Abstract
BackgroundCurrent approaches to early detection of clinical deterioration in children have relied on intermittent track-and-trigger warning scores such as the Pediatric Early Warning Score (PEWS) that rely on periodic assessment and vital sign entry. There are limited data on the utility of these scores prior to events of decompensation leading to pediatric intensive care unit (PICU) transfer.ObjectiveThe purpose of our study was to determine the accuracy of recorded PEWS scores, assess clinical reasons for transfer, and describe the monitoring practices prior to PICU transfer involving acute decompensation.MethodsWe conducted a retrospective cohort study of patients ≤21 years of age transferred emergently from the acute care pediatric floor to the PICU due to clinical deterioration over an 8-year period. Clinical charts were abstracted to (1) determine the clinical reason for transfer, (2) quantify the frequency of physiological monitoring prior to transfer, and (3) assess the timing and accuracy of the PEWS scores 24 hours prior to transfer.ResultsDuring the 8-year period, 72 children and adolescents had an emergent PICU transfer due to clinical deterioration, most often due to acute respiratory distress. Only 35% (25/72) of the sample was on continuous telemetry or pulse oximetry monitoring prior to the transfer event, and 47% (34/72) had at least one incorrectly documented PEWS score in the 24 hours prior to the event, with a score underreporting the actual severity of illness.ConclusionsThis analysis provides support for the routine assessment of clinical deterioration and advocates for more research focused on the use and utility of continuous cardiorespiratory monitoring for patients at risk for emergent transfer.
Highlights
Events of clinical deterioration leading to emergent pediatric intensive care unit (PICU) transfer can have dire consequences for children [1,2]
Current approaches to identify children at risk for clinical deterioration on the acute care floor include the use of early warning scoring systems, such as the Pediatric Early Warning Score (PEWS), to offer a “triggering” threshold based on https://pediatrics.jmir.org/2021/1/e25991
In a retrospective study conducted by Akre and colleagues [7], 85.5% of children with a rapid response team or code event leading to emergent ICU transfer had a PEWS score in the critical range documented many hours prior to the event of interest, suggesting there may be challenges with routine assessments, incomplete observations, lack of standardized scoring between clinicians, establishing situational awareness of changing risk scores, or uncertainty in how to initiate an appropriate proactive clinical action [7,11,12,13,14]
Summary
Events of clinical deterioration leading to emergent pediatric intensive care unit (PICU) transfer can have dire consequences for children [1,2]. Children likely deteriorate for many different reasons, and a single score is unlikely to detect them all well [15] These reasons may be why the PEWS score has not been shown to decrease hospital mortality despite its utility in initiating rapid response team intervention [10,16]. There are limited data on the utility of these scores prior to events of decompensation leading to pediatric intensive care unit (PICU) transfer
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