Paediatric Early Warning System Research Articles

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

ObjectiveTo determine the use of paediatric early warning systems (PEWS) and rapid response teams (RRTs) in paediatric units in Great Britain.DesignCross sectional survey.SettingAll hospitals with inpatient paediatric services in Great...

P08 Retrospective Evaluation of a New Neonatal Trigger Score

AimsAt present there is no published validated clinical scoring system for neonates. We aimed to design and validate an objective clinical scoring system to identify unwell neonates, using routinely collected...

Retrospective Evaluation of a New Neonatal Trigger Score

To design and validate an objective clinical scoring system to identify unwell neonates, by using routinely collected bedside observations. A Neonatal Trigger Score (NTS) was designed by using local expert consensus and incorporated into a new observation chart. All neonates >35 weeks' gestation admitted to the NICU over an 18-month period, and an age-matched "well" cohort, were retrospectively scored by using the newly constructed NTS and all established pediatric early warning system (PEWS) scores. Scores were calculated for 485 neonates. The NTS score area under the receiver operating characteristic curve was 0.924 with a score of 2 or more predicting need for admission to the NICU with 77% sensitivity and 97% specificity. Neonates scoring ≥2 had increased odds of needing intensive care (odds ratio [OR] 48.7, 95% confidence interval [CI] 27.5-86.3), intravenous fluids (OR 48.1, 95% CI 23.9-96.9), and continuous positive airway pressure (OR 29.5, 95% CI 6.9-125.8). The NTS was more sensitive than currently established PEWS scores. The NTS observation chart acts as an adjunct to clinical assessment, highlighting unwell neonates. Its simplicity allows successful and safe use by nonpediatric specialists. NTS out-performed PEWS, with significantly better sensitivity, particularly in neonates who deteriorated within the first 12 hours after birth (P < .001) or in neonates with sepsis or respiratory symptoms (P < .001). Neonates with a score of 1 should be reviewed and those scoring ≥2 should be considered for NICU admission for further management.

Comparison of Three Acute Care Pediatric Early Warning Scoring Tools

Pediatric Early Warning (PEW) scoring tools effectively identify hospitalized children at risk for clinical deterioration. The study compared the predictability of three previously validated PEW scoring tools. A retrospective case-control design was used that identified the PEW System Score (H. Duncan, J. Hutchison, & C. Parshuram, 2006) as a stronger predictor of cardiopulmonary arrest (CPA) than either the PEW Tool (C. Haines, M. Perrott, & P. Weir, 2006) or the Bedside PEW System Score (C. Parshuram, J. Hutchison, & K. Middaugh, 2009). The PEW System Score (H. Duncan, J. Hutchison, & C. Parshuram, 2006) demonstrated a greater sensitivity (86.6%) and specificity (72.9%) at a score of five. The PEW System Score (H. Duncan, J. Hutchison, & C. Parshuram, 2006) could benefit healthcare providers in potentially averting CPA.

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Introduction: There are no scoring systems that accurately predict the need for intervention during the interfacility transport of pediatric patients. Pediatric transport teams vary in composition, sometimes changing based on the perceived patient acuity or likelihood of invasive intervention or complex medical decision making; thus requiring different skill sets than a typical transport team. The Bedside Paediatric Early Warning System (B-PEWS) score has been previously shown to identify critically ill hospitalized. There are no published studies evaluating the B-PEWS in the transport setting. Hypothesis: Higher B-PEWS score at time of transport referral to the pediatric specialty transport team correlates with increased need for significant interventions by the transport team. Methods: A retrospective chart review was conducted of patients transported by a specialty pediatric transport team from 8/2010 – 1/2011. B-PEWS score was calculated at the times of referral, team arrival at referral facility, and transfer to the tertiary pediatric hospital. Significant interventions included volume resuscitation, intubation, initiation of positive pressure ventilation, systemic bronchodilator use, heliox or continuous nebulized therapy, intracranial pressure management, vasoactive therapy, treatment of status epilepticus, CPR, and insertion of chest tube, arterial or central line. Mann-Whitney U was used to compare referral B-PEWS scores between patients who did and did not require intervention. Results: The mean B-PEWS score was significantly higher (p<0.001) for patients requiring significant intervention; for patients requiring intervention the score was 9.7 (95% CI: 8.83-10.55), for patients not requiring intervention the score was 3.44 (95% CI: 3.08-3.80). Conclusions: Higher B-PEWS score at time of transport referral correlates with increased need for significant intervention during pediatric interfacility transport.

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Introduction: Serious bacterial infections (SBIs) account for significant morbidity and mortality in children. There is evidence that prompt initiation of antibiotics for SBIs has decreased adverse outcomes in adults. However, data on prompt antibiotic administration has been found to be increasingly inconsistent. Hypothesis: Our hypothesis was that those children who received STAT antibiotics <60min would have a shorter length of stay (LOS) than those who did not. Methods: We conducted a retrospective chart review. STAT antibiotic orders were collected as part of hospital quality improvement initiative. Inclusion criteria were receiving STAT IV antibiotics, admission to the acute care floor or pediatric intensive care unit (PICU), and a principal discharge diagnosis of sepsis, bacteremia, meningitis, pneumonia, or fever and neutropenia. Other data was age and gender, time from order to administration, time from presentation to administration, LOS, Pediatric Early Warning System score (PEWS) if on acute care, and the Pediatric Logistic Organ Dysfunction score (PELOD) if admitted to the PICU. Results: There were 4,924 STAT antibiotic orders. 1375 patients met inclusion criteria diagnoses. Only 350 met all inclusion criteria. The average age was 6 years old. 48% were male. The mean LOS for acute care unit was 5.2 [4.7-5.8] days and 11.1 [8.9-13.9] for the PICU. On the acute care unit, patients who received antibiotics <60min were 1.35 times more likely to be discharged earlier (p=0.019). Average LOS for antibiotic administration <60 mins was 4.7 [4.1 – 5.4] days versus those who received >60 mins: 6.0 [5.1 – 7.0] days. In the PICU, the average LOS for those who received antibiotics <60 mins was 10.2 [8.0 – 12.8] days versus those who receive antibiotics >60 mins was 12.9 [10 – 16.7] days. Conclusions: In conclusion, in the acute care setting, delayed time to antibiotics of >60min was associated with increased LOS in patients with SBIs. In the critical care setting, delayed time to antibiotics of >60min was not associated with increased LOS in patients with SBIs. Delayed time to antibiotics of >60min was not associated with escalation of care.

1483 Burton Paediatric Early Warning System Score

BackgroundEarly warning scores compliment clinical decision making and can identify trends depicting deterioration in patient’s condition. Age appropriate Burton Paediatric Early Warning System (BPEWS) score charts were developed in 2011...

Comparison of Severity of Illness Scores to Physician Clinical Judgment for Potential Use in Pediatric Critical Care Triage

A pediatric triage tool is needed during times of resource scarcity to optimize critical care utilization. This study compares the modified sequential organ failure assessment score (M-SOFA), the Pediatric Early Warning System (PEWS) score, the Pediatric Risk of Admission Score II (PRISA-II), and physician judgment to predict the need for pediatric intensive care unit (PICU) interventions. This retrospective cohort study evaluates three illness severity scores for all non-neonatal pediatric patients transported and admitted to a single center in 2006. The outcome of interest was receipt of a PICU intervention (mechanical ventilation, acute dialysis, depressed consciousness, or persistent hypotension). Predictive ability was assessed using receiver operating curves (ROCs). Of 752 patients admitted to the hospital, 287 received a PICU intervention. Median scores for all tools were significantly higher for children receiving an intervention than for those who did not. ROCs showed PEWS had the least discriminatory ability, followed by PRISA-II and pediatric M-SOFA. No value of the pediatric M-SOFA produced both positive and negative predictive values better than clinician judgment. No score had a clinically acceptable discriminate ability to predict patients who required a PICU intervention from those who did not. Physician judgment outperformed all three triage scores.

Validation of a Modified Pediatric Early Warning System Score

The Pediatric Early Warning System (PEWS) score may be useful for detection of deterioration in clinical condition. In this retrospective study, the cases were patients transferred to the pediatric intensive care unit (PICU), and controls were those not transferred to the PICU. The maximum PEWS score in both groups were analyzed using Mann-Whitney U test and receiver operating characteristic curve (ROC). The study population included 100 cases and 250 controls. There was no difference in the age of cases and controls (6.3 vs 6.3 years). The length of hospital stay (18.09 ± 32 vs 3.93 ± 2.9 days; P < .001) and the maximum PEWS score (2.95 ± 1.5 vs 1.4 ± 0.8) were significantly higher for the cases (P < .0001). The PEWS score area under the ROC was 0.81 (95% confidence interval = 0.75-0.86). The sensitivity and specificity for a score 2.5 were 62% and 89%, respectively. The use of the modified PEWS score can help identify patients on wards who are at risk for deterioration.

Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study

Late transfer of children with critical illness from community hospitals undermines the advantages of community-based care. It was hypothesized that implementation of the Bedside Paediatric Early Warning System (Bedside PEWS) would reduce late transfers. A prospective before-and-after study was performed in a community hospital 22-bed inpatient paediatric ward. The primary outcome, significant clinical deterioration, was a composite measure of circulatory and respiratory support before transfer. Secondary outcomes were stat calls and resuscitation team calls, paediatrician workload and perceptions of frontline staff. Care was evaluated for 842 patient-days before and 2350 patient-days after implementation. The median inpatient census was 13. Implementation of the Bedside PEWS was associated with fewer stat calls to paediatricians (22.6 versus 5.1 per 1000 patient-days; P<0.0001), fewer significant clinical deterioration events (2.4 versus 0.43 per 1000 patient-days; P=0.013), reduced apprehension when calling the physician and no change in paediatrician workload. Implementation of the Bedside PEWS is feasible and safe, and may improve clinical outcomes.

Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children

IntroductionThe timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals.MethodsWe performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients.ResultsA total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001).ConclusionsThe Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.

424 Did Paediatric Early Warning System(PEWS) Utilisation Impact on Severity of Illness and Outcome for Patients Admitted to a Tertiary Picu?

Introduction: PEWs was implemented at Alder Hey in August 2006. No screening tool was being used at District General Hospitals at that time. There has been no comparative data to date exploring the impact of such innovations on the severity of illness at first contact and their outcomes. Method: Data is prospectively collected on all children admitted to PICU as part of a national dataset. Data was analysed for a year before and a year following PEWs implementation comparing all unplanned admissions from wards within the hospital with external unplanned admissions transferred from DGHs. Results: There was no significant difference to the absolute numbers of patients admitted as emergency from wards 14.4-15.9% within the hospital or external sources 28.9-30.7%. For the internal unplanned admissions from wards in the hospital: Median PIM scores reduced from 0.060 to 0.048 Inotrope requirement reduced from 32.5 to 23.4% of patient group, Invasive ventilation requirement reduced from 75.1% to 62% of patient group, duration reduced from 6 to 4 days Median length of stay reduced from 4.5 to 3 days. For the unplanned admissions transferred from other hospitals Median PIM scores increased from 0.057 to 0.071 95-97% of children were invasively ventilated for transfer but median duration of ventilation was 3 days Inotrope requirement was similar 29.8-31.8% Median duration of stay increased from 2 to 3 days Mortality for both groups was similar 9-10.8% Implications: The wider use of PEWs at DGHs could reduce severity of illness and inotrope requirement of critically ill children.

Cohort study to test the predictability of the Melbourne criteria for activation of the medical emergency team

ObjectiveTo test the predictability of the Melbourne criteria for activation of the medical emergency team (MET) to identify children at risk of developing critical illness.DesignCohort study.SettingAdmissions to all paediatric wards...

Observations and monitoring: routine practices on the ward

To review routine observations on all children admitted to the Children's Hospital for Wales and the feasibility of implementing an early warning score for children developing critical illness. Nursing staff, while performing their routine duties, recorded the physiological observations of temperature, heart rate, respiratory rate and blood pressure, as well as identifying airway threat, recording oxygen saturation levels, level of consciousness using the AVPU scale (alert, responds to voice, responds to pain, unresponsive) and identifying if they had concerns about a child on a new paediatric observation chart. The clinical care policy for each ward determined the frequency of recording observations. Data were collected for 1,000 patients on whom 9,075 sets of observations were performed. Of those 9,075 sets, temperature was the most frequently recorded observation at 88.4% (95% confidence interval (CI) 87.7-89), followed by heart rate at 86.8% (95% CI 86.1-87.5), respiratory rate at 79.7% (95% CI 78.9-80.5), AVPU at 36.4% (95% CI 35.4-37.4) and blood pressure at 25.1% (95% CI 24.2-26.0). A complete set of observations needed for the Cardiff and Vale Paediatric Early Warning System to trigger effectively were only recorded in 52.7% (95% CI 52.4-53.1) of patients. There were variations in the frequency, type and recording of observations. This issue needs to be addressed if scoring systems are to be implemented. The findings of this observational study suggest that the required basic observations of acutely ill children are not being carried out.

Early warning system to help prevent unexpected hospital deaths

A confidential review of UK childhood deaths examined 89 hospital deaths in detail and deemed 63 (71 per cent) to be avoidable or potentially avoidable (Confidential Enquiry into Maternal and Child Health (CEMACH) 2007), with the failure to recognise the child’s deterioration cited as a major contributing factor. This prompted CEMACH to recommend the use of a paediatric early warning system (PEWS) in all hospitalised children. Although similar systems are well established for hospitalised adults, little has been published in paediatrics and this paper is a welcome addition to the literature.

Implementation of the Pediatric Early Warning Scoring System on a Pediatric Hematology/Oncology Unit

Despite improved outcomes for pediatric Hematology/Oncology patients over the past 15-20 years, sepsis and other acute events continue to cause serious illness in these children. Implementing a pediatric early warning scoring tool (PEWS) with an associated multi-disciplinary action algorithm in a pediatric Hematology/Oncology unit helped to remove barriers that prevented timely referral of children who are clinically deteriorating and requiring immediate help, enhanced multi-disciplinary team communication, and has led to a more than 3-fold increase in days between codes on the Hematology/Oncology unit.

Use of a paediatric early warning system in emergency departments

Stockport NHS Foundation Trust has recently implemented a generic paediatric early warning tool that can be used throughout its paediatric services, from admission to discharge. Informal feedback suggests that using the tool has encouraged staff to undertake full sets of observations; this has improved their confidence in recognising deterioration in children and initiating correct interventions.

Paediatric early warning systems: where do we go from here?

The Confidential Enquiry into Maternal and Child Health report published in 2008 recommended that there should be a standardised monitoring system with embedded early identification systems for children at risk of critical illness or deterioration. Recent studies have demonstrated improvement in patient outcomes following the implementation of paediatric early warning scores and response teams in children's units and hospitals. However, it is not enough to use an early warning score in isolation; it needs to be embedded into a paediatric early warning system, with a rationalised approach to the observation and monitoring of hospitalised children. Lessons can be learnt from the adult experience of implementing early warning systems. A national, multidisciplinary, collaborative approach to the development, implementation and evaluation of paediatric early warning systems is recommended.

Development and initial validation of the Bedside Paediatric Early Warning System score.

IntroductionAdverse outcomes following clinical deterioration in children admitted to hospital wards is frequently preventable. Identification of children for referral to critical care experts remains problematic. Our objective was to develop and validate a simple bedside score to quantify severity of illness in hospitalized children.MethodsA case-control design was used to evaluate 11 candidate items and identify a pragmatic score for routine bedside use. Case-patients were urgently admitted to the intensive care unit (ICU). Control-patients had no 'code blue', ICU admission or care restrictions. Validation was performed using two prospectively collected datasets.ResultsData from 60 case and 120 control-patients was obtained. Four out of eleven candidate-items were removed. The seven-item Bedside Paediatric Early Warning System (PEWS) score ranges from 0–26. The mean maximum scores were 10.1 in case-patients and 3.4 in control-patients. The area under the receiver operating characteristics curve was 0.91, compared with 0.84 for the retrospective nurse-rating of patient risk for near or actual cardiopulmonary arrest. At a score of 8 the sensitivity and specificity were 82% and 93%, respectively. The score increased over 24 hours preceding urgent paediatric intensive care unit (PICU) admission (P < 0.0001). In 436 urgent consultations, the Bedside PEWS score was higher in patients admitted to the ICU than patients who were not admitted (P < 0.0001).ConclusionsWe developed and performed the initial validation of the Bedside PEWS score. This 7-item score can quantify severity of illness in hospitalized children and identify critically ill children with at least one hours notice. Prospective validation in other populations is required before clinical application.

Prospective cohort study to test the predictability of the Cardiff and Vale paediatric early warning system

Objective:To develop and test the predictability of a paediatric early warning score to identify children at risk of developing critical illness.Design:Prospective cohort study.Setting:Admissions to all paediatric wards at the University...