The Brighton Paediatric Early
Warning Score
Alan Monaghan
Lecturer Practitioner
Brighton and Sussex University Hospitals
NHS Trust
Aims and Learning Outcomes
• To have an understanding of what is an Early Warning Tool and
why it should be used.
• To be able to use the Brighton Paediatric Early Warning Score.
• To be aware of future developments of the score.
History
• First used in adults in the early 90s.
• Obvious signs of deterioration prior to cardiac arrest.
(Franklynn and Mathew 1994)
• Early detection associated with improved outcomes in
adults. (McQuillan 1998)
• Work needed in education of staff in recognition of
the seriously ill patient. (Rouse 2001)
• 1st PEWS Brighton based on adult systems (2002)
• Published Feb 2005 (Monaghan 2005)
What is a Paediatric Early Warning
Score ?
• A tool to identify patients with serious physiological
disturbances at risk of deterioration.
• It is an objective assessment tool.
• It is a tool that may give us a numeric trend in the
patients condition.
• Safety Net
How the Brighton Pews was
designed
•
Interviewed staff
•
Why they call medical staff
•
Examined MEWS
•
Used knowledge experience
•
Examined observation charts.
•
Worked at Home
Design
1ST Draft
0
1
2
3
Behaviour
Playing /
Appropriate.
Sleeping.
Irritable.
Lethargic/
Confused
Reduced
response to pain.
Cardiovascular
Pink or Capillary
Pale
Grey
Grey and mottled
Respiratory
Within normal
parameters, no
recession or
tracheal tug.
10 above
Normal
Parameters,
Using
accessory
muscles,
30+% Fi02 or
4+ litres/min.
>20 above
Normal
Parameters
recessing,
tracheal tug.
40+% Fi02 or
6+ litres/min.
>30 above or 5
below normal
Parameters with
sternal recession,
tracheal tug or
grunting.50%
Fi02 or 8 +
litres/min.
Score
Royal Alexandra Hospital For Sick Children, Brighton Paediatric Early Warning Score.
0
Behaviour
1
Playing /
Appropriate.
2
3
Score
Sleeping.
Irritable or
Parents
concerned.
Lethargic/ Confused
Reduced response to
pain.
Cardiovascular Pink or Capillary
refill 1-2
seconds
Pale or Capillary
refill 3 seconds
Grey or Capillary
refill 4 seconds.
Tachycardia of 20
above normal
rate.
Grey and mottled or
capillary refill 5
seconds or above.
Tachycardia of 30
above normal rate or
bradycardia.
Respiratory
> 10 above mean,
Using accessory
muscles, 30+% Fi02
or 4+ litres/min.
>20 above mean
recessing,
tracheal tug.
40+% Fi02 or 6+
litres/min.
>30 above or 5 below
mean with sternal
recession, tracheal tug
or grunting. 50% Fi02
or 8 + litres/min.
Within normal
parameters, no
recession or
tracheal tug.
Score 2 extra for ¼ hourly nebulisers or persistent vomiting following surgery.
Heart rate
PEWS score calculated for all
patients All patients must have
respiratory rate recorded
Inform Nurse in charge –
Continue PEWS monitoring
Mean Respiratory
Infant <1yrs
120 -170
40
Toddler 1-2yrs
Preschool 3-4yrs
School 5-11yrs
Adolescent 12-16 yrs
80 - 110
70 - 110
70 - 110
60 - 90
35
31
27
16
2
3
Inform nurse in charge increase
frequency of PEWS and
observations
4 or Increase of
2 following
intervention
Contact SHO / Registrar
Consider Cardiac Arrest Call
Contact SHO/Reg inform PICU
anaesthetist
>4 or any red
column
Patient attended within 1 hour
Patient attended as soon as possible within 15 minutes
Management plan agreed:
All patients scoring more than 4 – Registrar to inform Consultant
Consider referral to PICU / HDU For further support consider contacting the
Critical Care Outreach team Extension 2508
How to use BPEWS
• Observe the child objectively.
• Consult the chart and score what you observe.
• If their score is usually high keep scoring them so to detect any
changes.
• Record the total in the observation chart.
• Carry out the actions as dictated.
Actions
• Actions range between informing the nurse in charge to calling
out the cardiac arrest team.
• Main aim to encourage discussion and management with child’s
own team
• Response times between 15 minutes and 1 hour.
• Critical Care Liaison informed if score of 4 or any concerns or
queries.
Challenges
•
•
•
•
•
•
•
•
•
•
New Concept.
Seen by staff as extra work.
Staff suspicious of motives.
What variables should be used?
Sensitivity
Verification
Fear of deskilling.
Change Management.
Lack of available evidence.
Education of Staff.
Common Misconceptions
•
•
•
•
•
It will get my patient to PICU
quicker.
Its too much paperwork.
Its time consuming.
I would recognise any sick
patient I don’t need a score.
Its too sensitive.
Make Sure
You Score
This
Valentine’s
Don’t forget this valentine’s day is the start of
The
2 week pilot (on Taaffe & Casualty)
of the EARLY WARNING SCORE.
For further information contact
Alan Monaghan Bleep 818121
Audit and Research
• Pilot study examined triggers initially only examined score 4.
• Should have examined all levels.
• Audit of observations.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Audit
• Examined standard of observations and the relationship to
PEWS.
• 2 main findings.
• Relationship between PEWS and quality of observations.
• Respiratory rate.
• PEWS and Respiratory rate.
Association Between Respiratory Rate
and PEWS
16
14
12
10
8
6
4
2
0
15
12
No Respiratory Rate
No Respiratory Rate
and No PEWS
No Respiratory
Rate
No Respiratory
Rate and No
PEWS
Research
•
1.
2.
•
•
2 studies submitted to LREC
To demonstrate that the Brighton Paediatric Early Warning Score reflects the child’s
severity of illness.
To demonstrate the interuser reliability of the (BPEWS)
1st study passed 2nd study to be resubmitted once study 1 is
complete
Study took 3 and a half years as difficulty recruiting group 3
subjects as scorer had to be the expert.
Study Protocol
1.
2.
3.
4.
5.
Identify Subject
Give patient / carer information
Obtain consent
Expert observes child
Documents what is observed
Category 1
•
•
•
•
Control Group
Outpatients
No acute Illness
Expect score to be between
0-1
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
0
1
2
3
4
5
6
7
8
9
10
10
Group 2
•
•
•
•
Acutely Ill Child
4%
Acute admission within 24
hours
Nursed in ward area
16%
Expect score to be between 24
0%
0%
0%
0%
0%
0%
14%
32%
34%
Score 1
Score 2
Score 3
Score 4
Score 5
Score 6
Score 7
Score 8
Score 9
Score 10
Group 3 Critically Ill
•
•
•
•
Acute onset within 24
hours.
5%
Classed as critically Ill
by medical and nursing 12%
staff.
Recruited from PICU
Expect score between
4-9
19%
0% 0% 0%
0%
2%
14%
23%
25%
Score 1
Score 2
Score 3
Score 4
Score 5
Score 6
Score 7
Score 8
Score 9
Score 10
Interobserver Variability of the
Brighton PEWS Score
• Currently in progress
• Two nurses or Drs score independently
• Scores sealed in envelope and sent for analysis.
Tucker et al 2008
• Examined 2979 Children using Brighton PEWS
• Evaluated its ability to detect deterioration
• Relationship between BPEWS and transfer to PICU
• For each rise of 1 in BPEWS there was a two fold increase in
likelihood of transfer.
• Sensitivity was 90%.
• Specificity was 75% at score of 3.
• And specificity was 99% for children scoring 9.
• Limitation using PICU as an outcome.
Discussion
Scenario 1
• 12 Year old Diabetic.
• Irritable,
• Heart Rate 100. Capillary refill 2-3 secs.
• Respiratory Rate 20.
• Afebrile.
• Blood glucose 10mmols.
Scenario 2
• 4yr old.
• Not interested in surroundings or toys.
• Heart rate 140 bpm. Capillary refill 2-3 seconds.
• Temperature 40 o C.
• Respiratory Rate 26. Recession, Tracheal tug.
Any Questions