Eur J Pediatr
DOI 10.1007/s00431-014-2357-8
ORIGINAL ARTICLE
Validation of a Paediatric Early Warning Score:
first results and implications of usage
Joris Fuijkschot & Bastiaan Vernhout & Joris Lemson &
Jos M. T. Draaisma & Jan L. C. M. Loeffen
Received: 16 April 2014 / Revised: 27 May 2014 / Accepted: 29 May 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract Timely recognition of deterioration of hospitalised
children is important to improve mortality. We developed a
modified Paediatric Early Warning Score (PEWS) and studied
the effects by performing three different cohort studies using
different end points. Taking unplanned Paediatric Intensive
Care Unit admission as end point and only using data until 2 h
prior to end point, we found a sensitivity of 0.67 and specificity of 0.88 to timely recognise patients. This proves that
earlier identification is possible without a loss of sensitivity
compared to other PEWS systems. When determining the
corresponding clinical condition in patients with an elevated
PEWS dichotomously as ‘sick’ or ‘well’, this resulted in a
total of 27 % false-positive scores. This can cause motivational problems for caregivers to use the system but is a consequence of PEWS design to minimise false-negative rates
because of high mortality associated with paediatric resuscitation. Using the need for emergency medical interventions as
end point, sensitivity of PEWS is high and it seems, therefore,
that it is also fit to alert health-care professionals that urgent
interventions may be needed. Conclusion: These data show
the effectiveness of a modified PEWS in identifying critically
Communicated by Patrick Van Reempts
J. Fuijkschot (*) : B. Vernhout : J. M. T. Draaisma :
J. L. C. M. Loeffen
Department of Paediatrics, Radboudumc Amalia Children’s
Hospital, PO box 9101, 6500 HB Nijmegen, The Netherlands
e-mail: [email protected]
J. Lemson
Department of Intensive Care, Radboudumc Amalia Children’s
Hospital, PO box 9101, 6500 HB Nijmegen, The Netherlands
J. L. C. M. Loeffen
Institute for Warranted Quality and Patient Safety, Radboudumc
Amalia Children’s Hospital, PO box 9101, 6500 HB Nijmegen, The
Netherlands
ill patients in an early phase making early interventions possible and hopefully reduce mortality.
Keywords Paediatric Early Warning Score (PEWS) . Rapid
response systems . Early interventions . Situational awareness
Abbreviations
PEWS
PICU
SA
SSE
Paediatric Early Warning Score
Paediatric Intensive Care Unit
Situational awareness
Serious safety event
Introduction
Vital parameters of hospitalised patients may deteriorate due
to several reasons and subsequently require emergency interventions or intensive care treatment. Early detection of deterioration coupled to effective interventions will likely improve
outcome. In the past decade, adult medicine has developed
several early warning scoring systems and rapid response
systems in order to improve recognition of clinical deterioration in hospitalised patients, thereby improving outcome.
Validation studies have shown their effectiveness in identifying patients at risk for serious safety events (SSEs); however,
its effect upon reducing overall mortality has yet to be determined [10, 14].
In paediatrics, early recognition of deterioration of vital
parameters of hospitalised children is challenging because of
the age-related range of reference vital parameters. Hence, the
implementation of an unequivocal Paediatric Early Warning
Score (PEWS) may improve early recognition and situational
awareness amongst health-care professionals.
Eur J Pediatr
A frequently quoted clinically validated PEWS system has
been designed by Parshuram and colleagues [11]. This scoring
system which is based on seven vital parameters was prospectively validated in three Canadian and one UK children’s
hospital. Other, comparable PEWS systems validated in the
West-European setting are referred to as the Brighton and
Cardiff PEWS [1, 6]. Most systems have been validated
retrospectively and suffer from missing data caused by incomplete scores. Still, when defining cardiopulmonary arrest or
unplanned Paediatric Intensive Care Unit (PICU) admission
as end points, these systems have shown to detect critically ill
children at least minutes to 1 h prior to reaching these end
points [1, 6, 13, 15]. These scoring systems therefore seem to
be useful clinical tools.
Most early warning systems are designed to predict the risk
for cardiopulmonary arrest or unplanned PICU admission.
However, warning systems that also identify the need for
emergency medical interventions in an early phase enable
health-care professionals to respond earlier and possibly reverse clinical deterioration, thereby preventing unplanned
PICU admission.
In the Netherlands, experience with regard to fully implemented PEWS systems was lacking. We decided to design and
implement a PEWS system that was specified to our setting
and which was constructed using latest insights from both
paediatric and adult warning systems. Subsequently, we studied its effects upon several patient groups.
Aims and objectives
The aim of this study is to show the additional value of PEWS
systems in clinical practice towards patient safety and healthcare quality. Objectives are to validate this PEWS system for
its applicability in timely identification of ‘sick’ patients
(using different end points) and to study its capacity to identify
the need for emergency medical interventions.
Method
Setting
The Radboudumc Amalia Children’s Hospital is a tertiary
referral university hospital with three paediatric wards adding
up to a total of 77 beds and is located in the Eastern part of the
Netherlands. Yearly, it receives an average of 4,000 admissions at these wards where patients get highly specialised care
from a broad spectrum of surgical and non-surgical hospital
specialists. The same group of nurses with standardised paediatric qualifications and training cares for the patients. In case
of clinical deterioration of patients, monitoring of vital norm
parameters as well as various emergency medical
interventions (such as a fluid challenge or supplemental oxygen, etc.) can be performed in the ward. In case of further
deterioration towards a critically ill state, patients can be
transferred to a 10-bed, full facility PICU.
PEWS design and implementation
From 2011, a modified PEWS system was implemented on all
three paediatric wards. This scoring system was based on the
data from the Parshuram study. Strikingly however, despite
evidence that fever is an important factor in the prediction of
paediatric sepsis, neither the Parshuram scoring system nor the
Brighton PEWS includes body temperature [8, 16]. Data from
adult warning systems show the importance of temperature as
a key physiological parameter in predicting clinical deterioration [5]. We therefore decided to add temperature to our
scoring system (addition of maximal 2 points to the total score
of a patient) expecting to increase PEWS performance, especially in sepsis.
Other minor adjustments were made to adapt the system to
our setting and to improve user-friendliness. These included a
simplified definition of work of breathing (normal or mildly,
moderately, severely increased) and supplemental oxygen
(room air, low-flow or high-flow supplemental oxygen). Operational proceedings for staff regarding usage of the scoring
system in clinical practice were defined. This resulted in an
eight-parameter-based bedside PEWS system with a possible
scoring range of 0–28 points. All patients admitted to the
paediatric wards are routinely scored every 8 h unless their
clinical condition deteriorates in which case the frequency of
scoring is intensified. A score of 0–3 indicates no specific
actions from nursing staff. At a score of 4–7 points, the
scoring frequency is automatically increased, and if the score
exceeds 7, the nursing staff is instructed to immediately contact the medical team enabling it to promptly identify potential
clinical deterioration and treat accordingly. The threshold was
chosen based upon the data from the Parshuram study (threshold of 7 points to identify children at risk of cardiopulmonary
arrest; corresponding sensitivity 0.64 and specificity 0.91) and
the addition of an extra parameter (body temperature) to our
scoring system. For each age category, a separate card was
developed (0–3 months/3 months–1 year/1–4 years/4–
12 years/≥12 years). An example of one card is given in Fig. 1.
Study design and participants
To study the performance of our warning system in general and in selected patient cohorts, we performed three
different case cohort studies focusing on both the timely
identification of ‘sick’ patients (case cohort studies 1 and
2) and identification of patients in need for emergency
medical interventions (case cohort study 3).
Eur J Pediatr
Fig. 1 PEWS card for age
category 3 months–1 year
Paediatric Early Warning Score
Age: 3 months – 1 year
Score
Respiratory rate
(breaths/min)
Respiratory effort*
4
< 15
Pulse saturation in
room air
Supplemental oxygen
Heart rate (bpm)
Capillary refill time
(sternum)
Systolic blood
pressure (mmHg)
Temperature (°C)
2
15-19
<91%
1
20-29
91-94%
0
30-60
1
61-80
2
81-90
4
>90
normal
mildly ↑
moderate
↑
severely ↑
or apnoeic
NRB-mask
>94%
Room air
<80
80-89
90-109
110-150
< 3 seconds
151-180
Low flow
oxygen
181-190
<45
45-49
50-59
60-80
81-100
101-130
<36
36.0-36.4
>190
≥3
seconds
>130
36.5-37.5
37.6-38.5
>38.5
* respiratory effort: nasal flaring or retracons
Standard: Scoring frequency 1x per 8 hours| PEWS 3x 0-2: reduce scoring frequency to 1x per day
PEWS score ≥ 4 points or worried sign: increase PEWS frequency to 1x per 4 hours
PEWS score ≥ 6 points: increase PEWS frequency to 1x per hour
PEWS score ≥ 8 points: contact aending physician within 10 minutes or call PMET
PMET dial pager 2148 | Resuscitaon dial 55555
Identification of sick patients
Identification of need for critical care type interventions
Case cohort study 1 This study was performed to test the
scoring system’s general ability to identify sick patients.
Correlation between warning score and severity of illness
was studied by performing a retrospective database review of early warning scores in all patients admitted at
the 20-bed paediatric oncology ward over a 3-month
period. The study was performed on this ward because
it was the very first at which PEWS was implemented in
2011 and also because of the clinical nature of paediatric
oncology patients. Though their physiological responses
may differ from other patients, it was expected that a
higher number of sick patients could be encountered at
this ward, thereby improving chances of successful
validation.
Focus was on the clinical condition of patients with
alarming high scores (≥8). In addition, the effects of the
added body temperature parameter upon the scores were
studied in both patients with alarming high scores and a
randomly selected control group consisting of one third
of the patients with PEWS <4 at all times during
admission.
Case cohort study 3 To study the capacity of our modified
PEWS to identify patients in need for emergency medical
interventions, we prospectively evaluated warning scores in
all patients receiving emergency medical interventions (definition outlined in Table 1) at the paediatric wards over a 4month period.
Case cohort study 2 To compare our modified PEWS with
other existing scoring systems and validate PEWS performance in the general paediatric population, its performance
was studied retrospectively over a 9-month period. A selected
cohort of patients whose clinical course at any time during
their admission at the general ward had deteriorated towards
the commonly used end points ‘cardiopulmonary arrest’ and
‘unplanned PICU admission’.
Table 1 Definition of ‘sick’
Results
Because of differences in methods and studied populations,
we discuss our results for each cohort study separately.
Case cohort study 1
In 118/199 (59 %) admissions to the paediatric oncology
ward, the PEWS was correctly performed and could be used
for inclusion in the study (adding to a total of 1,115 separate
PEWS values). In 91/118 (77 %) admissions, the scores were
<4 (baseline score) at all times during their stay (control
Any of the following criteria:
- Clinical condition considered sick by the senior member of medical
staff and documented as such
- Critical care-type intervention (listed below) performed
- Any involvement of paediatric intensive care staff including
cardiopulmonary arrest
Eur J Pediatr
group). Even more, in 103/118 (87 %) cases, all the scores
were <8 (threshold score).
There were no cardiopulmonary arrests at the ward during
the study period. Unplanned PICU admission was only seen
one time. This patient scored a PEWS ≥8 pending from up to
4 h prior to admission. In the 81 (41 %) excluded admissions,
neither cardiopulmonary arrest nor unplanned PICU admission was seen, excluding selection bias.
Furthermore, PEWS≥8 was scored 56 times in 15/118
admissions (13 %) resulting in a specificity of 0.88 when
taking unplanned PICU admission as end point. Sensitivity
was calculated at 1.00; however, due to only one unplanned
PICU admission, this parameter is not reliable.
The corresponding clinical condition of an elevated PEWS
was dichotomously determined as ‘sick’ (Table 2) or ‘well’. In
41/56 scores, the clinical condition of the patient was ‘sick’,
resulting in a total of 15 (27 %) false-positive scores (‘well’
patients with PEWS ≥8) and a positive predictive value of
0.73. The clinical condition in the false-positive patients was
dominated by PEWS-influencing factors such as pain (n=6),
fever (n=1) or a combination of both (n=8).
Whether or not patients with a PEWS below threshold
score (<8) were actually in fact sick but managed without
paediatric intensive care involvement could not be ascertained
due to methodological difficulties. The volume of this group
and corresponding amount of PEWS values was very large.
Besides, the criteria of sick could only be derived from patients’ files manually, resulting in over a thousand separate
queries. However, with regard to the commonly used end
point unplanned PICU admission or cardiopulmonary arrest,
we could ascertain that these scores contained no false
negatives.
Fever contributed to the score in 17/41 (41 %) cases in
the sick patient group, indicating its importance as a
Table 2 Definition of emergency medical interventions
Airway/breathing interventions
- 100 % supplemental oxygen by non-rebreathing mask
- Airway opening manoeuvre or oropharyngeal/nasopharyngeal airway
patency
- Bag valve mask resuscitation
- Adrenaline nebulisation
Circulation interventions
- Fluid challenge
- Emergency transfusion of blood products
- Adrenaline administration intramuscular/intravenous
- Sepsis work-up (blood/urine/spinal fluid cultures followed by start of
parenteral broad spectrum antibiotics)
Other interventions
- Any paediatric intensive care staff involvement
- Cardiopulmonary resuscitation
contributing factor. In the control group (PEWS <4 at all
times during the admittance), fever had a much lower
prevalence of 22 % (based upon a randomly chosen sample of 32/91 (35 %) cases).
Case cohort study 2
No cardiopulmonary arrests occurred at the general paediatric
wards during the study period. Out of 36 patients who had an
unplanned admission to the PICU, 24 had sufficient data to
retrospectively reconstruct the course of the PEWS in the
hours prior to their PICU admission. Out of 24 patients, 16
scored PEWS of ≥8 at 2–6 h prior to PICU admission. The
overall median PEWS 2–6 h prior to PICU admission was 8.5
(range 2–15). When excluding patients with acute and unforeseen clinical deterioration in whom early detection is extremely difficult such as an anaphylactic reaction to parenteral
administered drugs (n=1), epileptic seizures (n=1) and unexpected arterial haemorrhage (n=1), the median PEWS increased to 9 (range 5–15). A detailed analysis of PEWS
performance in subgroups is given in Table 3. The sensitivity
of our PEWS in identifying patients 2–6 h prior to unplanned
PICU admission (threshold score ≥8) is calculated at 0.67. At
time of their admission to the PICU, all of the included
patients scored PEWS ≥8, indicating a further increase of
sensitivity in the remaining time prior to reaching end point.
Case cohort study 3
A total of 17 cases that received emergency medical interventions as previously defined at the paediatric wards were evaluated. It showed a median PEWS of 10 (range 8–15) in these
patients at the time of the intervention. Therefore, with a
threshold score of 8, no falsely negative warning scores could
be detected in this study, indicating a high sensitivity in
identifying these patients.
Table 3 PEWS performance divided in subgroups; end point unplanned
PICU admission
Patient characteristics
Number
Median score PEWS [range]a
All
< 3 months
3 months<1 year
1 year<4 years
4 years<12 years
≥12 years
Male
Female
24
6
5
5
3
5
11
13
8.5 [2–15]
7 [5–9]
9 [6–11]
9 [2–15]
10 [8–10]
8 [2–14]
7 [2–15]
9 [2–14]
a
Two to 6 h prior to unplanned PICU admission
Eur J Pediatr
child’s severity of illness and other end points (e.g. need for
emergency medical interventions) may as well identify sick
children, perhaps even in an earlier phase.
Discussion
Key findings
With this study, we show that our modified PEWS is capable
of a timely identification of patients at risk for unplanned
PICU admission, with comparable sensitivity (0.67 versus
0.64) and specificity (0.88 versus 0.91) towards the Parshuram
PEWS. Sensitivity is lower than the Brighton PEWS (0.85),
but validation studies of the Brighton PEWS include data up
and until reaching the end point, thus increasing the apparent
performance of this score [1].
Even more, by including data only up and until 2 h prior
to reaching end point (instead of 1 h in the Parshuram
study), we have shown that earlier identification is possible
without a loss of sensitivity of the scoring system. A
comparison between the original PEWS and the modified
PEWS studied here is given in Table 4.
It is possible that the parameter temperature has an additional value to this improved performance. Though this postulation cannot be backed up by data from this study, this is in
line with findings from other studies [4, 5].
On the other hand, fever has direct and indirect (through
elevation of heart and respiratory rates) effects upon the total
PEWS. This may influence the scoring system negatively and
result in an increased number of falsely positive PEWS values.
Nonetheless, in the control group, fever never lead to an
elevated PEWS, and in the sick-patient group, only one falsely
fever-related elevated PEWS was seen. It therefore appears
that fever as a single factor in otherwise clinically stable
patients does not increase the scores above the alarming
threshold.
This study shows the capacity of warning systems in not
only timely identifying the patients who are at risk for unplanned PICU admission but also towards identifying sick
patients and the need for emergency medical interventions.
This is relevant because the commonly used end point unplanned PICU admission is only a surrogate measure of a
Strengths and limitations
Most studies in literature regarding paediatric warning systems use the same end points (cardiopulmonary arrest or
unplanned PICU admission) when validating the system. This
study adds insight in the effectiveness of such warning systems when also taking different end points (sick patients and
need for critical care type intervention) in respect.
However, some limitations are to be made.
In both studies 1 and 2, there is a substantial rate of falsepositive scores. This is in line with findings from the
Parshuram study. It could indicate that the cut-off point for
alarming high PEWS at score ≥8 should be higher. However, a
higher cut-off point would result in more false-negative,
missed patients. In general, paediatric cardiopulmonary arrest
or unplanned PICU admission is associated with high mortality and significant neurological disability [7]. This makes a
higher rate of false-negative scores unacceptable. It is however crucial that caregivers realise the background of the chosen
cut-off point and its consequences to keep them motivated to
use the system despite the false-positive scores they
encounter.
Due to small patient numbers, considerations are to be
made when interpreting our data. Also, the retrospective case
cohort studies 1 and 2 suffered from missing data caused by
incomplete scores, like many other studies on this subject
[12]. In study 1, only 59 % of the admissions during the study
period had sufficient data to be included in the study. Missing
data to calculate PEWS or non-compliance to scoring protocol
(e.g. PEWS scoring frequency below standard) was the main
reason for exclusion. Nursing and medical staffs worked in
different filing systems in our hospital during the time of this
study. Because data from nursing files were often not secured
Table 4 Comparison of original
PEWS and modified PEWS
Modified PEWS
Original PEWS
(Parshuram et al.)
Threshold score PEWS
(alarming score)
Temperature scoring item
End point in validation studies
Data inclusion in validation studies
Specificity
Sensitivity
≥7 points
≥8 points
No
Cardiopulmonary
resuscitation
Unplanned PICU
admission
Ending 1 h before event
91 %
64 %
Yes
Unplanned PICU admission
Need for emergency medical interventions
Ending 2 h before event
88 %
67 %
Eur J Pediatr
after the discharge of the patient, this resulted in a loss of data
causing a rather high number of exclusions in study 2.
This all reflects on the difficulties systems like PEWS
encounter upon implementation. In general, nursing staff welcomed the PEWS system and protocol. It provided an easy
accessible data set (hence: knowledge) together with a
straightforward protocol describing how to respond in critical
situations. Adherence to the system proved however difficult
because of lacking user-friendliness (e.g. additional paperwork) and scepticism mainly amongst medical staff towards
the need of such a scoring system to identify sick children.
Though not many patients were missed by the system (unplanned PICU admission without elevated PEWS in the hours
preceding), these also demotivated staff to adhere to the
PEWS protocol. In the past years, we have put in efforts to
improve the system by improving user-friendliness by eliminating additional paperwork and creating a completely automated, electronic system. Also, nursing and medical staffs
now work in the same electronic filing system and there is
no data loss after discharge of the patient. The results given
here provided insights in PEWS performance and were used
to counter scepticism, especially regarding false-positive
scores. PEWS patterns were used in the methodological analysis of serious safety events. All together, this resulted in a
recent steep increase of compliance to the PEWS protocol. It
is our belief that implementation of systems like PEWS can
only be successful if performance data are continuously
shared with the users improving insights in its
(im)possibilities.
In our hospital, cardiopulmonary arrests seldom occur at
the wards most likely because of early interventions and
referral to the PICU, indicating a rather safe environment.
Yet, for our study, it resulted in the limitation that no data
from patients with cardiopulmonary arrest could be included.
In general, the usage of warning score systems is based
upon the assumption that earlier identification and subsequently interventions performed earlier lead to fewer SSEs
and reduction of morbidity and mortality. For this assumption
however, compelling evidence is lacking in literature [9, 12].
Validation studies as given here only show that PEWS is, to a
certain degree, capable of detecting sick patients (using different surrogates to define this) but potential direct effects
upon a reduction of morbidity and mortality as well as SSEs
are not measured. However, the survival of paediatric inhospital cardiopulmonary resuscitation has improved significantly over the past decades and relatively more resuscitations
take place at PICU’s than at normal paediatric wards [7]. This
is a trend also seen in our own hospital. It is postulated that the
use of early warning scores leads to earlier transfer to units
with closer patient monitoring that allows for more prompt
initiation of resuscitation efforts and hence PEWS indirectly
improves outcome in resuscitation. If this is the case, then
PEWS has added value in terms of cost efficiency and patient
safety. However, studies to prove such a direct relationship are
almost impossible to design and therefore lacking in literature.
The same implies to potential effects of warning score
systems on human factor competencies, especially on situational awareness (SA). Lessons learned from aviation and the
nuclear power industries have shown the importance of situational awareness to the human decision maker in complex
situations with high data flow and situational complexity [2,
16]. A recent study showed some additional benefits of early
warning systems upon team communication and handling of
critical care situations [3]. We believe that the implementation
of a warning system alone is not enough to reduce SSEs and
improve outcome in hospitals. This can only be accomplished
when the warning system is part of a safety culture
characterised by sufficient professional (team) training (focusing on both technical and non-technical skills) and that high
PEWS values are promptly detected by rapid response teams
and followed by interventions (emergency medical intervention or PICU admission). This should be considered when
implementing such a system in a hospital.
Implications of usage
In our setting, we recently integrated PEWS with other risk
factors of serious safety events (such as the worried sign and
family concern), resulting in a Paediatric Risk Evaluation and
Stratification System (PRESS). Each clinically admitted patient is stratified into a risk category (standard, medium or
high) with safety rules and protocol matching accordingly. A
software system that provides the clinician on call with real
time data of warning scores and risk categories from admitted
patients was developed. We expect that the system increases
SA and forthwith improving team performance. Of course, we
need data from pending research to back up these postulations.
Conclusion
This study shows that, by using a modified paediatric warning
system, health-care professionals are able to identify sick
patients in an earlier stage, thereby enabling them to possibly
prevent further clinical deterioration and improve outcome.
Conflict of interest No conflict of interest is to be reported.
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