median time for collection of first set of vital signs to first intervention.

Gathering data during implementation is essential for understanding where you are starting from, assessing whether new processes are being adopted, identifying barriers, and determining whether you are progressing toward your process-measure goals. Consistent measurement helps teams understand how changes are performing in real practice and highlights areas where additional education, reinforcement, or workflow refinements may be needed. A variety of methods can be used to assess how well your interventions are working.

Examples include:

Chart Audits

Chart reviews are one of the most direct ways to evaluate whether key elements are being completed:

• Complete, accurate vital signs: Assess whether appropriate pediatric equipment (e.g., child-sized blood pressure cuffs) was used and if temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry were all obtained and documented.
• Reassessment of abnormal vital signs: Check for documentation of repeat vital signs within the expected timeframe.
• Provider notification: Verify if abnormal vital signs triggered timely RN-to-provider communication and documentation.

How to conduct chart audits:

• Real-time, "during the shift" audits conducted by charge nurses, quality champions, or QI staff.
• Retrospective audits of a representative sample, such as:
  • Every 5th pediatric chart
  • All children under a certain age
  • All patients presenting during specific shifts
  • All pediatric patients seen over a defined timeframe (e.g., one week per month)
• Automated electronic health record reports can pull fields such as weight units, pain score entries, and/or the number of vital sign sets obtained on pediatric patients.

Staff Surveys

Surveys can help you understand how changes are being adopted, perceived, and applied:

• Confidence in obtaining and interpreting pediatric vital signs.
• Barriers to vital sign reassessment (e.g., workflows, staffing, equipment access).
• Clarity around when and how to notify providers about abnormal findings.
• Perceptions of how realistic the expectations are within the flow of the ED.

Short, anonymous surveys tend to yield the best participation.

Family Feedback

Family experience can offer valuable insights:

• Whether families observed timely reassessment or follow-up.
• Whether communication about abnormal findings felt clear and reassuring.

Surveys can be offered by QR code, text message, or follow-up call.

Direct Observation or Workflow Mapping

Observing a portion of the triage or intake process can highlight practical barriers such as:

• Inconsistent access to pediatric blood pressure cuffs/tubing.
• Workarounds that bypass required documentation fields.

These observations often uncover issues that chart audits alone cannot.

Calculation of Key Metrics

Metrics may include:

• Percentage of complete vital signs obtained at the initial point of contact.
• Percentage with abnormal vital signs reassessed
• Percentage of charts with provider notification documented for abnormal findings.

Sharing Progress with Staff and ED Leadership

Communicating results is crucial for maintaining engagement and demonstrating improvement. Consider:

• Monthly visual dashboards (run charts, bar graphs) posted in staff areas.
• Quick “Wins of the Week” shared during huddles or shift reports.
• Quarterly summaries to ED leadership highlighting improvements, challenges, and resource needs.
• Story-based feedback, such as a brief example where early recognition of abnormal vital signs led to improved patient outcomes.
• Recognition programs, such as highlighting staff or shifts with high compliance.
• Email updates or intranet posts with simple, digestible data snapshots.

Clear, ongoing communication helps sustain interest, encourages accountability, and reinforces the importance of accurate pediatric vital sign assessment and reassessment.

Below are suggested interventions, or change strategy options, to support improvement in this process measure. These strategies provide practical steps to help your team achieve its aim and can be adapted to fit local workflows. Interventions generally fall into four categories: Guidelines/Protocols, Education, Electronic Health Record (EHR) Optimization, and Resources (personnel/equipment).

As local experts, your team may identify additional strategies that better align with your ED’s structure and needs. Working with ED leadership and/or other ED team members on this initiative can help improve and reinforce your approach.

WRITTEN POLICY/PROCEDURE

Change Strategies

• Develop or update written policies to include vital sign ranges for all pediatric age groups (e.g., PALS, ESI reference values).
• Include expectations for obtaining and documenting weight in kilograms, using age/size-appropriate equipment to obtain vital signs, and performing and documenting validated pain assessments and reassessments.
• Define site-specific thresholds that constitute abnormal vital signs and trigger reassessment, escalation, and/or provider notification.
• Embed expectations for timely vital sign reassessment and documentation in existing triage and workflow policies.

NOTIFICATION PROTOCOL

Change Strategies

• Define clear criteria that activate the abnormal vital sign notification protocol (e.g., abnormal heart rate/blood pressure /respiratory rate, concerning pain scores, trends of deterioration).
• Specify who must be notified, how quickly, and by which method (e.g., phone, secure messaging, EHR alert).
• Establish standardized intervals for repeat vital signs based on severity/risk level or change in patient condition.
• Implement a visual alert system (e.g., triage banner, wristband, EHR flag) to identify higher-risk patients.
• Outline recommended actions when vital signs fall outside normal ranges, using evidence-based pathways or guidelines.
• Adopt a validated pediatric triage tool to support early recognition (e.g., PAT-supported triage, ESI).
• As able, add standing orders in triage to support timely interventions (e.g., repeat vitals, analgesia per protocol).

EMR OPTIMIZATION

Change Strategies

• Develop a targeted education program emphasizing:
  • The importance of accurate vital sign measurement
  • Recognizing abnormal vital signs across common presentations (e.g., trauma, respiratory distress, infection)
  • Pediatric pain assessment using patient-appropriate validated scales
  • When and how to escalate abnormal findings
• Deliver training through multiple modalities: online modules, staff meetings, simulations, peer-to-peer coaching, skills days, or brief huddle refreshers.
• Include tabletop exercises or short scenario-based discussions to reinforce recognition of abnormal vital signs and escalation steps.

EHR OPTIMIZATION

Change Strategies

• Build EHR alerts that notify the care team when vital signs are outside age-appropriate ranges.
• Integrate clinical decision support tools that consider multiple risk factors (e.g., decision support for abnormal vitals, respiratory distress indicators, or sepsis tools).
• Standardize documentation fields for weight, pain scores, and vital sign reassessments to improve data capture and reliability.
• Enable automated reporting to track compliance with documentation and notification workflows.

KNOWLEDGE REINFORCEMENT FOR CARE TEAM

Change Strategies

• Use tabletop scenarios to illustrate early deterioration and the necessary response actions.
• Post visual aids in triage and clinical areas (normal vital sign ranges, escalation pathways, pain scale guides).
• Provide pocket/badge cards with age-based vital sign norms and notification triggers.
• Give real-time or follow-up feedback to staff based on chart audits or direct observations.
• Use color-coded tools aligned with length-based resuscitation tapes to support quick recognition of age-appropriate ranges.

PATIENT AND FAMILY-CENTERED STRATEGIES

Change Strategies

• Involve families in care: encourage caregivers to monitor their child’s condition and notify staff of any changes.
• Clear communication about vital sign monitoring: ensure families understand why, when, and how vital signs are checked, especially during long ED waits, so they know what to expect.
• Patient comfort during vital sign assessment: use child-friendly language and techniques (e.g., distraction tools, toys, or child-life specialists) to reduce stress and anxiety during vital sign assessment/reassessment.
• Education at discharge: provide written and verbal instructions on vital signs to monitor, empowering parents to seek care early if their child’s condition worsens.

WRITTEN POLICY/PROCEDURE

Change Strategies

• Create or update a policy that clearly defines when abnormal vital signs require reassessment, including expected time intervals (e.g., within 15–30 minutes depending on severity).
• Include guidance for repeat pain assessments following interventions and documentation expectations for both vital signs and pain scores.
• Define thresholds that require immediate vs. routine reassessment, acknowledging age-based norms and CYSHCN baseline variations.
• Incorporate expectations for using appropriate pediatric equipment to ensure accurate reassessment.

NOTIFICATION PROTOCOL

Change Strategies

• Establish criteria that trigger immediate provider notification when abnormal vital signs persist or worsen on reassessment.
• Clarify the escalation pathway: who is notified, how quickly, and how communication should occur (e.g., phone call, secure message, bedside huddle, structured handoff).
• Create standardized reassessment intervals and escalation steps for specific abnormalities (e.g., tachycardia, hypotension, hypoxia, high pain scores).
• Implement visual cues or flags (e.g., EHR or physical indicators) to identify patients requiring ongoing reassessment.

Align reassessment protocols with evidence-based pathways (e.g., sepsis, respiratory distress, trauma, dehydration, pain management).

EHR OPTIMIZATION

Change Strategies

• Build EHR triggers that prompt reassessment when vital signs fall outside age-based norms (e.g., pop-up reminders, track-board banners, or hard-stop documentation).
• Create an order set or standardized documentation template for reassessment, including frequency and required fields.
• Integrate decision support tools that help recognize deterioration through trending (e.g., repeated abnormal values, worsening pain scores).
• Enable automatic capture of time intervals between abnormal findings and reassessment for QI tracking.

EDUCATION

Change Strategies

• Provide brief training sessions or modules on:
  • The importance of timely reassessment in preventing clinical deterioration.
  • Recognizing patterns of worsening vital signs across common pediatric presentations (e.g., sepsis, respiratory distress, trauma, dehydration).
  • Appropriate documentation and communication expectations.
• Offer scenario-based learning (e.g., short tabletop exercises) focused on identifying when abnormal findings require immediate repeat assessment.
• Reinforce use of validated pediatric tools (e.g., PAT, clinical guidelines) as part of reassessment decision-making.

KNOWLEDGE REINFORCEMENT FOR THE CARE TEAM

Change Strategies

• Display quick-reference tools in triage and clinical areas: normal vital sign ranges, reassessment timelines, pain scale guides.
• Provide pocket/badge cards outlining when and how to reassess abnormal vital signs and which findings require provider notification.
• Give individualized feedback after chart audits to reinforce strong practices and identify opportunities for improvement.
• Use color-coded job aids aligned with length-based resources to help staff quickly determine age-appropriate reassessment thresholds.

Resources

• Emergency Severity Index, 5th edition
• Sample Policy: Vital Signs Measurement
• PEM PLAYBOOK Podcast: Vitals Signs Hits and Misses
• Stat Pearls Vital Sign Assessment
• EMSC Pediatric Emergency and Advocacy Kits (clinical guidelines)
• EMSC: QI Tools and Resources

References​​

1. ​​​Ramgopal, S., Martin-Gill, C., & Michelson, K. A. (2024). Pediatric Vital Signs Documentation in a Nationally Representative US Emergency Department Sample. Hospital pediatrics, 14(7), e2023007645. https://doi.org/10.1542/hpeds.2023-007645
2. Bae, W., Kim, K., & Lee, B. (2020). Distribution of Pediatric Vital Signs in the Emergency Department: A Nationwide Study. Children (Basel, Switzerland), 7(8), 89. https://doi.org/10.3390/children7080089
3. Gross, T. K., Lane, N. E., Timm, N. L., & COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE (2023). Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children. Pediatrics, 151(3), e2022060972. https://doi.org/10.1542/peds.2022-060972
4. Valentino, K., Campos, G. J., Acker, K. A., & Dolan, P. (2020). Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners, 34(6), 522–534. https://doi.org/10.1016/j.pedhc.2020.05.005
5. Huff, S., Stephens, K., Whiteman, K., Swanson-Biearman, B., & Mori, C. (2019). Implementation of a Vital Sign Alert System to Improve Outcomes. Journal of nursing care quality, 34(4), 346–351. https://doi.org/10.1097/NCQ.0000000000000384
6. Rao, S., Moss, A., Lamb, M., Innis, B. L., & Asturias, E. J. (2022). Vital sign predictors of severe influenza among children in an emergent care setting. PloS one, 17(8), e0272029. https://doi.org/10.1371/journal.pone.0272029
7. Gorski, J. K., Chaudhari, P. P., Spurrier, R. G., Goldstein, S. D., Zeineddin, S., Martin-Gill, C., Sepanski, R. J., Stey, A. M., & Ramgopal, S. (2024). Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA network open, 7(2), e2356472. https://doi.org/10.1001/jamanetworkopen.2023.56472
8. Remick, K., Gausche-Hill, M., Joseph, M. M., Brown, K., Snow, S. K., Wright, J. L., AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine and Section on Surgery, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency Medicine Committee, & EMERGENCY NURSES ASSOCIATION Pediatric Committee (2018). Pediatric Readiness in the Emergency Department. Pediatrics, 142(5), e20182459. https://doi.org/10.1542/peds.2018-2459