Overview
Definition:
Escalation pathways are structured protocols designed to ensure timely and appropriate recognition and response to clinical deterioration in pediatric patients admitted to general wards
They involve a systematic approach to identify at-risk children and mobilize the necessary resources for prompt assessment and intervention.
Epidemiology:
Deterioration in hospitalized children is a significant concern, with reported rates of adverse events or arrest varying from 1% to 10% in different studies
Early recognition and intervention can reduce mortality and morbidity, highlighting the critical importance of effective escalation strategies.
Clinical Significance:
Prompt recognition and management of deteriorating children are paramount to preventing cardiorespiratory arrest, reducing length of hospital stay, and improving patient outcomes
Well-defined escalation pathways empower ward teams to act decisively, ensuring that critically ill children receive timely specialist input and advanced care when needed.
Recognizing Deterioration
Early Warning Scores:
Utilize validated pediatric early warning score (PEWS) systems, such as the Pediatric Early Warning Score (PEWS) or the Modified Early Warning Score (MEWS)
These scores aggregate physiological parameters and clinical observations to identify children at risk of deterioration
Scores exceeding a defined threshold trigger an escalation response.
Physiological Derangements:
Key physiological parameters to monitor include: Heart rate (tachycardia or bradycardia)
Respiratory rate (tachypnea or bradypnea)
Oxygen saturation (hypoxia)
Blood pressure (hypotension or hypertension)
Level of consciousness (altered mental status, lethargy, irritability)
Temperature (fever or hypothermia)
Urine output (oliguria or anuria).
Clinical Signs Of Concern:
Non-reassuring clinical signs include: Worsening work of breathing (nasal flaring, grunting, retractions)
Mottled or cyanosed skin
Poor peripheral perfusion (prolonged capillary refill time >2 seconds)
Significant lethargy or unresponsiveness
Seizures
New or worsening pain.
Assessment Tools:
Systematic assessment using tools like ABCDE (Airway, Breathing, Circulation, Disability, Exposure) is crucial
A thorough head-to-toe examination should be performed, paying attention to subtle changes that may indicate impending collapse.
Escalation Pathway Components
Identification And Scoring:
Initial assessment of a child on the ward
Application of PEWS or other scoring systems if indicated by clinical concerns or routine monitoring
A score above a predefined threshold (e.g., >= 4) prompts the next step.
Notification And Communication:
Immediate notification of the senior nurse responsible for the ward
Communication with the registrar or pediatric resident on call
Clear, concise communication using a structured tool like SBAR (Situation, Background, Assessment, Recommendation).
Tiered Response Levels:
Level 1: Ward doctor/resident review within 15-30 minutes
Level 2: Senior resident/fellow review
Level 3: Pediatric intensivist/consultant review
Level 4: Transfer to PICU/HDU
Each level has specific timeframes for response and action.
Documentation:
Meticulous documentation of all assessments, scores, notifications, interventions, and responses
This ensures continuity of care and provides a record for audit and review.
Roles And Responsibilities
Nursing Staff:
Front-line in recognizing deterioration
Perform initial assessments, apply scoring systems, and escalate concerns to medical staff
Administer initial treatments as per protocol.
Pediatric Residents And Registrars:
Responsible for initial medical assessment and management of deteriorating children
May escalate further to senior colleagues or intensivists based on patient status.
Pediatric Intensivists And Consultants:
Provide expert consultation and management for critically ill or deteriorating children
Lead resuscitation efforts and guide transfer decisions to higher levels of care.
Multidisciplinary Team:
Involvement of allied health professionals (e.g., respiratory therapists, pharmacists) is essential for comprehensive care
Clear communication channels between all team members are vital.
Management Of Deterioration
Immediate Assessment And Stabilization:
Prioritize ABCDE assessment
Ensure adequate airway and ventilation
Optimize oxygenation
Secure intravenous access
Manage shock with fluid resuscitation and/or inotropes
Control seizures promptly.
Pharmacological Interventions:
Administer oxygen as required
Use bronchodilators (e.g., salbutamol, ipratropium) for respiratory distress
Administer antibiotics for suspected sepsis
Use antipyretics for fever
Consider analgesia for pain
Specific drug choices and dosages must be based on current guidelines and patient weight.
Transfer To Higher Level Of Care:
Indications for PICU/HDU transfer include: Persistent cardiorespiratory compromise despite maximal ward-based intervention
Need for mechanical ventilation or advanced hemodynamic support
Deteriorating neurological status
Suspected severe sepsis or septic shock not responding to initial management.
Monitoring And Reassessment:
Continuous monitoring of vital signs and clinical status
Frequent reassessments (e.g., every 15-30 minutes initially, then as per clinical condition)
Adjust management based on response to interventions.
Common Scenarios And Challenges
Sepsis Recognition And Management:
Early recognition of SIRS criteria and prompt initiation of antibiotics, fluids, and vasopressors is critical
Awareness of local epidemiology of resistant organisms is important.
Respiratory Distress In Children:
Distinguishing between upper and lower airway obstruction, bronchiolitis, pneumonia, and asthma
Management strategies vary significantly
Bronchodilators, steroids, and supplemental oxygen are key.
Neurological Deterioration:
Causes include hypoglycemia, seizures, meningitis, encephalitis, head injury
Assessment of neurological status (GCS, pupillary response) is vital
Management focuses on treating the underlying cause and supportive care.
Challenges In Resource Limited Settings:
Lack of specialized equipment, limited availability of intensivists, and transport difficulties can hinder effective escalation
Emphasis on standardized protocols, simulation training, and strong communication is crucial.
Key Points
Exam Focus:
Understand the triggers for escalation, the role of PEWS, structured communication tools (SBAR), and the tiered response system
Know the immediate management of common causes of deterioration (sepsis, respiratory failure).
Clinical Pearls:
Never hesitate to escalate
it is better to be over-cautious
Trust your instincts – if a child looks unwell, they probably are
Document everything thoroughly
Ensure you know the contact numbers for critical care teams.
Common Mistakes:
Delayed recognition of deterioration
Inadequate communication or failure to escalate
Inappropriate or delayed fluid resuscitation in shock
Underestimation of severity of illness
Lack of systematic assessment (e.g., neglecting ABCDE).