Pediatric Early Warning Score Research Articles

Emergency Profile of Pediatric Patients Based on Pediatric Early Warning Score in the Emergency Department of the Adam Malik Hospital

Background: High morbidity and mortality rates in pediatric patients indicate the necessity of a Pediatric Early Warning Score (PEWS) capable of early clinical deterioration identification and providing an opportunity for healthcare professionals to promptly manage patients. This study aimed to serve as foundational data and as an evaluative tool to enhance the proficiency of healthcare workers in assessing patient deterioration. Methods: This study utilized a descriptive method with a cross-sectional design and consecutive sampling technique who were treated from January to December 2022. Results: there were 119 samples, the majority of gender was male (54.6%), the majority of the age group was 1-4 years old (37.8%), and the majority of the disease group was infection (31.1%). Both male and female majority had green PEWS (54.6%) and (45.4%), the majority of patients with an age range of 1 month to 5 years had red PEWS, the majority of infectious disease group had green PEWS, and the majority of patients with green PEWS had discharge outcome. Conclusion: This study provides an overview of characteristics in pediatric patients and shows the majority of pediatric emergency department patients come with non-emergency conditions.

Non-thyroidal Illness in Children with Congestive Heart Failure.

To estimate the proportion and risk factors of non-thyroidal illness (NTI) in children with congenital heart disease (CHD) with congestive heart failure(CHF). This study enrolled children (6 weeks to 60 months age) with CHD and CHF. The clinical profile and disease severity using Pediatric Early Warning Score (PEWS) was recorded. Baseline blood samples were taken within 24hours of hospitalization and evaluated for fT3, fT4, TSH, NT pro-Brain natriuretic peptide (NT pro-BNP) and reverseT3. A total of 80 (64 acyanotic CHD) children of median (IQR) age 5 (2.5, 8.0) months were enrolled. NTI was seen in 37 (46%)- 27 with low fT3 levels. The proportion of NTI was maximum in children with severe disease (20/30), than moderate (4/9) or mild disease (13/41); p=0.018. Ten (27%) patients with NTI expired as compared to 2 (4.7%) without NTI with unadjusted odds ratio (95% CI) 7.593(1.54, 37.38); p-value=0.006. After adjusting for NTI, shock and NT-pro-BNP levels, PEWS was the only significant predictor of mortality (OR 1.41, 95% CI 1.03, 1.92; p=0.032).Linear regression for fT3 showed significant relation with log NT-BNP [beta -3.541, (95% CI -1.387, -0.388)] and with TSH [beta 2.652 (95%CI 0.054, 0.383)]. The cutoff (AUC, 95%CI) that predicted mortality were fT4 <14.5 pmol/L (0.737, 0.60, 0.88), fT3/rT3 index <1.86 pg/ng (0.284, 0.129, 0.438) and NT pro-BNP >3725 pg/mL (0.702; 0.53, 0.88). NTI was seen in a significant proportion of children with CHD and CHF. Free T3 level was significantly affected with NT-BNP levels (severity of CHF).

Study protocol of a national multicentre prospective evaluation study assessing the validity and impact of the Dutch Paediatric Early Warning Score (PEWS) in the Netherlands

IntroductionEarly recognition of clinical deterioration and timely intervention are important to improve morbidity and mortality in paediatric care. The Paediatric Early Warning Score (PEWS) is a scoring system aiming to...

Launch of the Paediatric Early Warning Score must be matched by workforce investment

Launch of the Paediatric Early Warning Score must be matched by workforce investment

Utility of pediatric early warning score at emergency room in predicting the level of care required for next 48 h: A single-center, prospective, observational study

Abstract Background: Pediatric scores such as the Pediatric Early Warning Score (PEWS) are based on parameters available at the bedside. The aim of this study was to assess the utility of PEWS to determine the need for critical care support within the next 24–48 h. this study aimed to see if PEWS could predict a suitable level of care, namely ward, high-dependency unit (HDU), or pediatric intensive care unit (PICU). Subjects and Methods: It was a prospective observational study and a convenient sample method was used with children of age groups from 1 month to 18 years, coming to the pediatrics department being the subject. We correlated the level of care at admission and also after 48 h with PEWS at the time of admission of children already intubated, children on inotropes at the time of admission, children with surgical illness, and children admitted only for procedure/procedural sedation were excluded from this study. The Brighton PEWS was used to calculate PEWS. Results: A total of 953 patients were enrolled in this study. In this study, the likelihood of admission to PICU correlated well with PEWS above 6 with a positive predictive value of 56% and a negative predictive value of 99.43%. Conclusions: The admission PEWS can be used as an effective tool for deciding the level of care area. Score &lt;3 admission PEWS can be kept at the ward, while &gt;3 score at HDU/PICU where frequent periodic monitoring should be done.

Comparison of bedside risk assessment scores to predict the outcome of patients with acute febrile illness admitted to pediatric intensive care unit: A single-center prospective observational study

Abstract Background: Acute febrile illness (AFI) is the most common presentation in the pediatric emergency room, and bedside risk assessment scores are very useful to identify those at risk. This study aimed to evaluate the predictive validity of quick Sequential Organ Failure Assessment (qSOFA), quick Pediatric Logistic Organ Dysfunction-2 (qPELOD-2), Liverpool qSOFA (LqSOFA), and Pediatric Early Warning Score (PEWS) to predict the outcome of patients with AFI admitted to the pediatric intensive care unit (PICU). Subjects and Methods: This prospective observational study included children under the age of 18 years admitted to PICU. A thorough history and examination was performed in the ER, and the qSOFA, the qPELOD-2, the LqSOFA, and the PEWS scores were calculated. The primary outcome was inhospital mortality. The capacity of the scores to predict outcome was evaluated for calibration (using Hosmer–Lemeshow adaptation of the Chi-square test) and discrimination (using receiver operating characteristic [ROC] curve). The scores were compared for any significant difference using z-statistics. Results: The study included 239 patients with the most common diagnosis of dengue fever. The overall mortality rate in the study was 8.4%. On the calibration of the models, all the scores showed a good fit to predict mortality. On discrimination by ROC curve, the LqSOFA score and PEWS had the best area under the curve for ROC curve (AUC-ROC) (0.913), followed by the qSOFA score (0.859). On comparing the AUC-ROC curve, no statistically significant difference was found between the scoring systems to predict mortality. Conclusions: Bedside risk stratification scores are a simple and convenient tool to identify patients at risk for mortality and assess prognosis. No single assessment tool was found superior to others.

Predicting transfers to intensive care in children using CEWT and other early warning systems

Background and ObjectiveThe Children’s Early Warning Tool (CEWT), developed in Australia, is widely used in many countries to monitor the risk of deterioration in hospitalized children. Our objective was to compare CEWT prediction performance against a version of the Bedside Pediatric Early Warning Score (Bedside PEWS), Between the Flags (BTF), and the pediatric Calculated Assessment of Risk and Triage (pCART). MethodsWe conducted a retrospective observational study of all patient admissions to the Comer Children’s Hospital at the University of Chicago between 2009–2019. We compared performance for predicting the primary outcome of a direct ward-to-intensive care unit (ICU) transfer within the next 12 h using the area under the receiver operating characteristic curve (AUC). Alert rates at various score thresholds were also compared. ResultsOf 50,815 ward admissions, 1,874 (3.7%) experienced the primary outcome. Among patients in Cohort 1 (years 2009–2017, on which the machine learning-based pCART was trained), CEWT performed slightly worse than Bedside PEWS but better than BTF (CEWT AUC 0.74 vs. Bedside PEWS 0.76, P < 0.001; vs. BTF 0.66, P < 0.001), while pCART performed best for patients in Cohort 2 (years 2018–2019, pCART AUC 0.84 vs. CEWT AUC 0.79, P < 0.001; vs. BTF AUC 0.67, P < 0.001; vs. Bedside PEWS 0.80, P < 0.001). Sensitivity, specificity, and positive predictive values varied across all four tools at the examined thresholds for alerts. ConclusionCEWT has good discrimination for predicting which patients will likely be transferred to the ICU, while pCART performed the best.

Validation of the Turkish version of the pediatric early warning score

Aim: The pediatric early warning score (PEWS) identifies pediatric patients at risk for clinical deterioration and can helpless-experienced providers get a sense of which patients may need escalation of care. The purpose of the study was to adapt the PEWS into Turkish and evaluate its validity in pediatric patients admitted to the emergency. &#x0D; Material and Methods: This study was conducted between May and October 2022 on 228 patients aged 17 and under in the pediatric emergency department of a tertiary care hospital. In the pilot phase of the study, scoring of the first 30 patients was performed by three nurses in the emergency department. In the second phase, the validity of the PEWS scale was evaluated. Validity of the scoring system in predicting admission was assessed using area under the receiver operating characteristics (ROC) curve (AUC), sensitivity, and specificity, positive predictive value (PPV) and negative predictive value (NPV).&#x0D; Results: The mean age of the children was 6.37 ± 4.72 years. Phase I demonstrated good inter-rater reliability (kappa = 0.75). In phase II, 22 patients (9.6%) were admitted to the intensive care unit (ICU) during the study period. AUC for predicting was 0.948 (95% CI: 0.915–0.981). According to ROC curve analysis, a cut-off value for PEWS score was found to be 4 (PEWS &gt;4) for admitted to the ICU. Sensitivity and specificity in predicting ICU admission with the cut-off PEWS ≥4 was 86.36% and 90.78%, respectively (PPV, 50%; NPV, 90.48%). The sensitivity and specificity in predicting admission with a cut-off of PEWS ≥1 was 100% and 59.22%, respectively (PPV, 20.75%; NPV, 100%).&#x0D; Conclusion: The Turkish version of PEWS can be helpful in assessing patient status in pediatric emergency department with acceptable validity and can serve as a potentially screening tool for prediction of ICU admission.

42 Enacting Meaningful Change in the Face of Adversity – Use of a Sentinel Event to Pilot the Creation of a Rapid Response System in a Tertiary Paediatric Care Centre

Abstract Introduction/Background Although rare, in-hospital paediatric mortality occurs at a rate of 12.66 per 1000 admissions. Delayed recognition of clinical deterioration is a modifiable factor in such adverse events. In paediatric patients, subtle changes in vital signs often precede acute deterioration and provide an opportunity for early intervention and prevention of further deterioration. Based on this rationale, rapid response systems (RRS), which include a critical care response team (CCRT) and a Paediatric Early Warning Score (PEWS), have been established to facilitate the detection of clinical deterioration and mobilize resources for timely treatment. There is evidence that RRS can significantly decrease inpatient clinical deterioration events and PICU utilization. Objectives At our institution, serious patient safety events identified system failures in recognition, communication, and escalation of care in response to clinical deterioration. The root cause analysis led to a quality improvement and patient safety initiative to implement an RRS at our tertiary paediatric care centre. Design/Methods Process implementation of this pilot project required consultations with key stakeholders and designation of unit champions to mobilize resources and promote buy-in. Based on other successful implementation strategies, we adopted the Modified Brighton PEWS, defined a response algorithm, created bedside tools, constructed an interdisciplinary CCRT, and organized simulation activities to implement the new process. We used the Plan-Do-Study-Act method to carry out change based on weekly feedback from frontline workers. To assess the feasibility and acceptability of this initiative, all CCRT activations during the pilot phase were reviewed and a survey was distributed pre- and post-implementation. The number of code blues and mortality data will also be measured. Results The pilot period spanned June to September 2022 on our medical inpatient unit. Average response time to CCRT activation was 12 minutes (IQR 7-13.5), a median of three therapeutic interventions were required per activation, and 33% of activations resulted in PICU admissions. Among the 27 post–implementation survey respondents, 87% identified CCRT as a useful addition to optimize care and address patient safety concerns. Qualitatively, it has created a shared safety culture and empowered junior members of healthcare teams to escalate care. Conclusion This quality improvement initiative pilot study has demonstrated feasibility and acceptability of RRS implementation with a positive impact on patient safety culture and earlier detection and intervention for deteriorating patients. Further prospective comparative clinical benefits and cost-benefit analyses are needed to support hospital-wide implementation.

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&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.

Evaluation of a modified paediatric early warning score for children with congenital heart disease.

Paediatric early warning score systems are used for early detection of clinical deterioration of patients in paediatric wards. Several paediatric early warning scores have been developed, but most of them are not suitable for children with cyanotic CHD who are adapted to lower arterial oxygen saturation. The present study compared the original paediatric early warning system of the Royal College of Physicians of Ireland with a modification for children with cyanotic CHD. Retrospective single-centre study in a paediatric cardiology intermediate care unit at a German university hospital. The distribution of recorded values showed a significant shift towards higher score values in patients with cyanotic CHD (p < 0.001) using the original score, but not with the modification. An analysis of sensitivity and specificity for the factor "requirement of action" showed an area under the receiver operating characteristic for non-cyanotic patients of 0.908 (95% CI 0.862-0.954). For patients with cyanotic CHD, using the original score, the area under the receiver operating characteristic was reduced to 0.731 (95% CI 0.637-0.824, p = 0.001) compared to 0.862 (95% CI 0.809-0.915, p = 0.207), when the modified score was used. Using the critical threshold of scores ≥ 4 in patients with cyanotic CHD, sensitivity and specificity for the modified score was higher than for the original (sensitivity 78.8 versus 72.7%, specificity 78.2 versus 58.4%). The modified score is a uniform scoring system for identifying clinical deterioration, which can be used in children with and without cyanotic CHD.

Development of the national Dutch PEWS: the challenge against heterogeneity and implementation difficulties of PEWS in the Netherlands

BackgroundFor the early recognition of deteriorating patients several Pediatric Early Warning Score (PEWS) systems have been developed with the assumption that early detection can prevent further deterioration. Although PEWS are widely being used in hospitals in the Netherlands, there is no national consensus on which score to use and how to embed the score into a PEWS system. This resulted in a substantial heterogeneity of PEWS systems, of which many are unvalidated or self-designed. The primary objective of this study was to develop a pragmatic consensus-based PEWS system that can be utilized in all Dutch hospitals (University Medical Centers, teaching hospitals, and general hospitals).MethodsThis study is an iterative mixed-methods study. The methods from the Core Outcome Measures in Effectiveness Trials (COMET) initiative were used and consisted of two Delphi rounds, two inventories set out to all Dutch hospitals and a focus group session with parents. The study was guided by five expert meetings with different stakeholders and a final consensus meeting that resulted in a core PEWS set.ResultsThe first Delphi round was completed by 292 healthcare professionals, consisting of pediatric nurses and physicians. In the second Delphi round 217 healthcare professionals participated. Eventually, the core PEWS set was been developed comprising of the parameters work of breathing, respiratory rate, oxygen therapy, heart rate and capillary refill time, and AVPU (Alert, Verbal, Pain, and Unresponsive). In addition, risk stratification was added to the core set with standardized risk factors consisting of [1] worried signs from healthcare professionals and parents and [2] high-risk treatment, with the option to add applicable local defined risk factors. Lastly, the three categories of risk stratification were defined (standard, medium, and high risk) in combination with standardized actions of the professionals for each category.ConclusionThis study demonstrates a way to end a country’s struggle with PEWS heterogeneity by co-designing a national Dutch PEWS system. Currently, the power of the system is being investigated in a large multi-center study in the Netherlands.

Prediction of GutCheck NEC and Its Relation to Severity of Illness and Measures of Deterioration in Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) risk has been shown to arise from multiple sources and risk awareness may be supported using bedside tools. The purpose of this research was to examine the extent to which GutCheck NEC was associated with scores for clinical deterioration, severity of illness, and clinical outcome, and further to examine how scores might improve NEC prediction. A retrospective, correlational case-control study with infant data from 3 affiliated neonatal intensive care units was conducted. Of 132 infants (44 cases, 88 controls), most were 28 weeks of gestation at birth and less (74%). Median age at NEC onset was 18 days (range: 6-34 days), with two-thirds diagnosed before 21 days. At 68 hours of life, higher GutCheck NEC scores were associated with NEC requiring surgery or resulting in death (relative risk ratio [RRR] = 1.06, P = .036), associations that persisted at 24 hours prior to diagnosis (RRR = 1.05, P = .046), and at the time of diagnosis (RRR = 1.05, P = .022) but showed no associations for medical NEC. GutCheck NEC scores were significantly correlated with pediatric early warning scores (PEWS) ( r > 0.30; P < .005) and SNAPPE-II scores ( r > 0.44, P < .0001). Increasing numbers of clinical signs and symptoms were positively associated with GutCheck NEC and PEWS at the time of diagnosis ( r = 0.19, P = .026; and r = 0.25, P = .005, respectively). GutCheck NEC provides structure to streamline assessment and communication about NEC risk. Yet, it is not intended to be diagnostic. Research is needed on how GutCheck NEC impacts timely recognition and treatment.

Prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit.

To analyze the prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit (PICU) and to compare the efficacy of different scoring systems for predicting the outcome of children. Patients with an acute leukemia diagnosis admitted to a tertiary care university hospital PICU due to sepsis during chemotherapy between May 2015 and August 2022 were retrospectively analyzed through an electronic medical record system. During this period, 693 children with acute leukemia initially diagnosed were admitted to the center, and 155 (22.3%) of them were transferred to PICU due to deterioration of the disease during treatment. Total 109 (70.3%) patients were transferred to PICU due to sepsis. Here, 17 patients was excluded (prior treatment from another hospital; referring from other hospitals; discontinued treatment; incomplete medical record). Of the 92 patients studied, the mortality rate was 35.9%. Multivariate analysis revealed that remission status, lactate level, invasive mechanical ventilation (IMV), and inotropic support within 48hours after PICU transfer were independent risk factors for PICU mortality. The pediatric sequential organ failure assessment (PSOFA) score had the greatest predictive validity for hospital mortality (area under the receiver operating characteristic curve [AUROC]: 0.83, 95% confidence intervals [CI]: 0.74-0.92), followed by the pediatric early warning score (PEWS) (0.82, 0.73-0.91) and pediatric critical illness score (PCIS) (0.79, 0.69-0.88). The mortality rate among children with acute leukemia complicated with sepsis is high after being transferred to the PICU. Various scoring systems can be used to monitor the clinical status of patients, identify sepsis early, detect critical illness, and determine the optimal time for transfer to the PICU for supportive treatment, thereby improving the prognosis of these patients.

Risk of in-hospital Deterioration for Children with Single Ventricle Physiology.

Children with single ventricle physiology (SV) are at high risk of in-hospital morbidity and mortality. Identifying children at risk for deterioration may allow for earlier escalation of care and subsequently decreased mortality.We conducted a retrospective chart review of all admissions to the pediatric cardiology non-ICU service from 2014 to 2018 for children < 18 years old. We defined clinical deterioration as unplanned transfer to the ICU or inpatient mortality. We selected children with SV by diagnosis codes and defined infants as children < 1 year old. We compared demographic, vital sign, and lab values between infants with and without a deterioration event. We evaluated vital sign and medical therapy changes before deterioration events.Among infants with SV (129 deterioration events over 225 admissions, overall 25% with hypoplastic left heart syndrome), those who deteriorated were younger (p = 0.001), had lower baseline oxygen saturation (p = 0.022), and higher baseline respiratory rate (p = 0.022), heart rate (p = 0.023), and hematocrit (p = 0.008). Median Duke Pediatric Early Warning Score increased prior to deterioration (p < 0.001). Deterioration was associated with administration of additional oxygen support (p = 0.012), a fluid bolus (p < 0.001), antibiotics (p < 0.001), vasopressor support (p = 0.009), and red blood cell transfusion (p < 0.001).Infants with SV are at high risk for deterioration. Integrating baseline and dynamic patient data from the electronic health record to identify the highest risk patients may allow for earlier detection and intervention to prevent clinical deterioration.

Use of Evidence-Based Vital Signs in Pediatric Early Warning Score to Predict Clinical Deterioration on Acute Care Units.

The pediatric early warning score (PEWS) is a tool used to predict clinical deterioration. Referenced vital sign parameters are based on expert opinion but heart rate and respiratory rate percentiles in hospitalized children have been published. This retrospective case-control study of unplanned intensive care unit (ICU) transfers compares evidence-based vital signs (EBVS) effect on PEWS sensitivity and specificity, determines the impact of age categories on PEWS deterioration prediction, and evaluates whether EBVS PEWS is associated with need for invasive ICU supports. EBVS PEWS improved sensitivity (43%-71% vs 30%-63%) for unplanned transfers with slightly decreased specificity (88%-98% vs 93%-99%). Logistic regression analysis and odds ratios (ORs) demonstrated EBVS PEWS was associated with increased risk for ICU-specific supports (OR = 1.16, 95% confidence interval [CI] = 1.0-1.34, P = .0498). Evidence-based vital signs can improve PEWS sensitivity to identify unplanned ICU transfers and identify patients requiring ICU-specific interventions.

A qualitative study of barriers and facilitators to pediatric early warning score (PEWS) implementation in a resource-limited setting.

Globally, pediatric hospitals have implemented Pediatric Early Warning Scores (PEWS) to standardize escalation of care and improve detection of clinical deterioration in pediatric patients. This study aims to utilize qualitative methodology to understand barriers and facilitators of PEWS implementation at Philippine Children's Medical Center (PCMC), a tertiary care hospital in Manila, Philippines. Semi-structured interviews querying current processes for clinical monitoring, Pediatric Intensive Care Unit (PICU) transfer, and clinician attitudes towards PEWS implementation were audio recorded. In-person hospital observations served to triangulate interview findings. The Systems Engineering Initiative for Patient Safety (SEIPS) framework guided content coding of interviews to characterize work systems, processes, and outcomes related to patient monitoring and care escalation. Thematic coding was performed using Dedoose software. This model allowed identification of barriers and facilitators to PEWS implementation. Barriers within PCMC workflow included: limited bed capacity, delay in referral, patient overflow, limited monitoring equipment, and high patient to staff ratio. Facilitators of PEWS implementation included support for PEWS adaptation and existence of systems for vital sign monitoring. Observations by study personnel confirmed validity of themes. Utilizing qualitative methodology to understand barriers and facilitators to PEWS in specific contexts can guide implementation at resource-limited hospitals.

Inaccurate Recording of Pediatric Early Warning Score Associated with Clinical Outcomes: An Experience from a Developing Country

BACKGROUND: The pediatric early warning score (PEWS) can assist in the identification of patients on wards who are at risk of deterioration. AIM: This study was aimed to examine the accuracy of PEWS recording and its association with clinical outcomes in a tertiary hospital. METHODS: A retrospective and case-controlled study was conducted on participants aged 1 month – 18 years admitted emergently from the ward to the pediatric intensive care unit (PICU) due to clinical deterioration between January and December 2021. The documented PEWS score was obtained from medical records, while the corrected PEWS score was calculated from the patients’ clinical data at the same time the documented PEWS score recorded. RESULTS: Total 70 patients who met the inclusion criteria were included for analysis. We observed about 38 patients (54.3%) had PEWS errors. We also observed significant difference in the respiratory and gastroenterology diagnosis categories between the PEWS error group and non-PEWS error group. The mean documented PEWS score at PICU admission was lower in PEWS error patients compared to non-PEWS error patients (1.34 ± 1.28 versus 4.31 ± 2.73, respectively, p &lt; 0.05). The need for vasoactive drugs was significantly higher at 72 h after PICU admission and at PICU discharge for the patients in PEWS errors group (p &lt; 0.05). PEWS errors group were associated with higher need for vasoactive drugs (RR = 2.01; 95% CI: 1.22–3.31; p &lt; 0.05). CONCLUSION: Inaccurate recording of PEWS caused earlier and higher need for vasoactive drugs in patients with unplanned PICU admission. We highlighted the importance of PEWS in the clinical outcome of pediatric patients.

[Early warning scores of clinical deterioration in pediatric patients: a literature review].

An early recognition of clinical worsening (the manifestation of signs and symptoms resulting in physiological instability) in pediatric inpatients may prevent the evolution towards cardiorespiratory arrest. In recent decades, several tools known as PEWS (Pediatric Early Warning Scores), have been developed, aiming to reduce in-hospital morbidity and mortality. To describe efficacy, sensitivity and specificity of the available tools for early detection of clinical worsening in children, based on literature review. Systematic review through the consultation of PubMed and Google Scholar, cross-combining Mesh terms and free text words. Out of 266 analysed papers, 34 were included in this review: 23 retrospective observational studies, 8 reviews, 1 reliability study, and 2 pilot studies. Overall, 23 main PEWS with sufficient evidence of efficacy were described (11 track and trigger and 12 aggregate). Ranges of sensibility and specificity were available only for 18 PEWS. It is not possible to recognize a gold standard, however, some PEWS are better in terms of validity and efficacy in different clinical settings. Internationally, the BPEWS (Brighton Pediatric Early Warning Score) is the most commonly adopted tool, able to identify clinical worsening of in-hospital children almost 11 hours before cardiac arrest. Although with limited evidence, validated PEWS have shown good ability to prevent the risk of clinical worsening by reducing adverse events. Further studies and greater standardization according to the clinical context are still needed.

Pediatric emergency triage systems.

ABSTRACTObjective:The aim of this study was to perform a narrative review of the leading pediatric triage systems in emergency departments (EDs).Data source:Articles published between 1999 and 2019 were identified by searching the MEDLINE, EMBASE, and PubMed databases using the keywords “pediatric triage”, “pediatric assessment tools”, and “emergency department triage” with an emphasis on studies that evaluated the validation and reliability of triage systems.Data synthesis:A total of 105 articles on pediatric emergency triage systems in 12 countries were evaluated. Triage systems were divided into two groups: color-stratified triage systems and alert systems. The color-stratified triage systems included in this review were the Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), Emergency Severity Index (ESI), and Australasian Triage Scale (ATS), and the alert systems included were the Paediatric Observation Priority Score (POPS), Pediatric Early Warning Score (PEWS), and Pediatric Approach Triangle (PAT). Evidence corroborates the validity and reliability of MTS, PaedCTAS, ESI version 4, PEWS, POPS, and PAT in pediatric emergency services.Conclusions:These are fundamental tools for risk classification of patients seeking treatment in EDs. Not all triage systems have been assessed for validity and reliability; nor are they well suited for all regions of the world. Employing triage systems in Brazil requires cultural adaptation and rigorous training of the local health staff, in addition to validation and reliability studies in our country, since the social and cultural context of this country differs from those where these tools were developed.