Early warning systems for identifying sick children

doi:10.1016/j.paed.2011.02.007

Paediatrics and Child Health

Volume 21, Issue 5, May 2011, Pages 230-233

https://doi.org/10.1016/j.paed.2011.02.007 Get rights and content

Abstract

Early warning scores are becoming increasingly topical and widespread in paediatrics. This article examines the evidence base behind them and reinforces the call for a nationally coordinated setup programme. We make the distinction between scores as trigger events for rapid review from a high dependency or critical care outreach team and the multilayered approach to risk reduction which we envisage by which an effective, audited and quality assured early warning system might be established.

Introduction

The Confidential Enquiry into Child Deaths in 2006 found that 26% had avoidable factors associated with them. The sample of cases subjected to case note review by multidisciplinary panels included 89 hospital deaths of which 19 had avoidable factors. One of the report’s recommendations was directed at this issue. It stated “For paediatric care in hospital we recommend a standardized and rational monitoring system with imbedded early identification systems for children developing critical illness – an early warning score”. This article attempts to explain why such a recommendation might have been made and how an institution should go about responding to it. We include examples from our own experience introducing early warning systems in a Children’s Hospital and District General Hospitals.

Section snippets

What is an early warning system?

An early warning system (EWS) creates all the necessary conditions to allow a bedside carer to summon expert help as and when required. If necessary such requests can bypass the normal chain of nursing or medical command and attract an immediate response. Hence there are two essential components of the system:

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a reliable method of early identification (afferent limb)
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an appropriate response (efferent limb) to a call for help from a team with the skills, competencies and experience to be of

Introducing an early warning system

There needs to be an understanding of the need for change at all levels in the institution of the sort that would induce a willingness to co-operate. This is where compliance with a national audit or research project would have the most use and where the CEMACH report had its greatest impact in our institution. Motivation also comes from public attention to institutional failures and, in our case, to audits of crash calls, unexpected ICU admissions and improved communication and dissemination

Evidence to support the use of early warning systems

It has been established that failure to recognize or respond appropriately to clinical deterioration can lead to life-threatening events including cardiopulmonary arrest in children and adults. Furthermore, early identification of potentially life-threatening events is possible and implementation of early warnings scores and response teams in paediatric hospitals has resulted in an increase in intensive care admissions, a reduction in cardiac and respiratory arrests and improved survival rates.

Choosing between early warning scores

There is no evidence or indeed consensus on the ideal score but it seems to us that a good warning score exploits appropriate, readily measurable parameters and combines them in a way that makes sense of the situation without introducing unnecessary complexity. The reports by Tibballs et al, Sharek et al, Hunt et al, Edwards et al, and Brilli et al relate to trigger scores. Monaghan, Duncan et al and Parshuram et al have published aggregate paediatric warning scores. Aggregate scores facilitate

What can we learn from implementation of adult early warning systems?

The development of EWS in the paediatric setting is a relatively new concept compared to the adult population. This gives us the opportunity to learn from the adult experience and use the benefit of hindsight to develop rational, paediatric systems on a national level. Unfortunately the evidence suggests that this opportunity is being missed. A survey performed in 2005 showed a 21% uptake of EWS within Trusts caring for children in the UK. However publications describing the development of

What needs to happen next?

With the demise of CEMACH, the future rational development and national implementation of “a standardized and rational monitoring system with imbedded early identification systems for children developing critical illness” will require comparable levels of clinical cooperation to those enjoyed by the confidential enquiries. Support and leadership from within the spheres of administration, training, audit and governance will be required. We recommend that the Royal Colleges of Paediatrics and

Conclusion

In order to be effective, a “paediatric early warning score” needs to be embedded into a “paediatric early warning system” with an effective response to each alert. A conscientious, comprehensive and standardized approach must be adopted to the observation and monitoring of hospitalized children. This should be linked to an administrative arm that reinforces the system, measures outcomes and reacts in order to optimize them. A national, multidisciplinary, collaborative approach to further

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Paediatric emergency scores have helped medical personnel to identify early signs of deterioration, thus bringing down the morbidity and mortality of children requiring more intensive care.
The objective of the study was to introduce an assessment score (Paediatric Emergency Warning Score PEWS) for all paediatric oncology patients admitted to the ward and to audit the accuracy of scoring done by the nursing staff.
The study also tried to find whether an emergency warning score could decrease the number of unplanned admissions to the PICU.
A number based PEWS was introduced to hospital over a period of 4 months. Case records were reviewed retrospectively before and after introduction of the PEWS.
Statistical analysis was done by Chi-square test.
PEWS was introduced from January 1 2018 to May 31st 2018 and 100% compliance in PEWS scoring was ensured. Out of the 234 admissions before introduction of the PEWS score, 14 children required to be shifted to Intensive unit. Out of this, 10 (4.2%) were planned and 4 (1.7%) were unplanned. Among the 727 admissions after the introduction of PEWS score, 28 were admitted for intensive care. There was only 1 (0.14%) unplanned admission during this period. There was a significant decrease in the unplanned admissions from 1.7% to 0.14% (p- <0.01%) after the introduction of PEWS score.
We could decrease the number of unplanned admissions in PICU after the introduction of PEWS score.
Results of applying a paediatric early warning score system as a healthcare quality improvement plan
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Introducir una escala de alerta clínica precoz en nuestra práctica habitual, evaluar su utilidad para prevenir el deterioro evitable en niños hospitalizados y capacitar al personal para comunicar la información y responder de forma efectiva.
Valoración de la aplicación de una escala de alerta clínica precoz incluida en la historia clínica electrónica, en pacientes hospitalizados de 0 a 15 años (febrero 2014-septiembre 2014). La puntuación máxima era 6. Se requería evaluación del personal de enfermería cuando era > 2 o conjunta médico-enfermera cuando era > 3. Indicadores de seguimiento: porcentaje de pacientes con escala; porcentaje de registros completos; porcentaje de escalas > 3; porcentaje de registros > 3 con aviso al médico; porcentaje de cambios de tratamiento derivados del aviso y pacientes trasladados a la unidad de cuidados intensivos pediátricos (UCIP) o fallecimientos no detectados por la escala.
La escala se aplicó al 100% de pacientes ingresados (931), realizándose 7.917 tomas, con el 78,8% de registros completos. El 1,9% de las tomas fueron > 3 y en el 70,5% se cumplió el aviso al médico. En el 14% de registros > 3 se registró intensificación del tratamiento o solicitud de pruebas complementarias. Un paciente precisó traslado a UCIP (puntuación 2) y no hubo fallecimientos. La preocupación de los familiares/personal quedó registrada en el 80% de tomas.
Las escalas de alerta clínica precoz infantil permiten homogeneizar la monitorización, unificar formularios y mejorar los registros. La escasa aparición de complicaciones graves que requieran ingreso en UCIP y fallecimientos obligan a buscar otras variables de resultado para su evaluación.
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.
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.
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.
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Citation Excerpt :
Other early warning systems to detect and respond to clinical deterioration have been developed for pediatric and adult populations and usually include some number of vital sign and laboratory abnormalities triggering notification of bedside caregivers and a rapid response team. Depending on the number of SIRS criteria and the thresholds for laboratory values such as serum lactate, these systems have a wide range of sensitivity and false positives [45,46]. Implementation of these early warning systems in various hospital settings has led to improved outcomes, including decreased time to antibiotic administration [47] and less progression to multi-organ failure [48].
Despite vigilant clinical assessment of infants in the neonatal intensive care unit (NICU), diagnosis of sepsis and necrotizing enterocolitis often does not occur until an infant has significant hemodynamic compromise. Predictive monitoring involves analysis of vital signs and other clinical data to identify infants at highest risk and to detect early-stage illness, leading to timelier treatment and improved outcomes. The first vital-sign predictive monitoring device developed for sepsis detection in babies in the NICU is the heart rate characteristics index (HeRO) monitor, which continuously analyzes the electrocardiogram signal for low heart rate variability and transient decelerations. Use of this monitor in very low birth weight infants (<1500 g) was shown in a large multicenter randomized clinical trial to significantly reduce mortality. The purpose of this review is (1) to summarize the physiologic changes in neonatal sepsis and progression to shock, (2) to review efforts toward risk stratification for sepsis shortly after birth based on demographic and physiologic scoring systems, (3) to describe development and implementation of heart rate characteristics monitoring and other important aspects of sepsis early warning systems, and (4) to provide an overview of current research analyzing multiple vital signs and other clinical variables in an attempt to develop even more effective predictive monitoring devices and systems.
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