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

Evaluating the performance of the National Early Warning Score in different diagnostic groups

BACKGROUND

The National Early Warning Score (NEWS) is used in hospitals across the UK to detect deterioration of patients within care pathways. It is used for most patients, but there are relatively few studies validating its performance in groups of patients with specific conditions.

METHODS

The performance of NEWS was evaluated against 36 other Early Warning Scores, in 123 patient groups, through use of the area under the receiver operating characteristic (AUROC) curve technique, to compare the abilities of each Early Warning Score to discriminate an outcome within 24hrs of vital sign recording. Outcomes evaluated were death, ICU admission, or a combined outcome of either death or ICU admission within 24 hours of an observation set.

RESULTS

The National Early Warning Score 2 performs either best or joint best within 120 of the 123 patient groups evaluated and is only outperformed in prediction of unanticipated ICU admission. When outperformed by other Early Warning Scores in the remaining 3 patient groups, the performance difference was marginal.

CONCLUSIONS

Consistently high performance indicates that NEWS is a suitable early warning score to use for all diagnostic groups considered by this analysis, and patients are not disadvantaged through use of NEWS in comparison to any of the other evaluated Early Warning Scores.

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

BACKGROUND

For 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).

METHODS

This 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.

RESULTS

The 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.

CONCLUSION

This 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.

Using technology to reduce critical deterioration (the DETECT study): a cost analysis of care costs at a tertiary children's hospital in the United Kingdom

BACKGROUND

Electronic early warning systems have been used in adults for many years to prevent critical deterioration events (CDEs). However, implementation of similar technologies for monitoring children across the entire hospital poses additional challenges. While the concept of such technologies is promising, their cost-effectiveness is not established for use in children. In this study we investigate the potential for direct cost savings arising from the implementation of the DETECT surveillance system.

METHODS

Data were collected at a tertiary children's hospital in the United Kingdom. We rely on the comparison between patients in the baseline period (March 2018 to February 2019) and patients in the post-intervention period (March 2020 to July 2021). These provided a matched cohort of 19,562 hospital admissions for each group. From these admissions, 324 and 286 CDEs were observed in the baseline and post-intervention period, respectively. Hospital reported costs and Health Related Group (HRG) National Costs were used to estimate overall expenditure associated with CDEs for both groups of patients.

RESULTS

Comparing post-intervention with baseline data we found a reduction in the total number of critical care days, driven by an overall reduction in the number of CDEs, however without statistical significance. Using hospital reported costs adjusted for the Covid-19 impact, we estimate a non-significant reduction of total expenditure from £16.0 million to £14.3 million (corresponding to £1.7 million of savings - 11%). Additionally, using HRG average costs, we estimated a non-significant reduction of total expenditure from £8.2 million to £ 7.2 million (corresponding to £1.1 million of savings - 13%).

DISCUSSION AND CONCLUSION

Unplanned critical care admissions for children not only impose a substantial burden on patients and families but are also costly for hospitals. Interventions aimed at reducing emergency critical care admissions can be crucial to contribute to the reduction of these episodes' costs. Even though cost reductions were identified in our sample, our results do not support the hypothesis that reducing CDEs using technology leads to a significant reduction on hospital costs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61279068, date of registration 07/06/2019, retrospectively registered.

Paediatric early warning systems: not a simple answer to a complex question

Paediatric early warning systems (PEWS) to reduce in-hospital mortality have been a laudable endeavour. Evaluation of their impact has rarely examined the internal validity of the components of PEWS in achieving desired outcomes. We highlight the assumptions made regarding the mode of action of PEWS and, as PEWS become more commonplace, this paper asks whether we really understand their function, process and outcome.

Performance of a single-ventricle home-monitoring programme: survival and predictors of adverse outcome

INTRODUCTION AND BACKGROUND

Mortality between stages 1 and 2 single-ventricle palliation is significant. Home-monitoring programmes are suggested to reduce mortality. Outcomes and risk factors for adverse outcomes for European programmes have not been published.

AIMS

To evaluate the performance of a home-monitoring programme at a medium-sized United Kingdom centre with regards survival and compare performance with other home-monitoring programmes in the literature.

METHODS

All fetal and postnatal diagnosis of a single ventricle were investigated with in-depth analysis of those undergoing stage 1 palliation and entered the home-monitoring programme between 2016 and 2020. The primary outcome was survival. Secondary outcomes included multiple parameters as potential predictors of death or adverse outcome.

RESULTS

Of 217 fetal single-ventricle diagnoses during the period 2016-2020, 50.2% progressed to live birth, 35.4% to stage 1 and 29.5% to stage 2. Seventy-four patients (including 10 with postnatal diagnosis) entered the home-monitoring programme with six deaths making home-monitoring programme mortality 8.1%. Risk factors for death were the hybrid procedure as the only primary procedure (OR 33.0, p < 0.01), impaired cardiac function (OR 10.3, p < 0.025), Asian ethnicity (OR 9.3, p < 0.025), lower mean birth-weight (2.69 kg versus 3.31 kg, p < 0.01), and lower mean weight centiles during interstage follow-up (mean centiles of 3.1 versus 10.8, p < 0.01).

CONCLUSION

Survival in the home-monitoring programme is comparable with other home-monitoring programmes in the literature. Hybrid procedure, cardiac dysfunction, sub-optimal weight gain, and Asian ethnicity were significant risk factors for death. Home-monitoring programmes should continue to raise awareness of these factors and seek solutions to mitigate adverse events. Future work to generalise home-monitoring programme and single-ventricle fetus to stage 2 outcomes in the United Kingdom will require multi-centre collaboration.

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (the DETECT study): A qualitative interview study

BACKGROUND

Failure to recognize and respond to clinical deterioration in a timely and effective manner is an urgent safety concern, driving the need for early identification systems to be embedded in the care of children in hospital. Pediatric early warning systems (PEWS) or PEW scores alert health professionals (HPs) to signs of deterioration, trigger a review and escalate care as needed. PEW scoring allows HPs to record a child's vital signs and other key data including parent concern.

AIM

This study aimed to explore the experiences and perceptions of parents about the acceptability of a newly implemented electronic surveillance system (the DETECT surveillance system), and factors that influenced acceptability and their awareness around signs of clinical deterioration and raising concern.

METHODS

Descriptive, qualitative semi-structured telephone interviews were undertaken with parents of children who had experienced a critical deterioration event (CDE) (n = 19) and parents of those who had not experienced a CDE (non-CDE parents) (n = 17). Data were collected between February 2020 and February 2021.

RESULTS

Qualitative data were analyzed using generic thematic analysis. Analysis revealed an overarching theme of trust as a key factor that underpinned all aspects of children's vital signs being recorded and monitored. The main themes reflect three domains of parents' trust: trust in themselves, trust in the HPs, and trust in the technology.

CONCLUSION

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (The DETECT system) were positive; they found it acceptable and welcomed the use of new technology to support the care of their child.

Characteristics and outcomes of children receiving intensive care therapy within 12 hours following a medical emergency team event

Objectives: To describe characteristics and outcomes of children requiring intensive care therapy (ICT) within 12 hours following a medical emergency team (MET) event. Design: Retrospective cohort study. Setting: Quaternary paediatric hospital. Patients: Children experiencing a MET event. Measurements and main results: Between July 2017 and March 2019, 890 MET events occurred in 566 patients over 631 admissions. Admission to intensive care followed 183/890 (21%) MET events. 76/183 (42%) patients required ICT, defined as positive pressure ventilation or vasoactive support in intensive care, within 12 hours. Older children had a lower risk of requiring ICT than infants aged < 1 year (age 1-5 years [risk difference, -6.4%; 95% CI, -11% to -1.6%; P = 0.01] v age > 5 years [risk difference, -8.0%; 95% CI, -12% to -3.8%; P < 0.001]), while experiencing a critical event increased this risk (risk difference, 16%; 95% CI, 3.3-29%; P = 0.01). The duration of respiratory support and intensive care length of stay was approximately double in patients requiring ICT (ratio of geometric means, 2.0 [95% CI, 1.4-3.0] v 2.1 [95% CI, 1.5-2.8]; P < 0.001) and the intensive care mortality increased (risk difference, 9.6%; 95% CI, 2.4-17%; P = 0.01). Heart rate, oxygen saturation and respiratory rate were the most commonly measured vital signs in the 6 hours before the MET event. Conclusions: Approximately one-fifth of MET events resulted in intensive care admission and nearly half of these required ICT within 12 hours. This group had greater duration of respiratory support, intensive care and hospital length of stay, and higher mortality. Age < 1 year and a critical event increased the risk of ICT.

Case for change: a standardised inpatient paediatric early warning system in England

Most children in hospital who are clinically deteriorating are monitored regularly, and their treatment is escalated effectively. However a small, but significant, number of deteriorating children experience suboptimal outcomes because of a failure to recognise and respond to acute deterioration early enough leading to unintended harm. Tragically this occasionally can have fatal consequences. Investigations into these rare events highlight common themes of missed early signs of deterioration in children, prompting regulatory agencies to suggest paediatric early warning systems (PEWS) to aid clinical practice. In England, track and trigger tools (TTT), which are one facet of PEWS have been widely rolled out but in a heterogeneous fashion. The evidence for TTT is mixed but they are complex interventions and current outcomes do not fully define the entirety of their potential impact. This article explains the rationale behind the decision of the NHS England and NHS Improvement, Royal College of Paediatrics and Child Health and Royal College of Nursing to implement a standardised inpatient PEWS as part of a system-wide paediatric observations tracking system in England and how this fits into a wider programme of activity.

Association of out of hospital paediatric early warning score with need for hospital admission in a Scottish emergency ambulance population

OBJECTIVE

Physiological derangement, as measured by paediatric early warning score (PEWS) is used to identify children with critical illness at an early point to identify and intervene in children at risk. PEWS has shown some utility as a track and trigger system in hospital and also as a predictor of adverse outcome both in and out of hospital. This study examines the relationship between prehospital observations, aggregated into an eight-point PEWS (Scotland), and hospital admission.

METHODS

A retrospective analysis of all patients aged less than 16 transported to hospital by the Scottish Ambulance Service between 2011 and 2015. Data were matched to outcome data regarding hospital admission or discharge and length of stay.

RESULTS

Full data were available for 21 202 paediatric patients, of whom 6340 (29.9%) were admitted to hospital. Prehospital PEWS Scotland was associated with an odds ratio for admission of 1.189 [95% confidence interval (CI): 1.176-1.202; P < 0.001]. The area under receiver operating curve of 0.617 (95% CI: 0.608-0.625; P < 0.001) suggests poorly predictive ability for hospital admission. There was no association between prehospital PEWS Scotland and length of hospital stay.

CONCLUSION

These data show that a single prehospital PEWS Scotland was a poor predictor of hospital admission for unselected patients in a prehospital population. The decision to admit a child to hospital is not solely based on the physiological derangement of vital signs, and hence physiological-based scoring systems such as PEWS Scotland cannot be used as the sole criteria for hospital admission, from an undifferentiated prehospital population.

Performance of seven different paediatric early warning scores to predict critical care admission in febrile children presenting to the emergency department: a retrospective cohort study

OBJECTIVE

Paediatric Early Warning Scores (PEWS) are widely used in the UK, but the heterogeneity across tools and the limited data on their predictive performance represent obstacles to improving best practice. The standardisation of practice through the proposed National PEWS will rely on robust validation. Therefore, we compared the performance of the National PEWS with six other PEWS currently used in NHS hospitals, for their ability to predict critical care (CC) admission in febrile children attending the emergency department (ED).

DESIGN

Retrospective single-centre cohort study.

SETTING

Tertiary hospital paediatric ED.

PARTICIPANTS

A total of 11 449 eligible febrile ED attendances were identified from the electronic patient record over a 2-year period. Seven PEWS scores were calculated (Alder Hey, Bedside, Bristol, National, Newcastle and Scotland PEWS, and the Paediatric Observation Priority Score, using the worst observations recorded during their ED stay.

OUTCOMES

The primary outcome was CC admission within 48 hours, the secondary outcomes were hospital length of stay (LOS) >48 hours and sepsis-related mortality.

RESULTS

Of 11 449 febrile children, 134 (1.2%) were admitted to CC within 48 hours of ED presentation, 606 (5.3%) had a hospital LOS >48 hours. 10 (0.09%) children died, 5 (0.04%) were sepsis-related. All seven PEWS demonstrated excellent discrimination for CC admission (range area under the receiver operating characteristic curves (AUC) 0.91-0.95) and sepsis-related mortality (range AUC 0.95-0.99), most demonstrated moderate discrimination for hospital LOS (range AUC 0.69-0.75). In CC admission threshold analyses, bedside PEWS (AUC 0.90; 95% CI 0.86 to 0.93) and National PEWS (AUC 0.90; 0.87-0.93) were the most discriminative, both at a threshold of ≥6.

CONCLUSIONS

Our results support the use of the proposed National PEWS in the paediatric ED for the recognition of suspected sepsis to improve outcomes, but further validation is required in other settings and presentations.

Implementation of a paediatric early warning system as a complex health technology intervention

The national implementation groups of early warning systems in the UK and Ireland have identified a need to understand implementation, adoption and maintenance of these complex interventions. The literature on how to implement, scale, spread and sustain these systems is sparse. We describe a successful adoption and maintenance over 10 years of a paediatric early warning system as a sociotechnical intervention using the Nonadoption, Abandonment, Challenges to the Scale-Up, Spread, and Sustainability Framework for Health and Care Technologies. The requirement for iterative processes within environment, culture, policy, human action and the wider system context may explain the possible reasons for improved outcomes in small-scale implementation and meta-analyses that are not reported in multicentre randomised control trials of early warning systems.

Characteristics of Pediatric Rapid Response Systems: Results From a Survey of PRIS Hospitals

BACKGROUND

Many hospitals use rapid response systems (RRSs) to identify and intervene on hospitalized children at risk for deterioration.

OBJECTIVES

To describe RRS characteristics across hospitals in the Pediatric Research in Inpatient Settings (PRIS) network.

METHODS

We developed the survey through a series of prospective respondent, expert, and cognitive interviews. One institutional expert per PRIS hospital (n = 109) was asked to complete the web survey. We summarized responses using descriptive statistics with a secondary analysis of univariate associations between RRS characteristics and perceived effectiveness.

RESULTS

The response rate was 72% (79 of 109). Respondents represented diverse hospital types and were primarily physicians (97%) with leadership roles in care escalation. Many hospitals used an early warning score (77%) for identification with variable characteristics (46% automated versus 54% full or partially manual calculation; inputs included vital signs [98%], physical examination findings [88%], diagnoses [23%], medications [19%], and diagnostic tests [14%]). Few incorporated a validated prediction model (9%). Similarly, many RRSs used a rapid response team for intervention (93%) with variable team composition (respiratory therapists [94%], ICU nurses [93%], ICU providers [67%], and pharmacists [27%]). Some used the early warning score to trigger the rapid response team (50%). Only a few staffed a clinician to proactively surveil hospitalized children for risk of deterioration (18%), and these tended to be larger hospitals (annual admissions 12 000 vs 6000, P = .007). Most responding experts stated their RRSs improved patient outcomes (92%).

CONCLUSIONS

RRS characteristics varied across PRIS hospitals.

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

OBJECTIVE

To 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.

DESIGN

The well-established but complex published data on normal BP ranges in prepubertal children were identified and analysed to determine if it was possible to produce a single, user-friendly, colour-coded chart, showing diagnostic hypertension thresholds for systolic and diastolic BP without losing clinically important information.

RESULTS

There were sufficient published normative childhood BP data available to define systolic and diastolic BP centiles from term onwards but only sufficient to determine systolic BP centiles from 28 weeks of gestation to term. Up to 13 years of age, it was possible to combine boys' and girls' data without loss of precision and to define the threshold between stage 1 and stage 2 (severe) hypertension as the 95th centile +12 mm Hg. This allowed the production of single colour-coded charts for systolic and diastolic BP and to advise on making simple adjustments for the impact of stature on individual children's results.

CONCLUSIONS

A simplified, integrated BP chart with colour-coded diagnostic thresholds was produced to assist the prompt diagnosis of hypertension in prepubertal children. This information could be included into a Paediatric Early Warning System score.

Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre study

BACKGROUND

Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS.

METHODS

The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece).

FINDINGS

Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82-0·90) for high-urgency patients and 0·67 (0·61-0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87-0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81-0·85).

INTERPRETATION

The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs.

FUNDING

Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.

The discrimination of quick Paediatric Early Warning Scores in the pre-hospital setting

In our previous study, a Paediatric Early Warning Score could be calculated for only one-fifth of 102,993 children transported by ambulance to hospital, as components other than supplemental oxygen were not reliably measured: respiratory rate 90,358 (88%); Glasgow Coma Score 83,648 (81%); heart rate 83,330 (81%); time to capillary reperfusion 81,685 (79%); oxygen saturation 71,372 (69%); temperature 60,402 (59%); systolic blood pressure 37,088 (36%). We tested 12 abbreviated scores with 3-5 components. The discrimination of these 12 scores for the primary outcome (30-day mortality or admission to paediatric intensive care), as measured by the area under the receiving operator characteristic curve, ranged from 0.69 to 0.80. Scores could be calculated for at most 74,508 (72%) children when heart rate, conscious level and respiratory rate were measured, with or without supplemental oxygen: the discrimination of these two versions was 0.75 and 0.77, respectively. Optimal threshold scores of 3 and 2 for these two abbreviated versions discriminated an outcome rate of 2-3% in about one third of children from the other children who had < 1% rate of outcome.

Missed opportunities: incomplete and inaccurate recording of paediatric early warning scores

BACKGROUND

Paediatric early warning scores (PEWS) are widely used as an adjunct to support staff in recognising deterioration in hospitalised children. Relatively little is known about how staff use these systems.

OBJECTIVE

To examine the completeness and accuracy of PEWS recording in hospitalised children in a tertiary specialist children's hospital.

DESIGN

This is a secondary analysis of retrospective, case-controlled study data. Case patients suffering from a critical deterioration event were matched with controls present on the same ward at the same time and matched for age. Data were extracted from the PEWS chart for the 48 hours before the critical deterioration event for case patients and the corresponding 48 hours period for the control. Observation sets were assessed for completeness and accuracy of PEWS scoring.

RESULTS

In total 297 case events in 224 patients were available for analysis. Overall 13 816 observations sets were performed, 8543 on cases and 5273 on controls. Only 4958 (35.9%) of observation sets contained a complete set of vital sign parameters and a concurrent PEWS. Errors were more prevalent in the observation sets of case patients versus controls (19.5% vs 14.1%). More errors resulted in the PEWS value being underscored rather than overscored for all observation sets (p<0.0001). 9.1% of inaccuracies for case patients were clinically significant, as the accurately calculated PEWS would have prompted a different escalation from the documented value.

CONCLUSION

Failure to record complete and accurate PEWS may jeopardise recognition of children who are deteriorating. Technology may offer an effective solution.

Dynamic Electronic Tracking and Escalation to reduce Critical care Transfers (DETECT): the protocol for a stepped wedge mixed method study to explore the clinical effectiveness, clinical utility and cost-effectiveness of an electronic physiological surveillance system for use in children

Background

Active monitoring of hospitalised adults, using handheld electronic physiological surveillance systems, is associated with reduced in-patient mortality in the UK. Potential also exists to improve the recognition and response to deterioration in hospitalised children. However, the clinical effectiveness, the clinical utility, and the cost-effectiveness of this technology to reduce paediatric critical deterioration, have not been evaluated in an NHS environment.

Method

This is a non-randomised stepped-wedge prospective mixed methods study. Participants will be in-patients under the age of 18 years, at a tertiary children’s hospital. Day-case, neonatal surgery and Paediatric Intensive Care Unit (PICU) patients will be excluded.

The intervention is the implementation of Careflow Vitals and Connect (System C) to document vital signs and sepsis screening. The underpinning age-specific Paediatric Early Warning Score (PEWS) risk model calculates PEWS and provides associated clinical decision support. Real-time data of deterioration risk are immediately visible to the entire clinical team to optimise situation awareness, the chronology of the escalation and response are captured with automated reporting of the organisational safety profile.

Baseline data will be collected prospectively for 1 year preceding the intervention. Following a 3 month implementation period, 1 year of post-intervention data will be collected.

The primary outcome is unplanned transfers to critical care (HDU and/or PICU). The secondary outcomes are critical deterioration events (CDE), the timeliness of critical care transfer, the critical care interventions required, critical care length of stay and outcome.

The clinical effectiveness will be measured by prevalence of CDE per 1000 hospital admissions and per 1000 non-PICU bed days.

Observation, field notes, e-surveys and focused interviews will be used to establish the clinical utility of the technology to healthcare professionals and the acceptability to in-patient families. The cost-effectiveness will be analysed using Health Related Group costs per day for the critical care and hospital stay for up to 90 days post CDE.

Discussion

If the technology is effective at reducing CDE in hospitalised children it could be deployed widely, to reduce morbidity and mortality, and associated costs.

Trial registration

Current Controlled Trials ISRCTN61279068, date of registration 03.06.19, retrospectively registered.

Clinician Perceptions of an Early Warning System on Patient Safety

BACKGROUND AND OBJECTIVES

The Pediatric Early Warning Score (PEWS) aims to improve early recognition of clinical deterioration and is widely used despite lacking evidence of effects on outcome measures such as hospital mortality. In this qualitative study, we aimed to study effects of both PEWS and the locally designed risk stratification system by focusing on professionals' perception of their performance. We also sought to gain insight into the perceived effects of PEWS and the risk stratification system on patient safety and to unravel the underlying mechanisms.

METHODS

A single-center cross-sectional observational study whereby 16 semistructured interviews were held with selected health care professionals focusing on perceived effects and underlying mechanisms. Interviews were transcribed verbatim and coded without using a predetermined set of themes.

RESULTS

Coding from semistructured interviews demonstrated that perceived value was related to effects on different levels of Endsley and co-workers' situational awareness (SA) model. PEWS mainly improved level 1 SA, whereas the risk stratification system also seemed to improve levels 2 and 3 SA.

CONCLUSIONS

This study shows clear effects of PEWS on SA among professionals. It also points to the additional value of other risk factor stratification systems to help further improve PEWS functioning.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

OBJECTIVE

To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.

DESIGN

Systematic review.

DATA SOURCES

British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.

ELIGIBILITY CRITERIA

We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered.

DATA EXTRACTION AND SYNTHESIS

Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.

RESULTS

36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.

CONCLUSION

There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

Early warning scores in paediatrics: an overview

Paediatric Early Warning Scores (PEWS)are used in hospitalised patients to detect physiological deterioration and is being used increasingly throughout healthcare systems with a limited evidence based. There are two versions in general use that can lead to a clinical response, either by triggering an action or by reaching a 'threshold' when graduated responses may occur depending on the value of the score. Most evidence has come from research based on paediatric inpatients in specialist children's hospitals, although the range of research is expanding, taking into account other clinical areas such as paediatric intensive care unit, emergency department and the prehospital setting. Currrently, it is uncertain whether a unified system does deliver benefits in terms of outcomes or financial savings, but it may inform and improve patient communication. PEWS may be an additional tool in context of a patient's specific condition, and future work will include its validation for different conditions, different clinical settings, patient populations and organisational structure. The incorporation of PEWS within the electronic health records may form a keystone of the safe system framework and allow the development of consistent PEWS system to standardise practice.

The Association Between Fever and Subsequent Deterioration Among Hospitalized Children With Elevated PEWS

OBJECTIVES

To evaluate the association between fever and subsequent deterioration among patients with Pediatric Early Warning Score (PEWS) elevations to ≥4 to inform improvements to care escalation processes at our institution.

METHODS

We performed a cohort study of hospitalized children at a single quaternary children's hospital with PEWS elevations to ≥4 between January 1, 2014 and March 31, 2014. Bivariable analysis was used to compare characteristics between patients with and without unplanned ICU transfers and critical deterioration events (CDEs) (ie, unplanned ICU transfers with life-sustaining interventions initiated in the first 12 ICU hours). A multivariable Poisson regression was used to assess the relative risk of unplanned ICU transfers and CDEs.

RESULTS

The study population included 220 PEWS elevations from 176 unique patients. Of those, 33% had fever (n = 73), 40% experienced an unplanned ICU transfer (n = 88), and 19% experienced CDEs (n = 42). Bivariable analysis revealed that febrile patients were less likely to experience an unplanned ICU transfer than those without fever. The same association was found in multivariable analysis with only marginal significance (adjusted relative risk 0.68; 95% confidence interval 0.45-1.01; P = .058). There was no difference in the CDE risk for febrile versus afebrile patients (adjusted relative risk 0.79; 95% confidence interval 0.43-1.44; P = .44).

CONCLUSIONS

At our institution, patients with an elevated PEWS appeared less likely to experience an unplanned ICU transfer if they were febrile. We were underpowered to evaluate the effect on CDEs. These findings contributed to our recognition that (1) PEWS may not include all relevant clinical factors used for clinical decision-making regarding care escalation and (2) further study is needed in this area.

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 scores are predictors of adverse outcome in the pre-hospital setting: A national cohort study

INTRODUCTION

Physiological deterioration often precedes clinical deterioration as patients develop critical illness. Use of a specific Paediatric Early Warning Score (PEWS), based on basic physiological measurements, may help identify children prior to their clinical deterioration. NHS Scotland has adopted a single national PEWS - PEWS (Scotland). We aim to look at the utility of PEWS (Scotland) in unselected paediatric ambulance patients.

METHODS

We performed a retrospective cohort of all ambulance patients aged under 16 years conveyed to hospital in Scotland between 2011 and 2015. Patients were matched to their 30 day mortality and ICU admission using data linkage.

RESULTS

Full results were available for 21,202 children and young people (CYP). On multivariate logistic regression, PEWS (Scotland) was an independent predictor of the primary outcome (ICU admission within 48 h or death within 30 days) with an odds ratio of 1.403 (95%CI 1.349-1.460, p < 0.001). Area Under Receiving Operator Curve (AUROC) for aggregated PEWS was 0.797 (95% CI 0.759 to 0.836, p < 0.001). The optimal PEWS using Youlden's Index was 5.

DISCUSSION

These data show PEWS (Scotland) to be a useful tool in a pre-hospital setting. A single set of physiological observations undertaken prior to arrival at hospital can identify a group of children at higher risk of an adverse in-hospital outcome. Paediatric care is becoming more specialised and focussed on a smaller number of centres. In this context, use of PEWS (Scotland) in the pre-hospital phase may allow changes to paediatric pre-hospital pathways to improve both admission to ICU and child mortality rates.

Defining significant childhood illness and injury in the Emergency Department: a consensus of UK and Ireland expert opinion

BACKGROUND

Clarifying whether paediatric early warning scores (PEWS) accurately predict significant illness is a research priority for UK and Ireland paediatric emergency medicine (EM). However, a standardised list of significant conditions to benchmark these scores does not exist.

OBJECTIVES

To establish standardised significant illness endpoints for use in determining the performance accuracy of PEWS and safety systems in emergency departments (ED), using a consensus of expert opinion in the UK and Ireland.

DESIGN

Between July 2017 and February 2018, three online Delphi rounds established a consensus on 'significant' clinical conditions, derived from a list of common childhood illness/injury ED presentations. Conditions warranting acute hospital admission in the opinion of the respondent were defined as 'significant', using a 5-point Likert scale. The consensus was a priori ≥80% (positive or negative). 258 clinical conditions were tested.

PARTICIPANTS AND SETTINGS

Eligible participants were consultants in acute or EM paediatrics, or adult EM, accessed via 53 PERUKI (Paediatric Emergency Research in the UK and Ireland)'s research collaborative sites, and 27 GAPRUKI (General and Adolescent Paediatric Research in the UK and Ireland)'s sites, 17 of which overlap with PERUKI.

MAIN OUTCOME MEASURES

To create a list of conditions regarded as 'significant'with ≥80% expert consensus.

RESULTS

43 (68%) of 63 PERUKI and GAPRUKI sites responded; 295 experts were invited to participate. Participants in rounds 1, 2 and 3 were 223 (76%), 177 (60%) and 148 (50%), respectively; 154 conditions reached positive consensus as 'significant'; 1 condition reached a negative consensus (uncomplicated Henoch-Schönlein purpura); and 37 conditions achieved non-consensus.

CONCLUSIONS

A list of significant childhood conditions has been created using UK and Irish expert consensus, for research purposes, for the first time. This will be used as the benchmark endpoint list for future research into PEWS/safety systems performance in EDs.

Refining and testing the diagnostic accuracy of an assessment tool (PAT-POPS) to predict admission and discharge of children and young people who attend an emergency department: protocol for an observational study

BACKGROUND

Increasing attendances by children (aged 0-16 years) to United Kingdom Emergency Departments (EDs) challenges patient safety within the National Health Service (NHS) with health professionals required to make complex judgements on whether children attending urgent and emergency care services can be sent home safely or require admission. Health regulation bodies have recommended that an early identification systems should be developed to recognise children developing critical illnesses. The Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score (PAT-POPS) was developed as an ED-specific tool for this purpose. This study aims to revise and improve the existing tool and determine its utility in determining safe admission and discharge decision making.

METHODS/DESIGN

An observational study to improve diagnostic accuracy using data from children and young people attending the ED and Urgent Care Centre (UCC) at three hospitals over a 12 month period. The data being collected is part of routine practice; therefore opt-out methods of consent will be used. The reference standard is admission or discharge. A revised PAT-POPs scoring tool will be developed using clinically guided logistic regression models to explore which components best predict hospital admission and safe discharge. Suitable cut-points for safe admission and discharge will be established using sensitivity and specificity as judged by an expert consensus meeting. The diagnostic accuracy of the revised tool will be assessed, and it will be compared to the former version of PAT-POPS using ROC analysis.

DISCUSSION

This new predictive tool will aid discharge and admission decision-making in relation to children and young people in hospital urgent and emergency care facilities.

TRIAL REGISTRATION

NIHR RfPB Grant: PB-PG-0815-20034. ClinicalTrials.gov: 213469. Retrospectively registered on 11 April 2018.

A prospective, mixed-methods, before and after study to identify the evidence base for the core components of an effective Paediatric Early Warning System and the development of an implementation package containing those core recommendations for use in the UK: Paediatric early warning system - utilisation and mortality avoidance- the PUMA study protocol

BACKGROUND

In hospital, staff need to routinely monitor patients to identify those who are seriously ill, so that they receive timely treatment to improve their condition. A Paediatric Early Warning System is a multi-faceted socio-technical system to detect deterioration in children, which may or may not include a track and trigger tool. It functions to monitor, detect and prompt an urgent response to signs of deterioration, with the aim of preventing morbidity and mortality. The purpose of this study is to develop an evidence-based improvement programme to optimise the effectiveness of Paediatric Early Warning Systems in different inpatient contexts, and to evaluate the feasibility and potential effectiveness of the programme in predicting deterioration and triggering timely interventions.

METHODS

This study will be conducted in two district and two specialist children's hospitals. It deploys an Interrupted Time Series (ITS) design in conjunction with ethnographic cases studies with embedded process evaluation. Informed by Translational Mobilisation Theory and Normalisation Process Theory, the study is underpinned by a functions based approach to improvement. Workstream (1) will develop an evidence-based improvement programme to optimise Paediatric Early Warning System based on systematic reviews. Workstream (2) consists of observation and recording outcomes in current practice in the four sites, implementation of the improvement programme and concurrent process evaluation, and evaluation of the impact of the programme. Outcomes will be mortality and critical events, unplanned admission to Paediatric Intensive Care (PICU) or Paediatric High Dependency Unit (PHDU), cardiac arrest, respiratory arrest, medical emergencies requiring immediate assistance, reviews by PICU staff, and critical deterioration, with qualitative evidence of the impact of the intervention on Paediatric Early Warning System and learning from the implementation process.

DISCUSSION

This paper presents the background, rationale and design for this mixed methods study. This will be the most comprehensive study of Paediatric Early Warning Systems and the first to deploy a functions-based approach to improvement in the UK with the aim to improve paediatric patient safety and reduce mortality. Our findings will inform recommendations about the safety processes for every hospital treating paediatric in-patients across the NHS.

TRIAL REGISTRATION

Sponsor: Cardiff University, 30-36 Newport Road, Cardiff, CF24 0DE Sponsor ref.: SPON1362-14. Funder: National Institute for Health Research, Health Services & Delivery Research Programme (NIHR HS&DR) Funder reference: 12/178/17. Research Ethics Committee reference: 15/SW/0084 [13/04/2015]. PROSPERO reference: CRD42015015326 [23/01/2015].

ISRCTN

94228292 https://doi.org/10.1186/ISRCTN94228292 [date of application 13/05/2015; date of registration: 18/08/2015]. Prospective registration prior to data collection and participant consent commencing in September 2014.

Analysing healthcare coordination using translational mobilization

Purpose

The purpose of this paper is to introduce translational mobilization theory (TMT) and explore its application for healthcare quality improvement purposes.

Design/methodology/approach

TMT is a generic sociological theory that explains how projects of collective action are progressed in complex organizational contexts. This paper introduces TMT, outlines its ontological assumptions and core components, and explores its potential value for quality improvement using rescue trajectories as an illustrative case.

Findings

TMT has value for understanding coordination and collaboration in healthcare. Inviting a radical reconceptualization of healthcare organization, its potential applications include: mapping healthcare processes, understanding the role of artifacts in healthcare work, analyzing the relationship between content, context and implementation, program theory development and providing a comparative framework for supporting cross-sector learning.

Originality/value

Poor coordination and collaboration are well-recognized weaknesses in modern healthcare systems and represent important risks to quality and safety. While the organization and delivery of healthcare has been widely studied, and there is an extensive literature on team and inter-professional working, we lack readily accessible theoretical frameworks for analyzing collaborative work practices. TMT addresses this gap in understanding.

Implementing paediatric early warning scores systems in the Netherlands: future implications

Background

Paediatric Early Warning Scores (PEWS) are increasingly being used for early identification and management of clinical deterioration in paediatric patients. A PEWS system includes scores, cut-off points and appropriate early intervention. In 2011, The Dutch Ministry of Health advised hospitals to implement a PEWS system in order to improve patient safety in paediatric wards. The objective of this study was to examine the results of implementation of PEWS systems and to gain insight into the attitudes of professionals towards using a PEWS system in Dutch non-university hospitals.

Methods

Quantitative data were gathered at start, midway and at the end of the implementation period through retrospective patient record review (n = 554). Semi-structured interviews with professionals (n = 8) were used to gain insight in the implementation process and experiences. The interviews were transcribed and analysed using an inductive approach.

Results

Looking at PEWS systems of the five participating hospitals, different parameters and policies were found. While all hospitals included heart rate and respiratory rate, other variables differed among hospitals. At baseline, none of the hospitals used a PEWS system. After 1 year, PEWS were recorded in 69.2% of the patient records and elevated PEWS resulted in appropriate action in 49.1%. Three themes emerged from the interviews: 1) while the importance of using a PEWS system was acknowledged, professionals voiced some doubts about the effectiveness and validity of their PEWS system 2) registering PEWS required little extra effort and was facilitated by PEWS being integrated into the electronic patient record 3) Without a national PEWS system or guidelines, hospitals found it difficult to identify a suitable PEWS system for their setting. Existing systems were not always considered applicable in a non-university setting.

Conclusions

After 1 year, hospitals showed improvements in the use of their PEWS system, although some were decidedly more successful than others. Doubts among staff about validity, effectiveness and communication with other hospitals during transfer to higher level care hospital might hinder sustainable implementation. For these purposes the development of a national PEWS system is recommended, consisting of a “core set” of PEWS, cut-off points and associated early intervention.

Pediatric Early Warning System Scores: Lessons to be Learned

The objective was to evaluate the use of a pediatric early warning system (PEWS) score in Dutch general and university hospitals, 4 years after the introduction of a national safety program in which the implementation of a PEWS was advised. An electronic cross-sectional survey was used. All general and university hospitals ( n  = 91) with a pediatric department in The Netherlands were included in the study. The response rate was 100%. Three-quarters of all Dutch hospitals were using a PEWS score in the pediatric department. A wide variation in the parameters was found leading to 45 different PEWS scores. Almost all PEWS scores were invalidated, self-designed, or modified from other PEWS scores. In one-third of the hospitals with an emergency room, a PEWS was used with a wide variation in the parameters leading to 20 different PEWS scores, the majority of which are invalidated. Three-quarters of the hospitals did implement a PEWS score. The majority implemented an invalidated PEWS score. This may lead to a false sense of security or even a potentially dangerous situation. Although these systems are intuitively experienced as useful, the scientific evidence in terms of hospital mortality reduction and patient safety improvement is lacking. It is recommended to establish a national working group to coordinate the development, validation, and implementation of a wide safety program and a PEWS usable for both general and university hospitals.

A multicentre, randomised intervention study of the Paediatric Early Warning Score: study protocol for a randomised controlled trial

Background

Patients’ evolving critical illness can be predicted and prevented. However, failure to identify the signs of critical illness and subsequent lack of appropriate action for patients developing acute and critical illness remain a problem. Challenges in assessing whether a child is critically ill may be due to children’s often uncharacteristic symptoms of serious illness. Children may seem relatively unaffected until shortly before circulatory and respiratory failure and cardiac arrest.

The Bedside Paediatric Early Warning Score has been validated in a large multinational study and is used in two regions in Denmark. However, healthcare professionals experience difficulties in relation to measuring blood pressure and to the lack of assessment of children’s level of consciousness. In addition, is it noteworthy that in 23,288-hour studies, all seven items of the Bedside Paediatric Early Warning Score were recorded in only 5.1% of patients.

This trial aims to compare two Paediatric Early Warning Score (PEWS) models to identify the better model for identifying acutely and critically ill children. The hypothesis is that the Central Denmark Region PEWS model is superior to the Bedside PEWS in terms of reducing unplanned transfers to intensive care or transfers from regional hospitals to the university hospital among already hospitalised children.

Methods/design

This is a multicentre, randomised, controlled clinical trial where children are allocated to one of two different PEWS models. The study involves all paediatric departments and one emergency department in the Central Denmark Region. The primary outcome is unplanned transfer to the paediatric intensive care unit or transfer from regional hospitals to the university hospital. Based on preliminary data, 14,000 children should be included to gain a power of 80% (with a 5% significance level) and to detect a clinically significant difference of 30% of unplanned transfers to intensive care or from regional hospitals to the paediatric department at the university department. A safety interim analysis will be performed after inclusion of 7000 patients.

Discussion

This is the first randomised trial to investigate two different PEWS models. This study demonstrates the safety and effectiveness of a new PEWS model and contributes to knowledge of hospitalised children’s clinical deterioration.

Trial registration

ClinicalTrials.gov, NCT02433327. Registered on 27 April 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2011-7) contains supplementary material, which is available to authorized users.

Accuracy and Efficiency of Recording Pediatric Early Warning Scores Using an Electronic Physiological Surveillance System Compared With Traditional Paper-Based Documentation

Pediatric Early Warning Scores are advocated to assist health professionals to identify early signs of serious illness or deterioration in hospitalized children. Scores are derived from the weighting applied to recorded vital signs and clinical observations reflecting deviation from a predetermined "norm." Higher aggregate scores trigger an escalation in care aimed at preventing critical deterioration. Process errors made while recording these data, including plotting or calculation errors, have the potential to impede the reliability of the score. To test this hypothesis, we conducted a controlled study of documentation using five clinical vignettes. We measured the accuracy of vital sign recording, score calculation, and time taken to complete documentation using a handheld electronic physiological surveillance system, VitalPAC Pediatric, compared with traditional paper-based charts. We explored the user acceptability of both methods using a Web-based survey. Twenty-three staff participated in the controlled study. The electronic physiological surveillance system improved the accuracy of vital sign recording, 98.5% versus 85.6%, P < .02, Pediatric Early Warning Score calculation, 94.6% versus 55.7%, P < .02, and saved time, 68 versus 98 seconds, compared with paper-based documentation, P < .002. Twenty-nine staff completed the Web-based survey. They perceived that the electronic physiological surveillance system offered safety benefits by reducing human error while providing instant visibility of recorded data to the entire clinical team.

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

OBJECTIVE

To 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 children.

METHOD

The electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised.

RESULTS

From a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration.

CONCLUSIONS

Despite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.

Early warning- and track and trigger systems for newborn infants: A review

Tools for clinical assessment and escalation of observation and treatment are insufficiently established in the newborn population. We aimed to provide an overview over early warning- and track and trigger systems for newborn infants and performed a nonsystematic review based on a search in Medline and Cinahl until November 2015. Search terms included 'infant, newborn', 'early warning score', and 'track and trigger'. Experts in the field were contacted for identification of unpublished systems. Outcome measures included reference values for physiological parameters including respiratory rate and heart rate, and ways of quantifying the extent of deviations from the reference. Only four neonatal early warning scores were published in full detail, and one system for infants with cardiac disease was considered as having a more general applicability. Temperature, respiratory rate, heart rate, SpO₂, capillary refill time, and level of consciousness were parameters commonly included, but the definition and quantification of 'abnormal' varied slightly. The available scoring systems were designed for term and near-term infants in postpartum wards, not neonatal intensive care units. In conclusion, there is a limited availability of neonatal early warning scores. Scoring systems for high-risk neonates in neonatal intensive care units and preterm infants were not identified.

Cohort study to test the predictability of the NHS Institute for Innovation and Improvement Paediatric Early Warning System

OBJECTIVE

To test the predictability of the National Health Service Institute for Innovation and Improvement (NHSIII) Paediatric Early Warning System (PEWS) score to identify children at risk of developing critical illness.

DESIGN

Cohort study.

SETTING

Admissions to all paediatric wards at the University Hospital of Wales between 1 December 2005 and 30 November 2006.

OUTCOME MEASURES

Unscheduled paediatric high dependency unit (PHDU) admission, paediatric intensive care unit (PICU) admission and death.

RESULTS

There were 9075 clinical observations from 1000 children. An NHSIII PEWS score of 2 or more, which triggers review, has a sensitivity of 73.2% (95% CI 62.2% to 82.4%), specificity of 75.2% (95% CI 74.3% to 76.1%), positive predictive value (PPV) of 2.6% (95% CI 2.0% to 3.4%), negative predictive value of 99.7% (95% CI 99.5% to 99.8%) and positive likelihood ratio of 3.0 (95% CI 2.6 to 3.4) for predicting PHDU admission, PICU admission or death. Six (37.5%) of the 16 children with an adverse outcome did not have an abnormal NHSIII PEWS score. The area under the receiver operating characteristic curve for the NHSIII PEWS score was 0.83 (95% CI 0.77 to 0.88).

CONCLUSIONS

The NHSIII PEWS has a low PPV and its full implementation would result in a large number of false positive triggers. The issue with PEWS scores or triggers is neither their sensitivity nor children with high scores which require clinical interventions who are not 'false positives'; but their low specificity and low PPV arising from the large number of children with low but raised scores.

[Results of applying a paediatric early warning score system as a healthcare quality improvement plan]

OBJECTIVES

The 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 METHODS

An 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.

RESULTS

The 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.

CONCLUSIONS

PEWS 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.

Scoring systems in paediatric emergency care: Panacea or paper exercise?

Scoring systems to recognise the most ill patients, or those at risk of deterioration, are increasingly utilised in hospitals that look after paediatric inpatients. There have been efforts to implement these systems in emergency and urgent care settings, but they have yet unproven value. This is because the child or young person presenting acutely is a different cohort than the 'treated' ward-based group. The majority of children presenting to emergency and urgent care settings are discharged home, and so, scoring systems need to recognise the most unwell but also assist in safe and appropriate discharge as well as highlighting those patients in need of more senior review. This article explores this conundrum, suggesting how cognitive factors have a role to play, and how scoring systems can have wider effects than just individual patient care.

Alterations to calling criteria for Between the Flags (an early warning system)

Early warning systems aim to detect clinical deterioration of patients at an early stage. Between the Flags was introduced in New South Wales Health for this purpose. When patients are transferred from the emergency department to the ward, there are circumstances when the calling criteria need to be altered to take into account the clinical context. It is recognised that confusion exists among junior medical staff about the process of making alterations to the Between the Flags calling criteria.

A quality improvement project was implemented by undertaking a baseline survey of junior medical staff, providing education and training (to junior medical staff on the existing guidelines for making alteration to the calling criteria), and conducting a post-implementation survey.

A baseline survey demonstrated that 74% of junior medical staff had received no education on making alterations and only 5% knew how long their alterations would last once the patient was transferred to the ward. This has potentially serious consequences for patient safety following transfer.

After implementation of training, we found that 63% of junior medical staff were aware of the guidelines on making alterations and 50% knew how long their alterations would last once the patient was transferred to the ward. We conclude that educating junior medical staff improved knowledge on the guidelines for making alterations to calling criteria.

Pediatric Early Warning Score and unplanned readmission to the pediatric intensive care unit

BACKGROUND AND OBJECTIVES

Early unplanned Pediatric Intensive Care Unit (PICU) readmission is associated with greater length of stay and mortality. No tools exist to identify children at risk for PICU readmission. The Pediatric Early Warning Score (PEWS) currently identify children at risk for deterioration on the ward. Our primary objective was to evaluate the ability of PEWS to identify children at risk for unplanned PICU readmission.

METHODS

A single-center case-control study of 189 children (38 cases and 151 age-matched controls) 18years or younger transferred from the PICU to the pediatric ward from January 1, 2010-March 30, 2013, at an urban tertiary care children's hospital was conducted.

RESULTS

Thirty-eight cases had unplanned PICU readmission within 48hours of transfer to pediatric ward, whereas 151 controls were not readmitted. The PEWS assigned prior to PICU discharge and first PEWS assigned on the ward were collected for cases and controls. Each 1-point increase in the PEWS score significantly increased risk of PICU readmission (odds ratios [95% confidence intervals], 1.6 [1.12-2.27; P = .009] and 1.89 [1.33-2.69; P < .001], respectively). Discrimination ability of PEWS for PICU readmission improved when chronic diagnoses were included.

CONCLUSIONS

Higher PEWS scores were associated with increased risk of unplanned PICU readmission. However, cutoff scores are not sensitive or specific enough to be clinically useful. Adding chronic disease variables may improve the clinical utility of cutoff PEWS scores.