Paediatric Early Warning System Research Articles

Adherence to the bedside paediatric early warning system (BedsidePEWS) in a pediatric tertiary care hospital

BackgroundThe aim of this study is to describe the adherence to the Bedside Pediatric Early Warning System (BedsidePEWS) escalation protocol in children admitted to hospital wards in a large tertiary care children’s hospital in Italy.MethodsThis is a retrospective observational chart review. Data on the frequency and accuracy of BedsidePEWS score calculations, escalation of patient observations, monitoring and medical reviews were recorded.Two research nurses performed weekly visits to the hospital wards to collect data on BedsidePEWS scores, medical reviews, type of monitoring and vital signs recorded. Data were described through means or medians according to the distribution. Inferences were calculated either with Chi-square, Student’s t test or Wilcoxon-Mann–Whitney test, as appropriate (P < 0.05 considered as significant).ResultsA total of 522 Vital Signs (VS) and score calculations [BedsidePEWS documentation events, (DE)] on 177 patient clinical records were observed from 13 hospital inpatient wards. Frequency of BedsidePEWS DE occurred < 3 times per day in 33 % of the observations. Adherence to the BedsidePEWS documentation frequency according to the hospital protocol was observed in 54 % of all patients; in children with chronic health conditions (CHC) it was significantly lower than children admitted for acute medical conditions (47 % vs. 69 %, P = 0.006). The BedsidePEWS score was correctly calculated and documented in 84 % of the BedsidePEWS DE. Patients in a 0–2 BedsidePEWS score range were all reviewed at least once a day by a physician. Only 50 % of the patients in the 5–6 score range were reviewed within 4 h and 42 % of the patients with a score ≥ 7 within 2 h.ConclusionsEscalation of patient observations, monitoring and medical reviews matching the BedsidePEWS is still suboptimal. Children with CHC are at higher risk of lower compliance. Impact of adherence to predefined response algorithms on patient outcomes should be further explored.

The implementation of a pediatric early warning system in the Sidra Pediatric Emergency Department, Qatar

Background: Establishing a paediatric early warning system in a paediatric Emergency Department (ED) is a complex process and more so with the COVID-19 pandemic. PUMA (PEWS Utilisation &amp; Morality Avoidance) is a qualitative system assessment survey tool which assesses the strengths and weaknesses of the patient care safety processes and systems within a department. This model draws together evidence from two theoretically informed systematic reviews. Methods: The Sidra Medicine ED Quality group surveyed online 200 staff from the department of physicians/nursing team focussing on processes of monitoring patients and documentation, communication amongst the team and with parents, staff empowerment, situational awareness, escalation processes and response to the deteriorating child in the three broad domains of Detect, Prepare, and Act, with a further seven smaller domains (monitor, record, interpret, review, prepare, escalate, and evaluate). Survey analysis enabled to review current practice, identify areas that are working well and areas for improvement. Results and implications: The online survey helped achieve a 85% return rate and identify seven areas for improvement in the system. The spider diagram illustrates the areas of strength and weakness in the seven domains with respect to Detect, Prepare, and Act. We collaborated with the Cerner team, created an automatic documentation of vital signs from triage and treatment areas to the patient’s Electronic Medical Record by associating patient’s cardiac monitors to reduce manual errors and for the timely monitoring of vital signs. A one-day “Back to Basics Training” refresher course for the nursing team was conducted. A senior nurse, as a watcher in the triage and treatment area, identified children at high risk of deterioration. A Pediatric ED Situational Awareness Tool (PEDSAT) was developed locally and is in trial to help manage sick children effectively. Conclusion: PUMA, a novel system assessment tool, empowered our ED to tailor a quality program with an aim to deliver effective and efficient patient care.

How to implement a PEWS in a resource-limited setting: A quantitative analysis of the bedside-PEWS implementation in a hospital in northeast Brazil.

OBJECTIVESQuantitative analysis of the implementation of the bedside paediatric early warning system (B‐PEWS) in a resource‐limited setting. The B‐PEWS serves to pre‐emptively identify hospitalised children who are at risk for cardiopulmonary arrest and subsequently to provide critical care in time.METHODSWe performed a retrospective review through the medical data records of patients after discharge from the paediatric ward of a philanthropic hospital in Brazil. Nurses’ performance using the system was measured with various parameters.RESULTSA total of 499 patients were included, and a total of 8024 scores were checked. During the 21‐week research period, the implementation rate increased significantly from 66.5% (SD 26.0) in Period 1 to 93.1% (SD 16.6) in Period 2. The number of scores that resulted in a correct total score went from 7.5% in Period 1 to 32.2% in Period 2, p < 0.001. There was an improvement in the correct choice of age group between the two periods (from 32.2% to 53.4%). There was no difference in the mean admission time of patients in the two periods: in the first period 4.8 days (SD 2.9) and in the second period 4.8 days (SD 4.1).CONCLUSIONSIt is possible to implement a PEWS in resource‐limited settings while achieving high implementation rates. However, this is a time‐ and energy‐consuming process. Having an active and involved team that is responsible for implementation is key for a successful implementation. Factors that likely hindered implementation were a large change in workflow for the nursing staff, non‐native speakers as main investigators.

Impact of PEWS on Perceived Quality of Care During Deterioration in Children With Cancer Hospitalized in Different Resource-Settings

BackgroundChildren with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting.MethodsWe conducted semi-structured interviews with 83 healthcare staff (nurses, pediatricians, oncology fellows, and intensivists) involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital (SJCRH; n = 42) and Unidad Nacional de Oncología Pediátrica (UNOP; n = 41). Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively.ResultsProviders discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse.ConclusionProviders that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice.

P0171 / #810: PRELIMINARY RESULTS OF THE INTRODUCTION OF AN EARLY SEVERITY ALERT SCORE IN A PEDIATRIC UNIT OF A PRIVATE HOSPITAL

Aims & Objectives: The pediatric early warning system was designed to provide an assessment that would reproduce the condition of the sick child based on physiological parameters according to an assessment scale using a score. Studies indicate that changes in physiological signs in children precede the deterioration of clinical status in hours The goal is to trigger the Rapid Response Team (RRT) within 10 minutes of identifying worsening health conditions, sudden cardiac arrest by the inpatient care team. Objective: To implement an early severity alert score in a pediatric inpatient unit to quickly identify the child’s clinical worsening Methods: Preliminary experience report experienced in the implementation of an alert score instrument in a general private hospital in the pediatric inpatient unit, from January 2018 to November 2019. To support the quality and safety of pediatric care, we identified the need to use a Pediatric Early Score (PEWS) instrument to evaluate simply, quickly, allowing immediate visualization of the result and directing care follow-up Results: The use of the instrument provided parameterization in the electronic medical record systematically optimizing visualization of the RRT start score. Based on this definition, we observed an improvement in the time between the first warning signal and the RRT attendance from 74% to 80.31% when compared to the previous year, with the rate of referral to the post-RRT ICU remaining unchanged. 18% Conclusions: The use of the instrument provided rapid identification using the score for child care in a shorter time after PEWS implantation and safer care according to the patient’s real need

Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration.

BackgroundPediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians’ emotional responses to deterioration events.MethodsSemi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children’s Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants’ native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content.ResultsEmotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children’s Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study.ConclusionClinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.

Development and validation of a deep-learning-based pediatric early warning system: A single-center study

BackgroundEarly detection and prompt intervention for clinically deteriorating events are needed to improve clinical outcomes. There have been several attempts at this, including the introduction of rapid response teams (RRTs) with early warning scores. We developed a deep-learning-based pediatric early warning system (pDEWS) and validated its performance. MethodsThis single-center retrospective observational cohort study reviewed, 50,019 pediatric patients admitted to the general ward in a tertiary-care academic children's hospital from January 2012 to December 2018. They were split by admission date into a derivation and a validation cohort. We developed a pDEWS for the early prediction of cardiopulmonary arrest and unexpected ward-to-pediatric intensive care unit (PICU) transfer. Then, we validated this system by comparing modified pediatric early warning score (PEWS), random forest (RF); an ensemble model of multiple decision trees and logistic regression (LR); a statistical model that uses a logistic function. ResultsFor predicting cardiopulmonary arrest, the pDEWS (area under the receiver operating characteristic curve (AUROC), 0.923) outperformed modified PEWS (AUROC, 0.769) and reduced the mean alarm count per day (MACPD) and number needed to examine (NNE) by 82.0% (from 46.7 to 8.4 MACPD) and 89.5% (from 0.303 to 0.807), respectively. Furthermore, for predicting unexpected ward-to-PICU transfer pDEWS also showed superior performance compared to existing methods. ConclusionOur study showed that pDEWS was superior to the modified PEWS and prediction models using RF and LR. This study demonstrates that the integration of the pDEWS into RRTs could increase operational efficiency and improve clinical outcomes.

Faktor-Faktor yang Berhubungan dengan Kejadian Luka Dekubitus Akibat Penggunaan Alat Medis di Ruang PICU

The use of medical devices in patients treated at the Pediatric Intensive Care Unit (PICU) is very high. Patients who are treated in intensive care are also at risk for medical device-related pressure injury (MDRPI). This study aimed to determine the factors associated with the incidence of MRDPI in the Pediatric Intensive Care Unit (PICU) RSUP DR. Wahidin Sudirohusodo Makassar. This study used an observational analytic method with a prospective cohort approach. The Sampling method used a simple random sampling of 76 people. This research was conducted on 8 May - 6 July 2019. The data collection technique used an observation sheet with the research instrument used in the form of the Pediatric Early Warning Scoring System to assess critical conditions, the level of awareness was fully used Full Outline of UnResponsiveness score (FOUR Score). The data were analyzed tested by using the statistical the Chi Square with a confidence level of 95%. All data were analyzed using the SPSS version 21.0 program (SPSS, Inc. Chicago, IL). Factors associated with the MDRPI incidence include critical conditions based on PEWSS (p = 0.002), level of awareness based on the FOUR Score (p = 0.025), number of devices installed (p = 0.015), and fixation techniques (p = 0.025). As for peripheral tissue perfusion (p = 0.268), albumin (p = 0.309), skin moisture (p = 0.888) were not related. Factors associated with the incidence of MDRPI include critical condition, level of awareness, number of devices installed, and fixation techniques. It’s recommended to make preventive efforts.

Qualitative Study of Pediatric Early Warning Systems' Impact on Interdisciplinary Communication in Two Pediatric Oncology Hospitals With Varying Resources.

PURPOSEHospitalized pediatric oncology patients are at high risk of deterioration and require frequent interdisciplinary communication to deliver high-quality care. Pediatric early warning systems (PEWS) are used by hospitals to reduce deterioration, but it is unknown how these systems affect communication about patient care in high- and limited-resource pediatric oncology settings.METHODSThis qualitative study included semistructured interviews describing PEWS and subsequent team communication at 2 pediatric cancer centers, 1 in the United States and 1 in Guatemala. Participants included nurses, and frontline and intensive care providers who experienced recent deterioration events. Transcripts were coded and analyzed inductively using MAXQDA software.RESULTSThe study included 41 providers in Guatemala and 42 providers in the United States (33 nurses, 30 ward providers, and 20 pediatric intensive care providers). Major themes identified include “hierarchy,” “empowerment,” “quality and method of communication,” and “trigger.” All providers described underlying medical hierarchies affecting the quality of communication regarding patient deterioration events and identified PEWS as empowering. Participants from the United States described the algorithmic approach to care and technology associated with PEWS contributing to impaired clinical judgement and a lack of communication. In both settings, PEWS sparked interdisciplinary communication and inspired action.CONCLUSIONPEWS enhance interdisciplinary communication in high- and limited-resource study settings by empowering bedside providers. Traditional hierarchies contributed to negative communication and, in well-resourced settings, technology and automation resulted in lack of communication. Understanding contextual elements is integral to optimizing PEWS and improving pediatric oncology outcomes in hospitals of all resource levels.

Wireless monitoring and real-time adaptive predictive indicator of deterioration

To assist in the early warning of deterioration in hospitalised children we studied the feasibility of collecting continuous wireless physiological data using Lifetouch (ECG-derived heart and respiratory rate) and WristOx2 (pulse-oximetry and derived pulse rate) sensors. We compared our bedside paediatric early warning (PEW) score and a machine learning automated approach: a Real-time Adaptive Predictive Indicator of Deterioration (RAPID) to identify children experiencing significant clinical deterioration. 982 patients contributed 7,073,486 min during 1,263 monitoring sessions. The proportion of intended monitoring time was 93% for Lifetouch and 55% for WristOx2. Valid clinical data was 63% of intended monitoring time for Lifetouch and 50% WristOx2. 29 patients experienced 36 clinically significant deteriorations. The RAPID Index detected significant deterioration more frequently (77% to 97%) and earlier than the PEW score ≥ 9/26. High sensitivity and negative predictive value for the RAPID Index was associated with low specificity and low positive predictive value. We conclude that it is feasible to collect clinically valid physiological data wirelessly for 50% of intended monitoring time. The RAPID Index identified more deterioration, before the PEW score, but has a low specificity. By using the RAPID Index with a PEW system some life-threatening events may be averted.

A Vital Sign-Based Model to Predict Clinical Deterioration in Hospitalized Children.

Clinical deterioration in hospitalized children is associated with increased risk of mortality and morbidity. A prediction model capable of accurate and early identification of pediatric patients at risk of deterioration can facilitate timely assessment and intervention, potentially improving survival and long-term outcomes. The objective of this study was to develop a model utilizing vital signs from electronic health record data for predicting clinical deterioration in pediatric ward patients. Observational cohort study. An urban, tertiary-care medical center. Patients less than 18 years admitted to the general ward during years 2009-2018. None. The primary outcome of clinical deterioration was defined as a direct ward-to-ICU transfer. A discrete-time logistic regression model utilizing six vital signs along with patient characteristics was developed to predict ICU transfers several hours in advance. Among 31,899 pediatric admissions, 1,375 (3.7%) experienced the outcome. Data were split into independent derivation (yr 2009-2014) and prospective validation (yr 2015-2018) cohorts. In the prospective validation cohort, the vital sign model significantly outperformed a modified version of the Bedside Pediatric Early Warning System score in predicting ICU transfers 12 hours prior to the event (C-statistic 0.78 vs 0.72; p < 0.01). We developed a model utilizing six commonly used vital signs to predict risk of deterioration in hospitalized children. Our model demonstrated greater accuracy in predicting ICU transfers than the modified Bedside Pediatric Early Warning System. Our model may promote opportunities for timelier intervention and risk mitigation, thereby decreasing preventable death and improving long-term health.

Anticipating Pediatric Patient Transfers From Intermediate to Intensive Care.

To explore characteristics of patients who were admitted to the intermediate care (IC) unit at a tertiary academic institution. In particular, we sought to compare the characteristics of IC patients who were transferred with the characteristics of those who were not transferred to PICU care and evaluate predictors of patient transfer. Data were collected on all admitted IC patients between July 2016 and June 2018. Patients whose index IC admission was from the PICU were excluded. Data collected included demographics and physiologic characteristics: heart rate, respiratory rate, temperature, oxygen therapy, as well as Bedside Pediatric Early Warning System (BPEWS) score. In this time period, 427 eligible patient visits occurred, with 66 patients (15.46%) being transferred to the PICU. Patients were commonly transferred early in their IC course (1.41 days into admission [0.66-3.87]); transferred patients had higher median admission BPEWS scores (7 [4.25-9] vs 5 [3-7]; P < .01). In the univariate analysis, no individual physiologic characteristic was predictive for transfer. In the multivariate analysis, BPEWS (P < .001) and need for any form of respiratory support (P = .04) were significant predictive factors for transfer (R 2 = 0.56). The need for close monitoring of physiologic parameters remains paramount, especially in the first 48 hours of admission, in predicting the need for transfer from the IC to PICU. The need for any form of respiratory support is predictive of transfer. Situational awareness and assessment including BPEWS score is of critical importance.

Single blood pressure chart for children up to 13 years to improve the recognition of hypertension based on existing normative data

ObjectiveTo produce a single ‘growth-chart-style’ blood pressure (BP) chart with clear diagnostic thresholds to assist paediatricians to make prompt and accurate diagnoses of hypertension.DesignThe well-established but complex published data on...

Use of paediatric early warning scores in intermediate care units

ObjectivePaediatric early warning scores (EWS) were developed to detect deterioration in paediatric wards or emergency departments. The aim of this study was to assess the relationship between three paediatric EWS...

The Vitals Risk Index-Retrospective Performance Analysis of an Automated and Objective Pediatric Early Warning System.

Pediatric in-hospital cardiac arrests and emergent transfers to the pediatric intensive care unit (ICU) represent a serious patient safety concern with associated increased morbidity and mortality. Some institutions have turned to the electronic health record and predictive analytics in search of earlier and more accurate detection of patients at risk for decompensation. Objective electronic health record data from 2011 to 2017 was utilized to develop an automated early warning system score aimed at identifying hospitalized children at risk of clinical deterioration. Five vital sign measurements and supplemental oxygen requirement data were used to build the Vitals Risk Index (VRI) model, using multivariate logistic regression. We compared the VRI to the hospital's existing early warning system, an adaptation of Monaghan's Pediatric Early Warning Score system (PEWS). The patient population included hospitalized children 18 years of age and younger while being cared for outside of the ICU. This dataset included 158 case hospitalizations (102 emergent transfers to the ICU and 56 "code blue" events) and 135,597 control hospitalizations. When identifying deteriorating patients 2 hours before an event, there was no significant difference between Pediatric Early Warning Score and VRI's areas under the receiver operating characteristic curve at false-positive rates ≤ 10% (pAUC10 of 0.065 and 0.064, respectively; P = 0.74), a threshold chosen to compare the 2 approaches under clinically tolerable false-positive rates. The VRI represents an objective, simple, and automated predictive analytics tool for identifying hospitalized pediatric patients at risk of deteriorating outside of the ICU setting.

Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up

BackgroundThe rapid identification of deterioration in the pediatric population is complex, particularly in the emergency department (ED). A comprehensive multi-faceted Pediatric Early Warning System (PEWS) might maximize early recognition of clinical deterioration and provide a structured process for the reassessment and escalation of care. The objective of the study was to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS implemented in the ED of an urban public general hospital in British Columbia, Canada, and to guide provincial scale up.MethodsWe used a before-and-after design to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS (pediatric assessment flowsheet, PEWS score, situational awareness, escalation aid, and communication framework). Sources of data included patient medical records, surveys of direct care staff, and key-informant interviews. Data were analyzed using mixed-methods approaches.ResultsThe majority of medical records had documented PEWS scores at triage (80%) and first bedside assessment (81%), indicating that the intervention was implemented with high fidelity. The intervention was effective in increasing vital signs documentation, both at first beside assessment (84% increase) and throughout the ED stay (> 100% increase), in improving staff’s self-perceived knowledge and confidence in providing pediatric care, and self-reported communication between staff. Satisfaction levels were high with the PEWS scoring system, flowsheet, escalation aid, and to a lesser extent with the situational awareness tool and communication framework. Reasons for dissatisfaction included increased paperwork and incidence of false-positives. Overall, the majority of providers indicated that implementation of PEWS and completing a PEWS score at triage alongside the Canadian Triage and Acuity Scale (CTAS) added value to pediatric care in the ED. Results also suggest that the intervention is aligned with current practice in the ED.ConclusionOur study shows that high-fidelity implementation of PEWS in the ED is feasible. We also show that a multi-component PEWS can be effective in improving pediatric care and be well-accepted by staff. Results and lessons learned from this pilot study are being used to scale up implementation of PEWS in ED settings across the province of British Columbia.

Assessing the electronic Bedside Paediatric Early Warning System: A simulation study on decision-making and usability

BackgroundThe Bedside Paediatric Early Warning System (BedsidePEWS) is a clinical decision support tool designed to augment clinician expertise, objectively identify children at risk for clinical deterioration, and standardize and prioritize care to improve outcomes in community settings. Although the paper-based BedsidePEWS documentation record has been shown to improve clinicians’ perception of their ability to detect deterioration and follow care recommendations, research is needed to asses this impact empirically. Furthermore, as hospitals progressively move toward electronic clinical systems, knowledge regarding the impact of BedsidePEWS’ novel electronic interface on clinicians’ performance and user experience is required. ObjectivesThe primary objectives of this study were (1) to compare adherence to evidence-based care recommendations using a) electronic health record software, b) paper BedsidePEWS, and c) a novel electronic BedsidePEWS interface, and (2) to describe end-users’ experiences of usability and opportunities for improvement of both paper and electronic BedsidePEWS. MethodsPaediatric nurses participated in a repeated measures simulation study. Participants assessed simulated patients, documented patient data, and responded to a series of questions regarding follow-up care for each patient. Three patient types (i.e., stable, mild deterioration, severe deterioration) were assessed in each of three intervention conditions (i.e., electronic health record, paper BedsidePEWS, electronic BedsidePEWS). Following simulation scenarios, participants provided comments regarding the usability of the paper and electronic tools. ResultsParticipants made 12.7% and 18.0% more appropriate care decisions with paper and electronic BedsidePEWS, respectively, than with the electronic health record intervention (p < 0.001). Accurate BedsidePEWS severity of illness score calculation was related to better adherence to evidence-based care recommendations (65%), compared to inaccurate calculation (55%), and electronic BedsidePEWS was associated with 15.7% fewer calculation errors than paper (p < 0.005). Electronic BedsidePEWS demonstrated usability benefits over its paper predecessor, including automatic score calculation and data plotting, and the potential to eliminate double charting, and participants expressed a preference for electronic BedsidePEWS in all aspects of the debrief questionnaire (p < 0.001). ConclusionsBedsidePEWS in both paper and electronic formats significantly improved participants’ ability to detect deterioration and follow care recommendations compared to electronic health record software. Furthermore, results suggest that electronic BedsidePEWS would afford improved patient care in excess of the paper-based original and further contribute to the standardization, prioritization, and improvement of care in community settings.

Risk stratification to improve Pediatric Early Warning Systems: it is all about the context

Early recognition of critically ill patients is of paramount importance to reduce pediatric mortality and morbidity. We created a risk stratification system combining vital parameters and predefined risk factors aimed at reducing the risk of unrecognized clinical deterioration compared with conventional Pediatric Early Warning Systems (PEWS). This single-center retrospective case cohort study included infants (gestational age ≥ 37 weeks) to adolescents (aged <18 years) with unplanned pediatric intensive care unit (PICU) admission between April 01, 2014, and February 28, 2018. The sensitivity in the 24 h prior to endpoint of the Pediatric Risk Evaluation and Stratification System (PRESS) was compared with that of the conventional PEWS and calculated as the proportion of study patients who received a high-risk score. Seventy-four PICU admissions were included. PRESS and PEWS sensitivities at 2 h prior to endpoint were 0.70 (95%CI 0.59 to 0.80) and 0.30 (95%CI 0.20 to 0.42) respectively (p < 0.001). Excluding patients with seizures, PRESS sensitivity increased to 0.75 (95%CI 0.64 to 0.85). Forty-nine patients (66%) scored positive on at least one high-risk factor, and “worried sign” was scored in 31 patients (42%).Conclusion: Risk stratification seems advantageous for a faster detection of clinical deterioration, providing opportunity for earlier intervention.What is Known:• Prompt detection of clinical deterioration is of essential importance to reduce morbidity and mortality.• Conventional Pediatric Early Warning Systems (PEWS) have limited sensitivity and a short window of detection of 1 to 2 h.What is New:• Risk stratification based on context factors allows earlier identification of patients at risk, well before deviation of vital signs.• Risk stratification combined with continuous monitoring of deteriorating trends in vital signs could lead to the development of next-generation warning systems achieving true patient safety.

Paediatric Early Warning Systems in 2019: What We Know and What We’ve Yet to Learn

Paediatric Early Warning Systems (PEWS) are used extensively in hospitals around the world in an attempt to recognise and respond to children who are at risk of harm from deterioration. Most systems are based on the ability of physiological measurements to predict future events. Evidence supporting their use however is limited especially for important measures such as death. This review seeks to examine history and experience of PEWS and to explore recent literature for ideas that would enhance existing PEWS and new concepts that might complement the goal of recognising and responding to deterioration in hospital. The largest study of PEWS, the EPOCH trial published in 2018, did not demonstrate a benefit in reducing mortality or other key indicators, from the use of the Canadian Bedside PEWS. There were several flaws that raise questions about the validity of the study; however, it also raises important issues for discussion. There have been recent studies published that propose alternative approaches to identifying deterioration including improved situation awareness and better teamwork. We propose that it is possible to recognise and respond to early signs of deterioration in a way that reduces important outcomes; however, this will require blended approaches that embrace the complexity of the task.

Paediatric early warning system in oncology hospital saves costs

Paediatric early warning system in oncology hospital saves costs