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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 imp...
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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 compar...
Citations
... Uno de los sistemas más utilizados internacionalmente es el triaje, que permite elegir y clasificar a los pacientes para tratamiento en los diferentes niveles de urgencia médica mediante la implementación de escalas de alerta temprana, utilizadas por profesionales de enfermería, cuya utilización, de acuerdo con la evidencia, requiere poco esfuerzo adicional y un tiempo que permite garantizar una gestión eficiente de los recursos 3 . ...
... 32 x x 'Save of the day'* through evaluation during shift transfers. 33 x Contribution of risk stratification in detection of clinical deterioration. 5 6 9 34 x ...
... The degree of implementation of the Dutch PEWS. 33 x Outcome measurement defined by the participating hospital (optional). ...
Introduction
Early recognition of clinical deterioration and timely intervention are important to improve morbidity and mortality in paediatric care. The Paediatric Early Warning Score (PEWS) is a scoring system aiming to identify hospitalised children at risk for deterioration. Currently, there is a large heterogeneity of PEWS systems in the Netherlands, with a considerable number remaining unvalidated or self-designed. Therefore, a consensus-based Dutch PEWS has been developed in a national study using the Core Outcome Measures in Effectiveness Trials initiative. The Dutch PEWS is a uniform system that integrates a core set of vital parameters together with pre-existing risk factors and uses risk stratification to proactively follow-up on patients at risk (so-called ‘watcher patients’). This study aims to validate the Dutch PEWS and to determine its impact on improving patient safety in various hospital settings.
Methods and analysis
This national study will be a large multicentre evaluation study, in which the Dutch PEWS will be implemented and evaluated in 12 hospitals in the Netherlands. In this study, a mixed methods methodology will be used and evaluated on predefined outcome measures. To examine the validity of the Dutch PEWS, statistical analyses will be undertaken on quantitative data retrieved from electronic health records. Surveys among physicians and nurses; semistructured interviews with healthcare providers and parents; and daily evaluation forms are being conducted to determine the impact of the Dutch PEWS. The study is being conducted from December 2020 to June 2024.
... [4][5][6][7][8][9][10] Multiple PEWS have been implemented around the world with some evidence revealing improved outcomes in clinical deterioration recognition. [11][12][13][14][15] A study from 2017 suggested PEWS to be effective on predicting deterioration in different subspecialty acute care patients. 16 It has been applied in other contexts with good results, such as in the oncology field, 17-21 burn centres, 22 and in the peritransport setting. ...
Introdução:
Os Pediatric Early Warning Scores foram desenvolvidos como auxiliares clínicos padronizados para o reconhecimento precoce de agravamento clínico em crianças e aumentam o grau de alerta entre os profissionais. Uma das principais preocupações é o aumento da carga de trabalho. Após a implementação na Unidade de Internamento de Curta Duração, pretendemos avaliar a eficácia na nossa população.
Métodos:
Revimos retrospetivamente os registos médicos de crianças internadas na Unidade de Internamento de Curta Duração entre julho de 2017 e fevereiro de 2020 e executámos análise estatística do desempenho do teste.
Resultados:
Foram incluídos 1323 doentes (mediana das idades 3,07 anos); 5,7% agravaram clinicamente (mediana do score máximo 7,00 vs 2,00) (p <0,001). A área sob a curva ROC foi de 0,947. Utilizando 4 como valor de corte, a sensibilidade é de 97,1% (especificidade 82,7%).
Conclusão:
Este score é um bom teste para identificação precoce de agravamento clínico na nossa população.
... In the Netherlands, a recommendation by the Ministry of Health to introduce paediatric early warning scores was issued in 2011. 15 Only in Ireland a uniform paediatric early warning score is present, developed by the Royal College of Physicians with extensive material for implementation. 11 Therefore, we chose this scoring system as a basis. ...
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.
... Although PEWS are widely used in almost all Dutch hospitals there is no national consensus on which system to use [9]. Also, none of the PEWS reported in the literature has proven to be superior in the recognition of clinical deterioration [10,11]. ...
... This large heterogeneity and use of unvalidated systems within one country are also seen in other European countries such as the United Kingdom (UK) [7]. Furthermore, while healthcare professionals in the Netherlands intuitively believe PEWS may be helpful in early recognition, they have also raised doubt due to the lack of validation and evidence of the effectiveness of PEWS and this hampers the successful implementation of PEWS in clinical practice [9,13,14]. ...
... The vast heterogeneity of PEWS in the Netherlands also results in a missed opportunity to validate the PEWS in different hospital settings. Due to this lack of validation, healthcare professionals in the Netherlands found it difficult to choose or develop a PEWS suitable for their local setting [9]. At the same time, a recent inventory in all hospitals in the Netherlands revealed that 98% of the hospitals would use a standardized PEWS system when available [12]. ...
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.
... Overall HPs had positive 'affective attitudes' towards DETECT e-PEWS, welcomed its introduction and most overcame the initial problems they experienced. Nurses (D-VS and R-VS) had the most positive initial, and ongoing affective attitudes, whereas resistance by doctors to the use of DETECT e-PEWS was reported by all HPs; similar resistance is evident in other studies [16,35]. Nurses' positivity about DETECT e-PEWS reflected attributes reported in other studies including PEWS are systematic [36], reduce errors [9,35], save time [9] and provide a safety net [32] via an audit trail. ...
... Nurses (D-VS and R-VS) had the most positive initial, and ongoing affective attitudes, whereas resistance by doctors to the use of DETECT e-PEWS was reported by all HPs; similar resistance is evident in other studies [16,35]. Nurses' positivity about DETECT e-PEWS reflected attributes reported in other studies including PEWS are systematic [36], reduce errors [9,35], save time [9] and provide a safety net [32] via an audit trail. It demonstrated good clinical utility (it did what it was supposed to) with those who used it regularly. ...
... The perception of 'burden' depended on the HPs' level of engagement with DETECT e-PEWS and how much it benefited them in daily practice. The initial effort required to learn to navigate and use the system was quickly overcome for HPs in the D-VS group; the benefits accrued were clear cut and real time documentation was faster and not burdensome as seen in other studies of adopting PEWS [35]. However, the burden of carrying an extra device (R-VS group) was perceived as problematic by the doctors although not by the nurses. ...
Background
Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability.
Methods
A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts.
Results
Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits.
Conclusions
Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation.
... La principal causa del ED fue sepsis/choque séptico 64%, dificultad respiratoria 41% con una mortalidad de 29%. 8 Esta problemática ha motivado la búsqueda de estrategias para la identificación temprana del ED en el paciente pediátrico hospitalizado, implementando sistemas o herramientas de alerta temprana que permitan identificar el deterioro del paciente y realizar las intervenciones pertinentes, 9 con el objetivo de disminuir la morbilidad y el riesgo de mortalidad intrahospitalaria; su aplicación en pediatría está dirigida a aumentar la seguridad del paciente, denominándose estos sistemas Pediatric Early Warning Systems (PEWS) o Sistemas Pediátricos de Alerta Temprana, recomendándose el desarrollo y validación en cada institución para asistir al clínico en el reconocimiento de ED. 10,11 En estos sistemas, a mayor puntuación, mayor inestabilidad fisiológica, lo cual debería desencadenar una respuesta temprana por parte de un equipo o de un clínico especializado. 10 Varios grupos han propuesto una variedad de PEWS para ser aplicados en hospitales de todo el mundo, este sistema consta de dos componentes: la herramienta que calcula la puntuación a intervalos regulares durante el ingreso hospitalario del paciente; y un algoritmo de respuesta con intervenciones o evaluaciones por el equipo especializado a cargo del paciente. ...
Antecedentes: El proceso de validación de un sistema pediátrico de alerta temprana para predicción de riesgo de eventos de deterioro debe realizarse en cada institución.
Objetivo: Determinar si la Escala de Valoración de Alerta Temprana para
Honduras (EVATH) tiene utilidad predictiva para evento de deterioro en el paciente oncológico pediátrico hospitalizado.
Métodos: Estudio de casos y controles llevado a cabo en la sala de Hemato-Oncología Pediátrica, Hospital Escuela, mayo 2017 a mayo 2019 que incluyó un grupo caso, pacientes que presentaron evento de deterioro (44) y un grupo control, pacientes no evento de deterioro (88). Se utilizó puntaje/categoría EVATH para riesgo bajo 0-2, moderado 3-4, alto ≥5.
Resultados: Edad 7-12 años, 43.1% (19/44) grupo caso y 2-6 años, 34.1% (30/88) controles. Fueron masculinos 61.4% (27/44) grupo caso y femenino 52.3% (46/88) control. El diagnóstico fue Leucemia Linfoblástica Aguda grupo caso 50.0% (22/44) y controles 61.4% (54/88). La condición de egreso fue vivo en el grupo caso 75% (33/44) y 100.0% (88/88) en los controles. Los fallecimientos ocurrieron en el grupo caso
25% (11/44), (IC95% 13.2-40.3). La clasificación de riesgo según EVATH bajo riesgo 31.8% (14/44) grupo caso y 100.0% (88/88) en controles.
Discusión. Se identificó utilidad predictiva de evento de deterioro utilizando estratificación de riesgo en categorías (AUCROC=0.841; IC95% 79.1-93.4) o utilizando solo el puntaje (AUCROC=0.860; IC95% 0.776-0.943). El punto de corte de la EVATH se demostró en el puntaje ≥3 con sensibilidad de 68.2% (IC95% 53.3-83.08) y especificidad de 100% (IC95% 99.4-100) con VPN 86.8% (IC95% 79.1-93.4).
... There are numerous validated PEWS with varying accuracy in predicting deterioration [2,9,10,11]. The validation and research on PEWS are mostly done in high-resource settings [2,4,9,10,11,12], while the literature on PEWS in resourcelimited settings is scarce [13]. Implementing PEWS in highresource settings has not shown to result in significant reduction in child mortality, presumably because the baseline mortality is too low to measure the impact of a PEWS, but it results in better child attention [14,15]. ...
... Earlier research shows that the success of implementing clinical guidelines and systems can depend greatly on how much the new practitioner workflow differs from the prior workflow [12,19]. The results from this study comply with these findings, as the implementation rate in the paediatric ward drastically improved after adjusting it to resemble the previous manner of monitoring the patients more closely. ...
OBJECTIVES
Quantitative analysis of the implementation of the bedside paediatric early warning system (B‐PEWS) in a resource‐limited setting. The B‐PEWS serves to pre‐emptively identify hospitalised children who are at risk for cardiopulmonary arrest and subsequently to provide critical care in time.
METHODS
We performed a retrospective review through the medical data records of patients after discharge from the paediatric ward of a philanthropic hospital in Brazil. Nurses’ performance using the system was measured with various parameters.
RESULTS
A total of 499 patients were included, and a total of 8024 scores were checked. During the 21‐week research period, the implementation rate increased significantly from 66.5% (SD 26.0) in Period 1 to 93.1% (SD 16.6) in Period 2. The number of scores that resulted in a correct total score went from 7.5% in Period 1 to 32.2% in Period 2, p < 0.001. There was an improvement in the correct choice of age group between the two periods (from 32.2% to 53.4%). There was no difference in the mean admission time of patients in the two periods: in the first period 4.8 days (SD 2.9) and in the second period 4.8 days (SD 4.1).
CONCLUSIONS
It is possible to implement a PEWS in resource‐limited settings while achieving high implementation rates. However, this is a time‐ and energy‐consuming process. Having an active and involved team that is responsible for implementation is key for a successful implementation. Factors that likely hindered implementation were a large change in workflow for the nursing staff, non‐native speakers as main investigators.
... Now, most countries have accepted emergency scores as a part and parcel of clinical care after adequate validation. (4,5,6,7) Our study was a part of a clinical audit to test the effectiveness of a PEWS system in a paediatric oncology unit of a tertiary cancer centre in South India. ...
Introduction
Pediatric 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.
Aims
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 done to find whether an emergency warning score could decrease the number of unplanned admissions to the PICU.
Materials and methods
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.
Results
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.
Conclusion
We could decrease the number of unplanned admissions in PICU after the introduction of PEWS score.
... These limitations can increase the documentation burden and reduce the efficacy of such systems when data entry is delayed. 26 Initiatives have begun to investigate using objective variables available in real-time within the EHR to identify patients at high-risk for clinical deterioration. 24 Our objective was to develop and validate an automated and objective pediatric early warning score utilizing predictive analytics modeling techniques that would perform as well as, or better than, our institution's current standard, a modified version of Monaghan's PEWS (see Supplemental Digital Content at http://links.lww.com/ ...
Introduction:
Pediatric in-hospital cardiac arrests and emergent transfers to the pediatric intensive care unit (ICU) represent a serious patient safety concern with associated increased morbidity and mortality. Some institutions have turned to the electronic health record and predictive analytics in search of earlier and more accurate detection of patients at risk for decompensation.
Methods:
Objective electronic health record data from 2011 to 2017 was utilized to develop an automated early warning system score aimed at identifying hospitalized children at risk of clinical deterioration. Five vital sign measurements and supplemental oxygen requirement data were used to build the Vitals Risk Index (VRI) model, using multivariate logistic regression. We compared the VRI to the hospital's existing early warning system, an adaptation of Monaghan's Pediatric Early Warning Score system (PEWS). The patient population included hospitalized children 18 years of age and younger while being cared for outside of the ICU. This dataset included 158 case hospitalizations (102 emergent transfers to the ICU and 56 "code blue" events) and 135,597 control hospitalizations.
Results:
When identifying deteriorating patients 2 hours before an event, there was no significant difference between Pediatric Early Warning Score and VRI's areas under the receiver operating characteristic curve at false-positive rates ≤ 10% (pAUC10 of 0.065 and 0.064, respectively; P = 0.74), a threshold chosen to compare the 2 approaches under clinically tolerable false-positive rates.
Conclusions:
The VRI represents an objective, simple, and automated predictive analytics tool for identifying hospitalized pediatric patients at risk of deteriorating outside of the ICU setting.
