Difficult but doable: Health professional perspectives of assessing clinical deterioration in children with dark-coloured skin.

BackgroundPaediatric early warning system (PEWS) is a well-recognised multi-faceted structure used to detect and manage clinical deterioration in children. There are multiple systems used in various clinical settings with limited...

Development and implementation of a paediatric observation and response chart

ObjectiveTo systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in...

Identification of the characteristics that put hospitalized children at high risk of deterioration may help to target patients whose physiologic status should be intensively monitored for signs of deterioration, and reduce unnecessary monitoring in patients at very low risk. Previous studies have evaluated vital sign-based early warning scores to detect deterioration that has already begun. To develop a predictive score for deterioration using non-vital sign patient characteristics in order to risk-stratify hospitalized children before signs of deterioration are detectable. Case-control study. A 460-bed children's hospital. Cases (n = 141) were children who deteriorated while receiving care on non-intensive care unit (non-ICU) inpatient units. Controls (n = 423) were randomly selected. The exposures were complex chronic conditions, other patient characteristics, and laboratory studies. The outcome was clinical deterioration, defined as cardiopulmonary arrest, acute respiratory compromise, or urgent ICU transfer. The 7-item score included age <1 year, epilepsy, congenital/genetic conditions, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. We grouped the patients into risk strata based on their scores. The very low-risk group's probability of deterioration was less than half of baseline risk. The high-risk group's probability of deterioration was more than 80-fold higher than the baseline risk. We identified a set of characteristics associated with clinical deterioration in children. Used in combination as a score, these characteristics may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive while hospitalized on non-ICU units.

To assess the value of respiratory rate (RR) as a predictor of clinical deterioration in children, compared with other vital sign measurements. A retrospective case-control study, comparing children who deteriorated, requiring admission to critical care with children who did not deteriorate. RR, heart rate (HR), and blood pressure (BP) measurements were collected from each patient for a 48-hour duration. The 95th centile was identified for each and 5% to 30% thresholds above the 95th centile were calculated. For each threshold the sensitivity, specificity, odds ratio, positive, and negative predictive value for deterioration was calculated. Forty cases (age range 7 weeks-15 years) and 40 control patients matched for age, gender, and hospital location were recruited. In 30/40 patients who deteriorated at least one RR ≥ 30% above the 95th centile for their age was recorded in the 48 hours before deterioration, compared with 10/40 controls, regardless of clinical diagnosis. Only 3/40 children that deteriorated had a HR > 30% greater than the 95th centile, compared with 2/40 controls. An elevated RR was the only vital sign whose odds ratios were significant at each threshold level above the 95th centile. Maximum RR occurred 16.8 hours before deterioration. RR is a more accurate predictor of clinical deterioration in children than other vital signs. Greater weighting and importance should be placed on RR, which is often omitted in children due to difficulties with its measurement.

Objective: To measure the degree of reliability of the construction of new items and the adaptation of the Brighton Pediatric Early Warning Score for children with cancer. Method: Methodological study to analyze the equivalence of inter-judge content regarding the inclusion of items in the scale to detect early clinical deterioration in children with cancer: signs of bleeding, changes in temperature, and presence of grade III/IV mucositis. The Intraclass Correlation Coefficient and Cronbach’s Alpha were used for analysis, considering a value ≥0.750. Results: Based on the judges’ feedback, the items proposed for inclusion were retained, with minor adjustments to the scores. Thirty nurses (86.1%) and six doctors (13.9%) from Brazil evaluated the scale, resulting in an intraclass correlation coefficient of 0.823. Conclusion: The instrument proved suitable, with theoretical relevance and practical application, for early detection of clinical deterioration in children with cancer. To this end, it contributes to timely identification by the team, minimizing unfavorable outcomes.

Unrecognized clinical deterioration is a common and significant source of preventable harm to hospitalized children. Yet, unlike other sources of preventable harm, clinical deterioration outside of the ICU lacks a clear, "gold standard" outcome to guide prevention efforts. This gap limits multicenter learning, which is crucial for identifying effective and generalizable interventions for harm prevention. In fact, to date, no coordinated safety/quality initiative currently exists targeting prevention of harm from unrecognized clinical deterioration in hospitalized pediatric patients, which is startling given the morbidity and mortality risk patients incur. In this article, we compare existing outcomes for evaluating clinical deterioration outside of the ICU, highlighting sources of variation and vulnerability. The broader aim of this article is to highlight the need for a standard, consensus outcome for evaluating clinical deterioration outside of the ICU, which is a critical first step to preventing this type of harm.

To evaluate the impact of newly designed Paediatric Early Warning Scores and an accompanying education package, COMPASS, on the frequency of documentation of vital signs and communication between health professionals and associated medical review in deteriorating paediatric patients. One thousand fifty-nine patients in the pre-intervention phase and 899 in the post-intervention phase were studied. The daily frequency of documentation of vital sign measurement, incidence of health professional communication and related medical reviews following clinical deterioration of a random subgroup of 262 pre-intervention and 221 post-intervention patients were studied in detail. There were no significant differences in hospital mortality, medical emergency team reviews or unplanned admissions to critical care areas between the pre-intervention and post-intervention groups. There were significant increases in the post-intervention group for the median daily frequency of documentation of respiratory effort (0.0 (0-0) to 7.8 (5.8-12.6), P < 0.001), capillary refill (0 (0-0) to 1.1 (0-3.1), P < 0.001), blood pressure (0 (0-1.1) to 0 (0-1.6), P = 0.007) and level of consciousness (0 (0-0) to 7.8 (5.8-12.0), P < 0.001) and appropriate communication concerning patient deterioration 63 (8.5%) to 216 (40.9%), P < 0.001). There was a significant reduction in the number of children fulfilling the medical emergency team criteria (102 (38.9%) to 45 (20.4), P < 0.001). A multifaceted intervention for the early recognition and response to clinical deterioration in children significantly improved documentation of vital signs, communication and time to medical review.

ABSTRACTBackgroundSigns of clinical deterioration may appear differently in children with dark‐coloured skin. How to assess children in this cohort is currently poorly defined.AimTo explore available information on the assessment of clinical deterioration in children with dark‐coloured skin and identify research deficits.MethodsA scoping review following Arksey and O'Malley and PRISMA‐ScR frameworks. Five online databases, grey literature and reference lists of eligible documents were searched. Source titles, abstracts and full texts were screened. Included documents were assessed for level of evidence according to the Joanna Briggs Institute. Data were charted on a pre‐defined data collection tool and analysed through descriptive and content analysis.ResultsOut of 2382 documents screened, 37 were included. Document types included 16 quantitative studies, 14 opinion papers, five reviews and two reports. Most sources (21) were low‐level evidence. Sixty‐six unique terms were used to describe dark‐coloured skin. Eighteen documents reported use of a skin classification system, including race/ethnicity, established colour scales, cosmetic references and observer opinion. Twelve focused on newborn hyperbilirubinaemia. Considerations for assessing jaundice, pallor, cyanosis, pulse oximetry, petechiae and signs of shock were reported. Techniques to improve assessment included optimising the environment, identifying baseline skin colour, and involving families and patients in assessment. No documents reported on assessment of mottling or capillary refill time for children with dark‐coloured skin.Linking Evidence to ActionAssessment of clinical deterioration for children with dark‐coloured skin is highly relevant to health professional practice. There is an overall deficit in high‐quality research. Specific information gaps in assessment are considerations for mottling, capillary refill time, APGAR scoring, and clinical implications of device overestimation of bilirubin and oxygen saturations in children with dark‐coloured skin. Health professionals are encouraged to use devices cautiously. Greater accuracy and objectivity are necessary to fill these gaps and support effective detection of signs of clinical deterioration.

OBJECTIVE: To evaluate the performance the Brighton Pediatric Early Warning Score for an early identification of clinical deterioration in children admitted to the pediatric ward of a tertiary hospital. METHODS: A prospective cohort observational study, involving 325 children with acute illnesses admitted to a pediatric ward, aged 29 days to 13 years, between August 2018 and March 2020. To assess the Brighton Pediatric Early Warning Score diagnostic accuracy, it was used the Cardiff and Vale Pediatric Early Warning System as reference, and the software used was the R Core Team 2020. The effectiveness of the Brighton Pediatric Early Warning Score was assessed using the indicators of sensitivity, specificity, positive predictive value, negative predictive value, area under the ROC curve, number of true positives and negatives and false positives and negatives. RESULTS: The Brighton Pediatric Early Warning Score showed a sensitivity of 19.2%, a specificity of 99.1%, a positive predictive value of 90.5%, a negative predictive value of 73.7%, and an area under the ROC curve of 0.839. In addition to that, for scores larger than 3, there were 19 true positives, 224 true negatives, 2 false positives and 80 false negatives. CONCLUSION: The Brighton Pediatric Early Warning Score performed well in the scenario analysis chosen by this research, showing how easy it is to use it for an early recognition of clinical deterioration in children admitted to pediatric wards.

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.

Aim: The aim is to highlight the importance of early detection, the efficacy of pediatric early warning signs (PEWS), and their implications for clinical practice, focusing on the specific signs that affect the detection and management of clinical deterioration in children with oncological diseases.Methods: The review included English-language studies retrieved from common databases using the keywords “pediatric,” “Early Warning Signs,” “clinical deterioration,” combined with terms related to “onchohematological” and “pediatric cancers.”Results: Sixteen articles were analyzed. The analysis revealed that the PEWS cohort was associated with a lower incidence of unplanned codes (p = 0.0001), cardiopulmonary arrest (P = 0.0001), and mortality (P = 0.01). The incidence of critical deterioration between the cohorts showed no significant variation (P = 0.07).Conclusion: PEWS significantly contributes to reducing mortality rates, unplanned codes, and cardiopulmonary arrest. However, further research is required to address the limitations and challenges associated with its application in this population

To characterize the temporal profile of pre-operative deterioration in children with lipomyelomeningocele (LMMC) including those with congenital deficits and identify risk factors for clinical worsening. Records of 87 children who underwent surgery for LMMC were retrospectively reviewed to study the temporal profile of pre-operative deterioration, defined by the onset of new neurological dysfunction or progression of a pre-existing deficit. Preoperative magnetic resonance imaging (MRI) studies were examined to identify radiological features associated with deterioration. In children with extra-spinal placodes, the angle subtended by the terminal placode with the cord at the level of the laminar-fascial defect ("J sign") was assessed. Pre-operative deterioration in function was seen in 37 children (43%), occurring at a median age of 36months and was more frequent in children without congenital deficits (54% versus 27%; p = 0.016). On Cox regression analysis, extra-spinal location of the placode (p = 0.003) and presence of a congenital deficit (p = 0.009) were positively and negatively associated with deterioration respectively. On Kaplan-Meier analysis, the median deterioration-free survival time was 72months and was positively associated with presence of congenital deficit (p = 0.026) and negatively associated with presence of an extra-spinal placode (p < 0.001) or a meningocele sac (p = 0.001). Extra-spinal location of the neural placode was associated with higher risk of clinical deterioration in children with LMMC, whereas the presence of a congenital deficit conferred a decreased risk. Risk stratification based on clinical and radiological features can be used to guide decisions regarding early prophylactic surgery in children with LMMC.

Harnessing the Data Universe to Understand and Reduce Clinical Deterioration in Children.

INTRODUCTION: Pediatric Early Warning Scores were developed as standardized clinical aides for early recognition of clinical deterioration in children. These systems improve situational awareness among professionals. A major concern is the workload increase. After implementation in the Short Stay Unit, we intended to evaluate its effectiveness in our population.METHODS: We reviewed medical records of children admitted to the Short Stay Unit between July 2017 and February 2020. We developed a statistical analysis to evaluate the test performance.RESULTS: One thousand three hundred twenty-three patients were included (median age 3.07 years-old); 5.7% were considered to have clinical deterioration (maximum score median 7.00 vs 2.00) (p&lt;0.001). The area under the ROC curve was 0.947. Defining 4 as cut-off value, the sensitivity is 97.1% (specificity 82.7%).CONCLUSION: This score proved to be a good test for early identification of clinical deterioration in our population.