Early warning scores in paediatrics: an overview

National survey conducted among Italian pediatricians examining the therapeutic management of croup

OBJECTIVES

Practice-to-recommendations gaps exist in croup management and have not been critically investigated. This study examined the therapeutic management of croup among a national sample of Italian pediatric providers.

METHODS

A survey was administered online to a sample of primary care and hospital-based pediatricians. Demographic data, perception regarding disease severity, treatment and knowledge of croup, choices of croup treatment medications, and knowledge of and adherence to treatment recommendations were compared between hospital and primary care pediatricians. Oral corticosteroids alone, oral corticosteroids with or without nebulized epinephrine and nebulized epinephrine plus oral or inhaled corticosteroids were considered the correct management in mild, moderate and severe croup, respectively. The determinants for correct management were examined using multivariate logistic regression analysis.

RESULTS

Six hundred forty-nine pediatricians answered at least 50% of the survey questions and were included in the analysis. Providers reported extensive use of inhaled corticosteroids for mild and moderate croup. Recommended treatment for mild, moderate and severe croup was administered in 46/647 (7.1%), 181/645 (28.0%) and 263/643 (40.9%) participants, respectively. Provider's age and knowledge of Westley Croup Score were significant predictors for correct management of mild croup. Being a hospital pediatrician and perception of croup as a clinically relevant condition were significant for moderate croup.

CONCLUSIONS

Significant differences exist between recommended guidelines and clinical practice in croup management. This study suggests wide variability in both the treatment of croup and clinical decision making strategies among hospital and primary care pediatricians. Addressing this issue could lead to noteworthy clinical and economic benefits.

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

BACKGROUND

Paediatric early warning score systems are used for early detection of clinical deterioration of patients in paediatric wards. Several paediatric early warning scores have been developed, but most of them are not suitable for children with cyanotic CHD who are adapted to lower arterial oxygen saturation.

AIM

The present study compared the original paediatric early warning system of the Royal College of Physicians of Ireland with a modification for children with cyanotic CHD.

DESIGN

Retrospective single-centre study in a paediatric cardiology intermediate care unit at a German university hospital.

RESULTS

The distribution of recorded values showed a significant shift towards higher score values in patients with cyanotic CHD (p < 0.001) using the original score, but not with the modification. An analysis of sensitivity and specificity for the factor "requirement of action" showed an area under the receiver operating characteristic for non-cyanotic patients of 0.908 (95% CI 0.862-0.954). For patients with cyanotic CHD, using the original score, the area under the receiver operating characteristic was reduced to 0.731 (95% CI 0.637-0.824, p = 0.001) compared to 0.862 (95% CI 0.809-0.915, p = 0.207), when the modified score was used. Using the critical threshold of scores ≥ 4 in patients with cyanotic CHD, sensitivity and specificity for the modified score was higher than for the original (sensitivity 78.8 versus 72.7%, specificity 78.2 versus 58.4%).

CONCLUSION

The modified score is a uniform scoring system for identifying clinical deterioration, which can be used in children with and without cyanotic CHD.

The use of information technology to improve interdisciplinary communication during infectious diseases ward rounds on the paediatric intensive care unit

Prospective audit with feedback during infectious diseases ward rounds (IDWR) is a common antimicrobial stewardship (AMS) practice on the Paediatric Intensive Care Unit (PICU). These interdisciplinary meetings rely on the quality of handover, with high risk of omission of information. We developed an electronic platform integrating infection-related patient data (COSARAPed). In the mixed PICU of a Belgian tertiary hospital we conducted an observational prospective cohort study comparing patient handovers during IDWRs using the COSARAPed-platform to those with access only to conventional resources. The quality of handover was investigated directly by assessment if the narrative was in accordance with Situation-Background-Assessment-Recommendation principles and if adequate demonstration of diagnostic information occurred, and also indirectly by registration if this was only achieved after intervention by the non-presenting AMS team members. We also recorded all AMS-recommendations. During a 6-month study period, 24 IDWRs and 82 patient presentations were assessed. We could only find a statistically significant advantage in favor of COSARAPed by indirect evaluation. We registered 92 AMS-recommendations, mainly resulting in reduced antibiotic pressure. We concluded that the IDWR is an appropriate platform for AMS on the PICU and that the utilisation of COSARAPed may enhance the quality of patient handover.

Adverse cardiovascular events are common during dexmedetomidine administration in neonates and infants during intensive care

AIM

This study aimed to assess the safety of a commonly used sedative, dexmedetomidine in neonates and infants during intensive care.

METHODS

A retrospective cohort study was conducted in the paediatric intensive care unit at Oulu University Hospital. The study population consisted of all children from birth up to 6 months of age who received dexmedetomidine during 2010-2016. Adverse cardiovascular outcomes were defined as abnormal heart rates or blood pressure values according to the Paediatric Early Warning Score.

RESULTS

Of the 172 infants, 56% had congenital malformation, and 48% had undergone surgery. Neonates and 1-3-month-olds experienced bradycardia (86% vs. 73% in 1-3-month-olds and 50% in 3-6-month-olds, p = 0.001) and severe bradycardia (17% vs. 14% in 1-3-month-olds and 0% in 3-6-month-olds, p = 0.005) more often than older patients. The median maximum rate of dexmedetomidine infusion was 0.86 μg/kg/h (IQR = 0.60-1.71 μg/kg/h). A dose-dependent increase in bradycardia and severe hypotension was found. Adverse cardiovascular events were managed with additional fluid boluses and discontinuation of the infusion.

CONCLUSION

Adverse cardiovascular events were common during dexmedetomidine administration in neonates and infants. Lower dexmedetomidine doses may be required in sedating neonates.

Lactate as a Screening Tool for Critical Illness in a Pediatric Emergency Department

OBJECTIVES

Lactate has in some pediatric emergency departments (PEDs) gained acceptance as a screening tool for critical illness, with cut-off values of 2.0 to 2.5 mmol/L. We aimed to investigate if lactate could predict the need of acute resuscitation in patients in a PED.

PATIENTS AND METHODS

This retrospective observational cohort study included patients aged 0 to 17 years admitted to the PED at Copenhagen University Hospital in Denmark from January 1, 2019 to January 1, 2021. Patients were included if they had lactate measured as part of their routine blood sampling because of acute PED evaluation. Area under the receiver operating characteristic (ROC) curve (AUC) was calculated to assess the ability of lactate to predict the need of acute resuscitation. In patients without need of acute resuscitation, we calculated the lactate upper limit as the 95th percentile, and significant predictors were included in a multiple linear regression model.

RESULTS

A total of 1355 children were included. Fourteen (1%) children with a need of acute resuscitation had a median lactate of 1.7 mmol/L (interquartile range, 1.4-2.3) versus 1.6 mmol/L (interquartile range, 1.3-2.1) in children without need of resuscitation ( P > 0.05). The AUC for lactate to predict acute resuscitation was 0.56 (95% confidence interval, 0.54-0.59). In children without need of acute resuscitation, the 95th percentile of lactate was 3.2 mmol/L, and 392 (29.8%) had lactate greater than 2.0 mmol/L. Increasing age and venous sampling were associated with lower lactate. Lactate was not associated with sex, pediatric early warning score, or duration of hospital admission. The 95th percentile of lactate after inhaled beta-2-agonists was 5.0 mmol/L.

CONCLUSIONS

In children evaluated in a PED, lactate achieved a low AUC, suggesting a poor ability of predicting acute resuscitation. In children without need of acute resuscitation, the 95th percentile for lactate was 3.2 mmol/L, higher than the generally accepted cut-off values. This is important to recognize to avoid concern in otherwise clinically stable children. Our data did not support the use of lactate as a screening tool for early recognition of critical illness in a PED.

The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration

OBJECTIVES

Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program.

DESIGN

Retrospective cohort study.

SETTING

Nationwide Children's Hospital, a freestanding, quaternary-care, academic children's hospital in Columbus, OH.

PATIENTS

All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization.

INTERVENTIONS

We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021.

MEASUREMENTS AND MAIN RESULTS

The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001).

CONCLUSIONS

The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.

Validation of a modified bedside Pediatric Early Warning System score for detection of clinical deterioration in hospitalized pediatric oncology patients: A prospective cohort study

BACKGROUND

Hospitalized pediatric oncology patients are at risk of severe clinical deterioration. Yet Pediatric Early Warning System (PEWS) scores have not been prospectively validated in these patients. We aimed to determine the predictive performance of the modified BedsidePEWS score for unplanned pediatric intensive care unit (PICU) admission and cardiopulmonary resuscitation (CPR) in this patient population.

METHODS

We performed a prospective cohort study in an 80-bed pediatric oncology hospital in the Netherlands, where care has been nationally centralized. All hospitalized pediatric oncology patients aged 0-18 years were eligible for inclusion. A Cox proportional hazard model was estimated to study the association between BedsidePEWS score and unplanned PICU admissions or CPR. The predictive performance of the model was internally validated by bootstrapping.

RESULTS

A total of 1137 patients were included. During the study, 103 patients experienced 127 unplanned PICU admissions and three CPRs. The hazard ratio for unplanned PICU admission or CPR was 1.65 (95% confidence interval [CI]: 1.59-1.72) for each point increase in the modified BedsidePEWS score. The discriminative ability was moderate (D-index close to 0 and a C-index of 0.83 [95% CI: 0.79-0.90]). Positive and negative predictive values of modified BedsidePEWS score at the widely used cutoff of 8, at which escalation of care is required, were 1.4% and 99.9%, respectively.

CONCLUSION

The modified BedsidePEWS score is significantly associated with requirement of PICU transfer or CPR. In pediatric oncology patients, this PEWS score may aid in clinical decision-making for timing of PICU transfer.

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

Pediatric patients with cardiovascular disease are at increased risk of cardiopulmonary arrest. Despite utilization of Cardiac Pediatric Early Warning Scores to identify patients at risk of decompensation, our institution had a twofold increase in cardiac arrests (CAs) in the acute care cardiology unit (ACCU) over 2 years. Through a quality improvement initiative, we developed a watcher program, HeartWatch, to reduce the CA arrest rate in the ACCU by 50% over the first year of implementation.

METHODS

HeartWatch aims to identify patients not adequately captured by Cardiac Pediatric Early Warning Scores who are at high risk for sudden decompensation. Inclusion criteria were developed and evaluated during pilot and implemented phases (April 2020-April 2021) and then monitored in a sustained phase through June 2022. Our primary outcome was the reduction in the out-of-ICU CA rate.

RESULTS

During the 13 months, we enrolled 169 patients, and the CA rate decreased from 0.7 to 0.33 per 1,000 patient days, a 53% reduction. The CA rate further decreased to 0.28 events per 1,000 patient days, a 60% reduction, by June 2022. The most common indications for HeartWatch inclusion were high-risk single-ventricle patients (31%) and patients with diminished ventricular function (20%).

CONCLUSIONS

Implementation of HeartWatch was associated with a meaningful reduction in CA in the ACCU. Creating shared mental models for high-risk patients is essential for patient safety. Future work will optimize local processes that focus on the sustainability of our gains. We will also evaluate opportunities to adapt and implement a similar framework in other institutions to assess reproducibility.

Evaluating a novel, integrative dashboard for health professionals' performance in managing deteriorating patients: a quality improvement project

BACKGROUND

The quality of recording and documentation of deteriorating patient management by health professionals has been challenged during the COVID-19 pandemic. Non-adherence to escalation and documentation guidelines increases risk of serious adverse events. Electronic health record (EHR)-integrated dashboards are auditing tools of patients' status and clinicians' performance, but neither the views nor the performance of health professionals have been assessed, relating to management of deteriorating patients.

OBJECTIVE

To develop and evaluate a real-time dashboard of deteriorating patients' assessment, referral and therapy.

SETTINGS

Five academic hospitals in the largest National Health Service (NHS) trust in the UK (Barts Health NHS Trust).

INTERVENTION

The dashboard was developed from EHR data to investigate patients with National Early Warning Score (NEWS2)>5, assessment, and escalation of deteriorating patients. We adopted the Plan, Do, Study, Act model and Standards for Quality Improvement Reporting Excellence framework to evaluate the dashboard.

DESIGN

Mixed methods: (1) virtual, face-to-face, interviews and (2) retrospective descriptive EHR data analysis.

RESULTS

We interviewed three nurses (two quality and safety and one informatics specialists). Participants perceived the dashboard as a facilitator for auditing NEWS2 recording and escalation of care to improve practice; (2) there is a need for guiding clinicians and adjusting data sources and metrics to enhance the functionality and usability. Data analysis (2019-2022) showed: (1) NEWS2 recording has gradually improved (May 2021-April 2022) from 64% to 83%;(2) referral and assessment completion increased (n: 170-6800 and 23-540, respectively).

CONCLUSION

The dashboard is an effective real-time data-driven method for improving the quality of managing deteriorating patients. Integrating health systems, a wider analysis NEWS2 and escalation of care metrics, and clinicians' learning digital solutions will enhance functionality and experience to boost its value. There is a need to examine the generalisability of the dashboard through further validation and quality improvement studies.

Postoperative general medical ward admission following Chiari malformation decompression

OBJECTIVE

Prior to 2019, the majority of patients at Children's Hospital Colorado were admitted to the pediatric intensive care unit (PICU) following Chiari malformation (CM) decompression surgery. This study sought to identify the safety and efficacy of postoperative general ward management for these patients.

METHODS

After a retrospective baseline assessment of 150 patients, a quality improvement (QI) initiative was implemented, admitting medically noncomplex patients to the general ward postoperatively following CM decompression. Twenty-one medically noncomplex patients were treated during the QI intervention period. All patients were assessed for length of stay, narcotic use, time to ambulation, and postoperative complications.

RESULTS

PICU admission rates postoperatively decreased from 92.6% to 9.5% after implementation of the QI initiative. The average hospital length of stay decreased from 3.4 to 2.6 days, total doses of narcotic administration decreased from 12.3 to 8.7, and time to ambulation decreased from 1.8 to 0.9 days. There were no major postoperative complications identified that were unsuitable for management on a conventional pediatric medical/surgical nursing unit.

CONCLUSIONS

Medically noncomplex patients were safely admitted to the general ward postoperatively at Children's Hospital Colorado after decompression of CM. This approach afforded decreased length of stay, decreased narcotic use, and decreased time to ambulation, with no major postoperative complications.

Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America

BACKGROUND

Pediatric early warning systems (PEWS) aid in the early identification of deterioration in hospitalized children with cancer; however, they are under-used in resource-limited settings. The authors use the knowledge-to-action framework to describe the implementation strategy for Proyecto Escala de Valoracion de Alerta Temprana (EVAT), a multicenter quality-improvement collaborative, to scale-up PEWS in pediatric oncology centers in Latin America.

METHODS

Proyecto EVAT mentored participating centers through an adaptable implementation strategy to: (1) monitor clinical deterioration in children with cancer, (2) contextually adapt PEWS, (3) assess barriers to using PEWS, (4) pilot and implement PEWS, (5) monitor the use of PEWS, (6) evaluate outcomes, and (7) sustain PEWS. The implementation outcomes assessed included the quality of PEWS use, the time required for implementation, and global program impact.

RESULTS

From April 2017 to October 2021, 36 diverse Proyecto EVAT hospitals from 13 countries in Latin America collectively managing more than 4100 annual new pediatric cancer diagnoses successfully implemented PEWS. The time to complete all program phases varied among centers, averaging 7 months (range, 3-13 months) from PEWS pilot to implementation completion. All centers ultimately implemented PEWS and maintained high-quality PEWS use for up to 18 months after implementation. Across the 36 centers, more than 11,100 clinicians were trained in PEWS, and more than 41,000 pediatric hospital admissions had PEWS used in their care.

CONCLUSIONS

Evidence-based interventions like PEWS can be successfully scaled-up regionally basis using a systematic approach that includes a collaborative network, an adaptable implementation strategy, and regional mentorship. Lessons learned can guide future programs to promote the widespread adoption of effective interventions and reduce global disparities in childhood cancer outcomes.

LAY SUMMARY

Pediatric early warning systems (PEWS) are clinical tools used to identify deterioration in hospitalized children with cancer; however, implementation challenges limit their use in resource-limited settings. Proyecto EVAT is a multicenter quality-improvement collaborative to implement PEWS in 36 pediatric oncology centers in Latin America. This is the first multicenter, multinational study reporting a successful implementation strategy (Proyecto EVAT) to regionally scale-up PEWS. The lessons learned from Proyecto EVAT can inform future programs to promote the adoption of clinical interventions to globally improve childhood cancer outcomes.

Differentiating vaccine reactions from invasive bacterial infections in young infants presenting to the emergency department in the 4CMenB era: a retrospective observational comparison

BACKGROUND

Differentiating infants with adverse events following immunisation (AEFIs) or invasive bacterial infection (IBI) is a significant clinical challenge. Young infants post vaccination are therefore often admitted to the hospital for parenteral antibiotics to avoid missing rare cases of IBI.

METHODS

During a service evaluation project, we conducted a single-centre retrospective observational study of infants with IBI, urinary tract infection (UTI) or AEFI from two previously published cohorts. All patients presented to hospital in Oxfordshire, UK, between 2011 and 2018, spanning the introduction of the capsular group-B meningococcal vaccine (4CMenB) into routine immunisation schedules. Data collection from paper and electronic notes were unblinded. Clinical features, including National Institute for Health and Care Excellence (NICE) 'traffic light' risk of severe illness and laboratory tests performed on presentation, were described, and comparisons made using regression models, adjusting for age and sex. We also compared biochemical results on presentation to those of well infants post vaccination, with and without 4CMenB regimens.

RESULTS

The study included 232 infants: 40 with IBI, 97 with probable AEFI, 24 with possible AEFI, 27 with UTI and 44 post vaccination 'well' infants. C-reactive protein (CRP) was the only discriminatory blood marker, with CRP values above 83 mg/L only observed in infants with IBI or UTI. NICE risk stratification was significantly different between groups but still missed cases of IBI, and classification as intermediate risk was non-differential. Fever was more common in probable AEFI cases, while seizures and rashes were equally frequent. Diarrhoea and clinician-reported irritability or rigours were all more common in IBI.

CONCLUSIONS

Clinical features on presentation may aid risk stratification but cannot reliably differentiate IBI from AEFI in infants presenting to the emergency department. Blood results are generally unhelpful due to post vaccination inflammatory responses, particularly in children receiving 4CMenB vaccination. Improved biomarkers and clinical prediction tools are required to aid management in febrile infants post vaccination.

Pediatric Early Warning Systems (PEWS) improve provider-family communication from the provider perspective in pediatric cancer patients experiencing clinical deterioration

BACKGROUND

Communication between providers and patients' families is an integral part of clinical care. Family concern is a validated component of Pediatric Early Warning Systems (PEWS); however, little is known about the impact of PEWS on provider-family communication.

METHODS

Semi-structured interviews were conducted with 83 ward and Pediatric Intensive Care Unit (PICU) providers involved in the care of patients with deterioration at two pediatric oncology hospitals of different resource levels: St. Jude Children's Research Hospital (n = 42) in the United States and Unidad Nacional de Oncología Pediátrica (UNOP, n = 41) in Guatemala. Interviews were conducted in the participants' native language (English or Spanish), transcribed, and translated into English. Transcripts were coded by two researchers and analyzed for thematic content surrounding family communication and concern.

RESULTS

All participants recognized patients' families as a valuable part of the care team, particularly during events requiring escalation of care. Perceived barriers to communication included limited time spent at the bedside, and, at UNOP, language and literacy challenges which occasionally limited providers' ability to assess family concern and involve families in patient care. Despite these barriers, providers perceived PEWS improved communication by facilitating more interaction with families, allowing for relationship-building, anticipatory guidance, and destigmatization of the PICU. PEWS assessments also allowed families to contribute to identification of deterioration.

CONCLUSIONS

PEWS improve the quality of communication between providers and families by providing more opportunities for interaction, building relationships, and trust. These findings further support the use of PEWS in the care of children with cancer in hospitals of all resource-levels.

Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis

Aim

We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS?

Methods

We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias.

Results

Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies.

Conclusions

Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems.

PROSPERO registration: CRD42021269579.

Prognostic value of National Early Warning Score and Modified Early Warning Score on intensive care unit readmission and mortality: A prospective observational study

Background

Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) are widely used in predicting the mortality and intensive care unit (ICU) admission of critically ill patients. This study was conducted to evaluate and compare the prognostic value of NEWS and MEWS for predicting ICU readmission, mortality, and related outcomes in critically ill patients at the time of ICU discharge.

Methods

This multicenter, prospective, observational study was conducted over a year, from April 2019 to March 2020, in the general ICUs of two university-affiliated hospitals in Northwest Iran. MEWS and NEWS were compared based on the patients’ outcomes (including mortality, ICU readmission, time to readmission, discharge type, mechanical ventilation (MV), MV duration, and multiple organ failure after readmission) using the univariable and multivariable binary logistic regression. The receiver operating characteristic (ROC) curve was used to determine the outcome predictability of MEWS and NEWS.

Results

A total of 410 ICU patients were enrolled in this study. According to multivariable logistic regression analysis, both MEWS and NEWS were predictors of ICU readmission, time to readmission, MV status after readmission, MV duration, and multiple organ failure after readmission. The area under the ROC curve (AUC) for predicting mortality was 0.91 (95% CI = 0.88–0.94, P < 0.0001) for the NEWS and 0.88 (95% CI = 0.84–0.91, P < 0.0001) for the MEWS. There was no significant difference between the AUC of the NEWS and the MEWS for predicting mortality (P = 0.082). However, for ICU readmission (0.84 vs. 0.71), time to readmission (0.82 vs. 0.67), MV after readmission (0.83 vs. 0.72), MV duration (0.81 vs. 0.67), and multiple organ failure (0.833 vs. 0.710), the AUCs of MEWS were significantly greater (P < 0.001).

Conclusion

National Early Warning Score and MEWS values of >4 demonstrated high sensitivity and specificity in identifying the risk of mortality for the patients’ discharge from ICU. However, we found that the MEWS showed superiority over the NEWS score in predicting other outcomes. Eventually, MEWS could be considered an efficient prediction score for morbidity and mortality of critically ill patients.

Development and External Validation of a Machine Learning Model for Prediction of Potential Transfer to the PICU

OBJECTIVES

Unrecognized clinical deterioration during illness requiring hospitalization is associated with high risk of mortality and long-term morbidity among children. Our objective was to develop and externally validate machine learning algorithms using electronic health records for identifying ICU transfer within 12 hours indicative of a child's condition.

DESIGN

Observational cohort study.

SETTING

Two urban, tertiary-care, academic hospitals (sites 1 and 2).

PATIENTS

Pediatric inpatients (age <18 yr).

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Our primary outcome was direct ward to ICU transfer. Using age, vital signs, and laboratory results, we derived logistic regression with regularization, restricted cubic spline regression, random forest, and gradient boosted machine learning models. Among 50,830 admissions at site 1 and 88,970 admissions at site 2, 1,993 (3.92%) and 2,317 (2.60%) experienced the primary outcome, respectively. Site 1 data were split longitudinally into derivation (2009-2017) and validation (2018-2019), whereas site 2 constituted the external test cohort. Across both sites, the gradient boosted machine was the most accurate model and outperformed a modified version of the Bedside Pediatric Early Warning Score that only used physiologic variables in terms of discrimination ( C -statistic site 1: 0.84 vs 0.71, p < 0.001; site 2: 0.80 vs 0.74, p < 0.001), sensitivity, specificity, and number needed to alert.

CONCLUSIONS

We developed and externally validated a novel machine learning model that identifies ICU transfers in hospitalized children more accurately than current tools. Our model enables early detection of children at risk for deterioration, thereby creating opportunities for intervention and improvement in outcomes.

Evaluation of Pulse Rate, Oxygen Saturation, and Respiratory Effort after Different Types of Feeding Methods in Preterm Newborns

Background

During the initial days of hospitalization, preterm newborns are given combinations of breastfeeding, spoon/paladai feeding, and/or gavage feeding. Each method of feeding may have a different effect on vital parameters.

Objective

To study changes in vital parameters in relation to different feeding methods and postmenstrual age (PMA) in preterm newborns. Study Design. This prospective observational study was carried out at a tertiary care neonatal unit. Participants. Physiologically stable preterm newborns with PMA less than 37 weeks on full enteral feeds were included in the study. Intervention. None. Outcomes. Respiratory rate (RR), pulse rate (PR), oxygen saturation (SPO2), nasal flaring, and lower chest indrawing were monitored before and up to 3 h after the breastfeeding/spoon (paladai) feeding/gavage feeding or their combinations. These vital parameters were assessed in relation to the feeding methods and PMA groups using ANOVA.

Results

A total of 383 records were analyzed from 110 newborns. No infant developed chest indrawing or nasal flaring after any feeding method. During the 3 h period of monitoring, vital parameters changed significantly except in the gavage feeding group. The mean PR did not change, but the mean RR and SPO2 changed significantly at different PMA.

Conclusion

Vital parameters changed after different types of feeding methods and at different PMA. A further multicentric prospective study is needed to understand the effect of different feeding methods and PMA on vital parameters.

The predictive performance and impact of pediatric early warning systems in hospitalized pediatric oncology patients-A systematic review

Pediatric early warning systems (PEWS) arewidely used to identify clinically deteriorating patients. Hospitalized pediatric oncology patients are particularly prone to clinical deterioration. We assessed the PEWS performance to predict early clinical deterioration and the effect of PEWS implementation on patient outcomes in pediatric oncology patients. PubMED, EMBASE, and CINAHL databases were systematically searched from inception up to March 2020. Quality assessment was performed using the Prediction model study Risk-Of-Bias Assessment Tool (PROBAST) and the Cochrane Risk-of-Bias Tool. Nine studies were included. Due to heterogeneity of study designs, outcome measures, and diversity of PEWS, it was not possible to conduct a meta-analysis. Although the studies reported high sensitivity, specificity, and area under the receiver operating characteristics curve (AUROC) of PEWS detecting inpatient deterioration, overall risk of bias of the studies was high. This review highlights limited evidence on the predictive performance of PEWS for clinical deterioration and the effect of PEWS implementation.

Accessibility of e-EWSS versus Manual EWSS for Detecting the Emergency Condition among Patients with Coronavirus Disease 2019: A Survey Research on Register Nurse in Indonesia

BACKGROUND: The early warning scoring system (EWSS) during the coronavirus disease 2019 (COVID-19) pandemic is essential, because it will reduce the risk of organ damage and the death of patients with COVID-19. Health professionals argue that EWSS will be needed in electronic form, because it will be easier to use and quick to identify patient conditions in an emergency situation. There is no study that provides information on the comparison between the use of Electronic EWSS (e-EWSS) and manual EWSS in accessibility among health professionals in a clinical setting. AIM: The purpose of this study was to analyze the difference of accessibility of e-EWSS versus manual EWSS through survey research on registered nurses in Indonesia. METHODS: A survey research was designed in this study. A study was conducted from July to November 2021 on 38 nurses at the COVID-19 referral hospital in Mataram city. Data were collected by a questionnaire containing 12 questions related to the accessibility of e-EWSS and manual EWSS in 19 participants on intervention and 19 participants in the control group. RESULTS: The response to the accessibility of e-EWSS was more positive, namely, 64.5%, while the negative accessibility response was 35.5%. On the other hand, for EWSS, the response to accessibility was more negative, namely, 51.6%, while the response to accessibility was positive as much as 48.4%. The accessibility of emergency examinations of patients with COVID-19 using the e-EWSS was easier than the EWSS with p = 0.000. CONCLUSION:e-EWSS was easier in accessibility compared to EWSS by convenience, speed, and effectiveness indicators. The computerized system on the e-EWSS was capable of performing calculations automatically about patients’ emergency situations.

Evaluating a community respiratory physiotherapy service for children with neurodisability

BACKGROUND

Children with neurodisability are at an increased risk of respiratory problems and complications, which often result in prolonged, frequent hospital admissions and are the biggest cause of mortality in this client group. The Children's Community Respiratory Physiotherapy Service (CCRPS) was established in 2010 to support children with severe neurodisabilities at home during acute chest infections and to prevent emergency department attendances and hospital admissions. This service evaluation looked at patient/parent satisfaction and prevented admissions to ensure clinical and cost-effectiveness, despite the rising demand for the service.

METHODS

Over a 3-month period, patients and parents/carers on the CCRPS caseload were given a Picker feedback survey following 100 emergency visits from the team. The number of prevented hospital admissions for respiratory tract infection over 12 months (April 2019-March 2020) was identified from existing CCRPS data and hospital admissions costs saved were estimated.

RESULTS

The Picker survey responses were extremely positive with all respondents reporting that they felt well looked after and that the main reason for the emergency visit was dealt with well. Based on key indicators, the CCRPS prevented 182 hospital admissions for respiratory tract infection in 2019/2020, equating to 1638 bed days and estimated cost savings ranging between £751 728 and £1 009 986.

CONCLUSIONS

The Picker survey response demonstrates the positive impact that the CCRPS has on both quality of life and experience for patients and families. The CCRPS rapid response service prevents hospital admissions for respiratory tract infections in children and young people with severe neurodisability and the cost savings from admissions prevented allows the service to more than pay for itself.

A Single-Center Retrospective Evaluation of Unplanned Pediatric Critical Care Upgrades

Background Inappropriate triage of critically ill pediatric patients can lead to poor outcomes and suboptimal resource utilization. This study aimed to determine and describe the demographic characteristics, diagnostic categories, and timing of unplanned upgrades to the pediatric intensive care unit (PICU) that required short (< 24 hours of care) and extended (≥ 24 hours of care) stays. In this article, we hypothesized that we will identify demographic characteristics, diagnostic categories, and frequent upgrade timing periods in both of these groups that may justify more optimal triage strategies.

Methods This was a single-institution retrospective study of unplanned PICU upgrades between 2012 and 2018. The cohort was divided into two groups (short and extended PICU stay). We reviewed the electronic health record and evaluated for: demographics, mortality scores, upgrade timing (7a-3p, 3p-11p, 11p-7a), lead-in time (time spent on clinical service before upgrade), patient origin, and diagnostic category.

Results Four hundred and ninety-eight patients' unplanned PICU upgrades were included. One hundred and nine patients (21.9%) required a short and 389 (78.1%) required an extended PICU stay. Lead-in time (mean, standard deviation) was significantly lower in the short group (0.65 ± 0.66 vs. 0.91 ± 0.82) (p = 0.0006). A higher proportion of short group patients (59, 46.1%) were upgraded during the 3p-11p shift (p = 0.0077).

Conclusion We found that approximately one-fifth of PICU upgrades required less than 24 hours of critical care services, were more likely to be transferred between 3p-11p, and had lower lead-in times. In institutions where ill pediatric patients can be admitted to either a PICU or a monitored step-down unit, this study highlights quality improvement opportunities, particularly in recognizing which pediatric patients truly need critical care.

Anticipating Pediatric Patient Transfers From Intermediate to Intensive Care

OBJECTIVES

To explore characteristics of patients who were admitted to the intermediate care (IC) unit at a tertiary academic institution. In particular, we sought to compare the characteristics of IC patients who were transferred with the characteristics of those who were not transferred to PICU care and evaluate predictors of patient transfer.

METHODS

Data were collected on all admitted IC patients between July 2016 and June 2018. Patients whose index IC admission was from the PICU were excluded. Data collected included demographics and physiologic characteristics: heart rate, respiratory rate, temperature, oxygen therapy, as well as Bedside Pediatric Early Warning System (BPEWS) score.

RESULTS

In this time period, 427 eligible patient visits occurred, with 66 patients (15.46%) being transferred to the PICU. Patients were commonly transferred early in their IC course (1.41 days into admission [0.66-3.87]); transferred patients had higher median admission BPEWS scores (7 [4.25-9] vs 5 [3-7]; P < .01). In the univariate analysis, no individual physiologic characteristic was predictive for transfer. In the multivariate analysis, BPEWS (P < .001) and need for any form of respiratory support (P = .04) were significant predictive factors for transfer (R ² = 0.56).

CONCLUSIONS

The need for close monitoring of physiologic parameters remains paramount, especially in the first 48 hours of admission, in predicting the need for transfer from the IC to PICU. The need for any form of respiratory support is predictive of transfer. Situational awareness and assessment including BPEWS score is of critical importance.

Pediatric Resuscitation

This article describes evidence-based nursing practices for detecting pediatric decompensation and prevention of cardiopulmonary arrest and outlines the process for effective and high-quality pediatric resuscitation and postresuscitation care. Primary concepts include pediatric decompensation signs and symptoms, pediatric resuscitation essential practices, and postresuscitation care, monitoring, and outcomes. Pediatric-specific considerations for family presence during resuscitation, ensuring good outcomes for medically complex children in community settings, and the role of targeted temperature management, continuous electroencephalography, and the use of extracorporeal membrane oxygenation in pediatric resuscitation are also discussed.

Identifying the critically ill paediatric oncology patient: a study protocol for a prospective observational cohort study for validation of a modified Bedside Paediatric Early Warning System score in hospitalised paediatric oncology patients

INTRODUCTION

Hospitalised paediatric oncology patients are at risk to develop acute complications. Early identification of clinical deterioration enabling adequate escalation of care remains challenging. Various Paediatric Early Warning Systems (PEWSs) have been evaluated, also in paediatric oncology patients but mostly in retrospective or case-control study designs. This study protocol encompasses the first prospective cohort with the aim of evaluating the predictive performance of a modified Bedside PEWS score for non-elective paediatric intensive care unit (PICU) admission or cardiopulmonary resuscitation in hospitalised paediatric oncology patients.

METHODS AND ANALYSIS

A prospective cohort study will be conducted at the 80-bed Dutch paediatric oncology hospital, where all national paediatric oncology care has been centralised, directly connected to a shared 22-bed PICU. All patients between 1 February 2019 and 1 February 2021 admitted to the inpatient nursing wards, aged 0-18 years, with an International Classification of Diseases for Oncology (ICD-O) diagnosis of paediatric malignancy will be eligible. A Cox proportional hazard regression model will be used to estimate the association between the modified Bedside PEWS and time to non-elective PICU transfer or cardiopulmonary arrest. Predictive performance (discrimination and calibration) will be assessed internally using resampling validation. To account for multiple occurrences of the event of interest within each patient, the unit of study is a single uninterrupted ward admission (a clinical episode).

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional ethical review board of our hospital (MEC protocol number 16-572/C). We adapted our enrolment procedure to General Data Protection Regulation compliance. Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Netherlands Trial Registry (NL8957).

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.

Association of transcutaneous CO2 with respiratory support: a prospective double blind observational study in children with bronchiolitis and reactive airway disease

The use of clinical scoring to assess for severity of respiratory distress and respiratory failure is challenging due to subjectivity and interrater variability. Transcutaneous Capnography (TcpCO₂) can be used as an objective tool to assess a patient’s ventilatory status. This study was designed to assess for any correlation of continuous monitoring of TcpCO₂ with the respiratory clinical scores and deterioration in children admitted for acute respiratory distress. A prospective observational study over one year on children aged 2 weeks to 5 years admitted with acute respiratory distress or failure secondary to Bronchiolitis and Reactive airway disease was performed. Continuous TcpCO₂ monitoring for upto 48 h was recorded. Investigators, bedside physicians, respiratory therapists, and nurses were blinded from the transcutaneous trends at the time of data collection. Total of 813 TcpCO₂ measurements at standard intervals of 30 min were obtained on 38 subjects. Subjects with abnormal TcpCO₂ (> 45 mmHg) were younger (6.9 ± 5.2 vs. 23.05 ± 17.7 months,) and were more likely to be on higher oxygen flow rate (0.52 L/min/kg vs 0.46 lier/min/kg, p = 0.004) and higher FiO₂ (38.4 vs 33.6, p < 0.001 using heated high flow nasal cannula. No difference was found in bronchiolitis score or PEW score in subjects with normal and abnormal TcpCO₂. A small but statistically significant increase in TcpCO₂ was observed at the escalation of care. Even though odds of escalation of care are higher with abnormal TcpCO₂ (OR 1.92), this difference did not reach statistical significance. pCO₂ can provide additive information for non-invasive clinical monitoring of children requiring varying respiratory support; however, it does not provide predictive value for escalation or de-escalation of care.

Update on early warning scores

Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.

A Prospective Cohort Study of the Clinical Predictors of Bacteremia in Under-Five Children With Acute Undifferentiated Fever Attending a Secondary Health Facility in Northwestern Nigeria

BACKGROUND

Children with acute febrile illness with no localizing signs often receive antibiotics empirically in most resource-poor settings. However, little is known about the burden of bacteremia in this category of patients, and an appraisal is thus warranted. This will guide clinical practice and promote rational antibiotics use.

METHODS

We prospectively followed up 140 under-five children who presented with acute undifferentiated fever at the emergency/outpatient pediatric unit of a secondary healthcare facility. Baseline clinical and laboratory information was obtained and documented in a structured questionnaire. We compared baseline characteristics between participants with bacteremia and those without bacteremia. We further fitted a multivariable logistic regression model to identify factors predictive of bacteremia among the cohort.

RESULT

The prevalence of bacteremia was 17.1%, and Salmonella Typhi was the most frequently (40.9%) isolated pathogen. The majority (78.6%) of the study participants were managed as outpatients. The participants who required admission were four times more likely to have bacteremia when compared to those managed as outpatients (AOR 4.08, 95% CI 1.19 to 14.00). There is a four times likelihood of bacteremia (AOR 4.75, 95% CI 1.48 to 15.29) with a fever duration of beyond 7 days. Similarly, participants who were admitted with lethargy were six times more likely to have bacteremia (AOR 6.20, 95% CI 1.15 to 33.44). Other significant predictors were tachypnea and lymphopenia.

CONCLUSION

Among under-five children with acute undifferentiated fever, longer duration of fever, lethargy, inpatient care, tachypnea, and lymphopenia were the significant predictors of bacteremia.

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

OBJECTIVES

Clinical deterioration in hospitalized children is associated with increased risk of mortality and morbidity. A prediction model capable of accurate and early identification of pediatric patients at risk of deterioration can facilitate timely assessment and intervention, potentially improving survival and long-term outcomes. The objective of this study was to develop a model utilizing vital signs from electronic health record data for predicting clinical deterioration in pediatric ward patients.

DESIGN

Observational cohort study.

SETTING

An urban, tertiary-care medical center.

PATIENTS

Patients less than 18 years admitted to the general ward during years 2009-2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome of clinical deterioration was defined as a direct ward-to-ICU transfer. A discrete-time logistic regression model utilizing six vital signs along with patient characteristics was developed to predict ICU transfers several hours in advance. Among 31,899 pediatric admissions, 1,375 (3.7%) experienced the outcome. Data were split into independent derivation (yr 2009-2014) and prospective validation (yr 2015-2018) cohorts. In the prospective validation cohort, the vital sign model significantly outperformed a modified version of the Bedside Pediatric Early Warning System score in predicting ICU transfers 12 hours prior to the event (C-statistic 0.78 vs 0.72; p < 0.01).

CONCLUSIONS

We developed a model utilizing six commonly used vital signs to predict risk of deterioration in hospitalized children. Our model demonstrated greater accuracy in predicting ICU transfers than the modified Bedside Pediatric Early Warning System. Our model may promote opportunities for timelier intervention and risk mitigation, thereby decreasing preventable death and improving long-term health.

Use of paediatric early warning scores in intermediate care units

OBJECTIVE

Paediatric early warning scores (EWS) were developed to detect deterioration in paediatric wards or emergency departments. The aim of this study was to assess the relationship between three paediatric EWS and clinical deterioration detected by the nurse in paediatric intermediate care units (PImCU).

METHODS

This was a prospective, observational, multicentre study at seven French regional hospitals that included all children <18 years of age. Clinical parameters included in three EWS (Paediatric Advanced Warning Score, Paediatric Early Warning Score and Bedside Paediatric Early Warning System) were prospectively recorded every 8 hours or in case of deterioration. The outcome was a call to physician by the nurse when a clinical deterioration was observed. The cohort was divided into derivation and validation cohorts. An updated methodology for repeated measures was used and discrimination was estimated by the area under the receiver-operating curve.

RESULTS

A total of 2636 children were included for 14 708 observations to compute a posteriori the EWS. The discrimination of the three EWS for predicting calls to physicians by nurses was good (range: 0.87-0.91) for the derivation cohort and moderate (range: 0.71-0.76) for the validation cohort. Equations for probability thresholds of calls to physicians, taking into account the time t, the score at time t and the score at admission, are available.

CONCLUSION

These three EWS developed for children in paediatric wards or emergency departments can be used in PImCU to detect a clinical deterioration and predict the need for medical intervention.

Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront

In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.