Clinical Deterioration In Children Research Articles

Feasibility and acceptability of implementing an evidence-based ESCALATION system for paediatric clinical deterioration.

The ESCALATION system is a novel paediatric Early Warning System that incorporates family involvement and sepsis recognition. This study aimed to assess the feasibility and iteratively refine the ESCALATION system in a variety of hospital settings in preparation for full-service implementation. A series of four multi-methods studies using an Implementation Science and co-design approach were conducted. We examined concepts of implementation, context, and mechanisms of action across a variety of hospitals. Data collected included practice and chart audits, surveys (health professionals), interviews (families) and focus groups (health professionals). Quantitative data were analysed descriptively with qualitative findings assessed by content analysis or thematic analysis. There were 650 audits (Study I-IV), 205 health professional survey responses (Study I), 154 health professionals participated in focus groups (Study II-IV), 13 parents of hospitalised children interviewed (Study I), and 107 parents reported their involvement in the ESCALATION system (Study III-IV). Each of the studies further refined and confirmed the feasibility, specifically the components of family involvement and the sepsis recognition pathway. The Implementation Science evaluation of the ESCALATION system resulted in a uniform approach that was feasible and acceptable to users and appropriate for full-service implementation. This series of four studies used a co-production approach built on the Medical Research Council framework to understand feasibility and acceptability of an intervention to improve recognition and response to clinical deterioration in children to the point of full-service implementation. We have reported a detailed, systematic approach to assessing feasibility and acceptability of a complex intervention using established methodologies for whole of health system implementation. The ESCALATION System is an evidence based paediatric early warning system that is a highly refined, well accepted and accommodates a health system that has substantial contextual variation.

ACUTE LYMPHOBLASTIC LEUKEMIA IN CHILDREN HOSPITALIZED IN THE INTENSIVE CARE UNIT: A RETROSPECTIVE ANALYSIS

Relevance: The most common pediatric malignancy is acute lymphoblastic leukemia (ALL), with a prevalence of 4.2 per 100,000 children. Some patients diagnosed with ALL will require hospitalization in intensive care units (ICU) at some point in their treatment. The study aimed to identify significant clinical and laboratory parameters in prognosis to identify indicators of clinical deterioration in children with ALL and develop a scale for early detection of precursors of critical illness in children with ALL. Methods: This retrospective study included inpatient medical records of all patients (0-18 years old) diagnosed with ALL and hospitalized in the intensive care unit (ICU) for oncohematological patients at the Scientific Center for Pediatrics and Pediatric Surgery (Almaty, Kazakhstan). The study period was three years – 2020 to 2022. Results: The clinical and laboratory parameters of children with ALL were analyzed a day before admission to the ICU since those patients demonstrated worsening clinical status. This window of time was chosen to allow us to understand what were the precursors of early deterioration in children with ALL before hospitalization in the ICU. Study data were collected before hospitalization in the ICU during admission to the ICU, and there is data at transfer from the ICU depending on the outcome of the disease. During the study period, 188 patients with ALL were admitted to the ICU. Leukopenia and neutropenia were present in 60-80% of the patients, and elevated leukocyte count was observed in 30-40%, while normal leukocyte count was only 10%-20%. CRP and procalcitonin levels were elevated, showing the presence of inflammation. Conclusions: Based on the retrospective analysis of the data, it can be said that the presented data are harbingers of critical conditions in children with ALL. Neurological, respiratory, cardiac, renal, and other parameters are important for patient treatment and management.

Critical Emergency Department Interventions and Clinical Deterioration in Children With Nonsevere Traumatic Intracranial Hemorrhage.

Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification. We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models. Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS ( P = 0.001) and nonaccidental trauma ( P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH. Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics.

Pediatric Early Warning System in the Short Stay Unit

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<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.

The Need for a Standard Outcome for Clinical Deterioration in Children's Hospitals.

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.

Effect of paediatric early warning systems (PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a prospective, multicentre cohort study

Paediatric early warning systems (PEWS) aid in the early identification of clinical deterioration events in children admitted to hospital. We aimed to investigate the effect of PEWS implementation on mortality due to clinical deterioration in children with cancer in 32 resource-limited hospitals across Latin America. Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement PEWS in hospitals providing childhood cancer care. In this prospective, multicentre cohort study, centres joining Proyecto EVAT and completing PEWS implementation between April 1, 2017, and May 31, 2021, prospectively tracked clinical deterioration events and monthly inpatient-days in children admitted to hospital with cancer. De-identified registry data reported between April 17, 2017, and Nov 30, 2021, from all hospitals were included in analyses; children with limitations on escalation of care were excluded. The primary outcome was clinical deterioration event mortality. Incidence rate ratios (IRRs) were used to compare clinical deterioration event mortality before and after PEWS implementation; multivariable analyses assessed the correlation between clinical deterioration event mortality and centre characteristics. Between April 1, 2017, and May 31, 2021, 32 paediatric oncology centres from 11 countries in Latin America successfully implemented PEWS through Proyecto EVAT; these centres documented 2020 clinical deterioration events in 1651 patients over 556 400 inpatient-days. Overall clinical deterioration event mortality was 32·9% (664 of 2020 events). The median age of patients with clinical deterioration events was 8·5 years (IQR 3·9-13·2), and 1095 (54·2%) of 2020 clinical deterioration events were reported in male patients; data on race or ethnicity were not collected. Data were reported per centre for a median of 12 months (IQR 10-13) before PEWS implementation and 18 months (16-18) after PEWS implementation. The mortality rate due to a clinical deterioration event was 1·33 events per 1000 patient-days before PEWS implementation and 1·09 events per 1000 patient-days after PEWS implementation (IRR 0·82 [95% CI 0·69-0·97]; p=0·021). In the multivariable analysis of centre characteristics, higher clinical deterioration event mortality rates before PEWS implementation (IRR 1·32 [95% CI 1·22-1·43]; p<0·0001), being a teaching hospital (1·18 [1·09-1·27]; p<0·0001), not having a separate paediatric haematology-oncology unit (1·38 [1·21-1·57]; p<0·0001), and having fewer PEWS omissions (0·95 [0·92-0·99]; p=0·0091) were associated with a greater reduction in clinical deterioration event mortality after PEWS implementation; no association was found with country income level (IRR 0·86 [95% CI 0·68-1·09]; p=0·22) or clinical deterioration event rates before PEWS implementation (1·04 [0·97-1·12]; p=0·29). PEWS implementation was associated with reduced clinical deterioration event mortality in paediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of PEWS as an effective evidence-based intervention to reduce disparities in global survival for children with cancer. American Lebanese Syrian Associated Charities, US National Institutes of Health, and Conquer Cancer Foundation. For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Predicting Clinical Deterioration and Mortality at Differing Stages During Hospitalization: A Systematic Review of Risk Prediction Models in Children in Low- and Middle-Income Countries

To determine which risk prediction model best predicts clinical deterioration in children at different stages of hospital admission in low- and middle-income countries. For this systematic review, Embase and MEDLINE databases were searched, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The key search terms were "development or validation study with risk-prediction model" AND "deterioration or mortality" AND "age 0-18years" AND "hospital-setting: emergency department (ED), pediatric ward (PW), or pediatric intensive care unit (PICU)" AND "low- and middle-income countries." The Prediction Model Risk of Bias Assessment Tool was used by two independent authors. Forest plots were used to plot area under the curve according to hospital setting. Risk prediction models used in two or more studies were included in a meta-analysis. We screened 9486 articles and selected 78 publications, including 67 unique predictive models comprising 1.5 million children. The best performing models individually were signs of inflammation in children that can kill (SICK) (ED), pediatric early warning signs resource limited settings (PEWS-RL) (PW), and Pediatric Index of Mortality (PIM) 3 as well as pediatric sequential organ failure assessment (pSOFA) (PICU). Best performing models after meta-analysis were SICK (ED), pSOFA and Pediatric Early Death Index for Africa (PEDIA)-immediate score (PW), and pediatric logistic organ dysfunction (PELOD) (PICU). There was a high risk of bias in all studies. We identified risk prediction models that best estimate deterioration, although these risk prediction models are not routinely used in low- and middle-income countries. Future studies should focus on large scale external validation with strict methodological criteria of multiple risk prediction models as well as study the barriers in the way of implementation. PROSPERO International Prospective Register of Systematic Reviews: Prospero ID: CRD42021210489.

Опыт стандартизации подходов к раннему выявлению рисков клинического ухудшения у пациентов детского возраста в инфекционном стационаре

In recent years, healthcare professionals are actively developing new systemic approaches to monitor vital signs at the bedside of a sick child by a nurse. One of these approaches is the Pediatric Early Warning Systems (PEWS). Objective. To standardize approaches to early detection of risks and timely prevention of clinical deterioration in children treated in hospitals for infectious diseases using the PEWS scale. Patients and methods. This study was conducted between September 28 and October 29, 2021 in the Pediatric Department for Infectious Diseases, Central Clinical Hospital No 40 and included 749 patients aged from 1 month to 19 years. The majority of patients were under 6 years of age. MS Excel 2021 was used for statistical analysis. Fisher's exact test with Yate's correction was used to identify significant changes. Results. As many as 352 patients (47.0 ± 1.8%) had no risk for poor prognosis (PEWS 0). We found no significant differences between the groups of children studied (acute upper respiratory infection, unspecified, n = 412; other and unspecified gastroenteritis and colitis of infectious origin, n = 233) in the frequency of PEWS scores. Thirteen out of 25 patients with PEWS ≥5 were admitted to the intensive care unit, whereas the remaining 12 patients received timely adequate care in specialized departments. Conclusion. Our first experience with the PEWS scale allows us to recommend it for pediatric hospitals. The PEWS scale is aimed at early detection of clinical signs associated with a risk of possibly deterioration in children treated in the departments of infectious diseases and helps to identify patients that require more extensive examination and treatment. Key words: children, infection, monitoring, risks, condition, scale, deterioration

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

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

Aplicação de um sistema de pontuação de alerta precoce em uma enfermaria pediátrica de um hospital terciário

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.

The Impact of the Thermal Seasons on Adenoid Size, Its Mucus Coverage and Otitis Media with Effusion: A Cohort Study.

Background: The purpose of this study is to analyze seasonal differences in adenoid size and related mucus levels via endoscopy, as well as to estimate changes in middle ear effusion via tympanometry. Methods: In 205 children with adenoid hypertrophy, endoscopic choanal assessment, adenoid hypertrophy assessment using the Bolesławska scale, and mucus coverage assessment using the MASNA scale were performed in two different thermal seasons, summer and winter. The study was conducted in two sequences of examination, summer to winter and winter to summer, constituting two separate groups. Additionally, in order to measure changes in middle ear effusion, tympanometry was performed. Results: Overall, 99 (48.29%) girls and 106 (51.71%) boys, age 2–12 (4.46 ± 1.56) were included in the study. The first group, examined in summer (S/W group), included 100 (48.78%) children, while the group first examined in winter (W/S group) contained 105 (51.22%) children. No significant relationship was observed between the respective degrees of adenoid hypertrophy as measures by the Bolesławska scale between the S/W and W/S groups in winter (p = 0.817) and in summer (p = 0.432). The degrees of mucus coverage of the adenoids using the MASNA scale and tympanograms were also comparable in summer (p = 0.382 and p = 0.757, respectively) and in winter (p = 0.315 and p = 0.252, respectively) between the S/W and W/S groups. In the total sample, analyses of the degrees of adenoid hypertrophy using the Bolesławska three-step scale for seasonality showed that patients analysed in the summer do not differ significantly when compared to patients analysed in the winter (4.39%/57.56%/38.05% vs. 4.88%/54.63%/40.49%, respectively; p = 0.565). In contrast, the amount of mucus on the adenoids increased in winter on the MASNA scale (p = 0.000759). In addition, the results of tympanometry showed deterioration of middle ear function in the winter (p = 0.0000149). Conclusions: The obtained results indicate that the thermal seasons did not influence the size of the pharyngeal tonsils. The increase and change in mucus coverage of the adenoids and deterioration of middle ear tympanometry in winter may be the cause of seasonal clinical deterioration in children, rather than tonsillar hypertrophy. The MASNA scale was found to be useful for comparing endoscopy results.

Risk factors for pre-operative functional deterioration in children with lipomyelomeningocele.

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.

Validation of Brighton pediatric early warning score for predicting clinical deterioration in the emergency department

Objectives: The objectives of the study were to validate the pediatric early warning score (PEWS) for predicting clinical deterioration in children attending the emergency department (ED) and its inter-rater agreement between nurses and pediatric trainees. Methods: This prospective observational study was done on patients aged 1 month–12 years attending the ED in tertiary care institute of South India, from June 2017 to June 2018. They were evaluated using PEWS at time of admission (S0) and after 1 h (S1) by both nurses and pediatric trainees. The scores were correlated with outcome. A receiver operating curve (ROC) was plotted to determine the cutoff value for PEWS in predicting deterioration. Inter-rater reliability between nurses and pediatric trainee was evaluated. Results: A total of 738 patients were included in the study. Patients admitted in pediatric intensive care unit (S0 2.623±2.075 and S1 2.024±1.592) had higher mean PEWS both at the time of admission and at 1 h, compared to patients admitted to the ward (S0 – 0.7551±1.129 and S1 – 0.5165±) (p&lt;0.001). The optimal cutoff scores on the ROC for predicting clinical deterioration are S0 = 2 and S1 = 2 with areas under the curve of 0.76 and 0.78, respectively. The sensitivity, specificity, and likelihood ratios of these scores are as follows: S0 – sensitivity – 67.46%, specificity – 76.34%, positive likelihood ratio – 2.85, and negative likelihood ratio – 0.43; and S1 – sensitivity – 61.9%, specificity – 88.89%, positive likelihood ratio – 5.57, and negative likelihood ratio – 0.43. Inter-rater reliability between nurses and pediatric trainees was excellent (intraclass coefficient 0.99). Conclusions: Pediatric early warning score can be a useful clinical tool for identifying children at risk of deterioration. PEWS can be effectively used by nursing personnel in the triage room to identify a sick child.

Accuracy and Monitoring of Pediatric Early Warning Score (PEWS) Scores Prior to Emergent Pediatric Intensive Care Unit (ICU) Transfer: Retrospective Analysis.

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.

Comparing Two Proximal Measures of Unrecognized Clinical Deterioration in Children.

Critical deterioration events (CDEs) and emergency transfers (ETs) are two proximal measures to cardiopulmonary arrest, and both aim to evaluate how systems recognize and respond to clinical deterioration in children. This retrospective observational study sought to (1) characterize CDEs and ETs by timing, overlap, and intervention category, and (2) evaluate the performance of the watcher identification system and the pediatric early warning score (PEWS) to identify patients who experience these events. A total of 359 CDEs and 88 ETs occurred during the study period. Respiratory events were most common and accounted for 80.5% of CDEs and 47.7% of ETs. A narrow majority of patients were identified as watchers (55.4% of CDEs and 51.1% of ETs). In total, 85.5% of CDEs and 87.5% of ETs were identified as watchers, elevated PEWS, or both. Opportunities exist for improved escalation plans for high-risk patients to prevent the need for emergent intervention.

Feasibility of Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Income Settings.

To determine the feasibility of having caregivers assist in recognition of clinical deterioration in children hospitalized with febrile illness in a resource-limited setting. Single-center, prospective, interventional pilot study. General pediatric wards at Kenyatta National Hospital, Nairobi, Kenya's largest public tertiary-care hospital. Children hospitalized with acute febrile illness, accompanied by caregivers available at the bedside for 24 hours soon after hospital admission. Caregivers were trained to recognize signs of critical illness using the Family-Assisted Severe Febrile Illness Therapy tool, which quantifies patients' work of breathing, mental status, and perfusion, producing color-coded flags to signal illness severity. Caregivers' Family-Assisted Severe Febrile Illness Therapy assessments were compared with healthcare professional assessments and to established Pediatric Early Warning Scores (PEWS). An initial study stage was followed by refinement of training and a larger second stage with intervention/control arms. A total of 107 patient/caregiver pairs were enrolled in the interventional arm; 106 caregivers underwent Family-Assisted Severe Febrile Illness Therapy training and were included in the analysis. Patient characteristics included median age 1.1 years (0.2-10 yr), 55 (52%) female, and diagnoses: pneumonia (64 [60%]), meningitis (38 [36%]), gastroenteritis (24 [23%]), and malaria (21 [20%]). Most caregivers had primary (34 [32%]) or secondary (53 [50%]) school education. Fourteen of 106 patients (13%) died during their stay, six within 2 days. Across all severity levels, caregiver Family-Assisted Severe Febrile Illness Therapy assessments matched professionals in 87% and 94% for stages 1 and 2, respectively. Caregiver Family-Assisted Severe Febrile Illness Therapy assessments had a moderate to strong correlation with coinciding Pediatric Early Warning Scores and were sensitive to life-threatening deterioration: for all six patients who died within 2 days of admission, caregiver assessment reached the highest alert level. Caregiver involvement in recognition of critical illness in hospitalized children in low-resource settings may be feasible. This may facilitate earlier detection of clinical deterioration where staffing is severely limited by constrained resources. Further validation of the Family-Assisted Severe Febrile Illness Therapy tool is warranted, followed by its application in a larger multisite patient population to assess provider response and associated clinical outcomes.

Respiratory rate is an early predictor of clinical deterioration in children.

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.

Utility of Pediatric Early Warning Scoring System in Predicting Clinical Deterioration in Children: A Review

Utility of Pediatric Early Warning Scoring System in Predicting Clinical Deterioration in Children: A Review

Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review

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...

Resultados de la aplicación de una escala de alerta clínica precoz en pediatría como plan de mejora de calidad asistencial

ObjectivesThe aims of this study were to introduce a paediatric early warning score (PEWS) into our daily clinical practice, as well as to evaluate its ability to detect clinical deterioration in children admitted, and to train nursing staff to communicate the information and response effectively. Material and methodsAn analysis was performed on the implementation of PEWS in the electronic health records of children (0-15 years) in our paediatric ward from February 2014 to September 2014. The maximum score was 6. Nursing staff reviewed scores >2, and if >3 medical and nursing staff reviewed it. Monitoring indicators: % of admissions with scoring; % of complete data capture; % of scores >3; % of scores >3 reviewed by medical staff, % of changes in treatment due to the warning system, and number of patients who needed Paediatric Intensive Care Unit (PICU) admission, or died without an increased warning score. ResultsThe data were collected from all patients (931) admitted. The scale was measured 7,917 times, with 78.8% of them with complete data capture. Very few (1.9%) showed scores >3, and 14% of them with changes in clinical management (intensifying treatment or new diagnostic tests). One patient (scored 2) required PICU admission. There were no deaths. Parents or nursing staff concern was registered in 80% of cases. ConclusionsPEWS are useful to provide a standardised assessment of clinical status in the inpatient setting, using a unique scale and implementing data capture. Because of the lack of severe complications requiring PICU admission and deaths, we will have to use other data to evaluate these scales.