Overview
Definition:
Pediatric Early Warning Scores (PEWS) are validated clinical tools designed to systematically assess and monitor physiological parameters in children, enabling early identification of clinical deterioration and timely intervention
They aim to standardize the recognition of illness severity and facilitate prompt escalation of care by nurses and physicians.
Epidemiology:
Deterioration in hospitalized children can occur in up to 10% of cases, with a significant proportion leading to adverse outcomes like cardiac arrest or death if not recognized early
PEWS implementation aims to reduce these preventable events
The incidence of adverse events varies by hospital setting and patient acuity, but PEWS aims to mitigate risks across diverse pediatric populations.
Clinical Significance:
Effective PEWS implementation is crucial for improving patient safety and outcomes in pediatric healthcare settings
By providing a structured approach to monitoring, PEWS assists clinicians in detecting subtle signs of deterioration before a crisis occurs
This allows for earlier initiation of interventions, potentially reducing the need for intensive care, length of hospital stay, and mortality rates
It standardizes communication between healthcare providers, fostering a collaborative approach to critical care.
Implementation Strategy
Workflow Integration:
Integrating PEWS into existing nursing and medical workflows is paramount
This involves defining clear roles and responsibilities for score calculation, interpretation, and escalation
The process should be seamless and minimize disruption to routine patient care
Electronic health record (EHR) integration can automate calculations and trigger alerts, but manual systems are also viable with adequate training.
Staff Training:
Comprehensive and ongoing training for all healthcare professionals involved in pediatric care is essential
This includes nurses, physicians, and allied health staff
Training should cover the rationale behind PEWS, how to accurately calculate scores, understanding the scoring thresholds, appropriate escalation protocols, and the importance of timely response
Regular simulation exercises can reinforce skills.
Scoring Parameters:
Typical PEWS parameters include physiological measures like respiratory rate, heart rate, blood pressure, oxygen saturation, and neurological status (e.g., AVPU or Glasgow Coma Scale)
Behavioral changes (e.g., increased irritability, lethargy) and observable clinical signs (e.g., skin color, hydration) are also often incorporated
Specific scoring systems may vary in their exact parameters and weighting.
Escalation Protocols:
Clear, tiered escalation protocols are vital
These protocols should define the actions to be taken at different PEWS score thresholds, ranging from increased observation to immediate activation of a rapid response team or PICU transfer
Communication pathways must be clearly defined, ensuring that the right people are notified promptly
These protocols should be evidence-based and tailored to the local healthcare setting.
Audit And Evaluation:
Regular auditing of PEWS implementation and performance is necessary
This involves reviewing the accuracy of scoring, timeliness of interventions, and the impact on patient outcomes
Data collection on PEWS alerts, interventions, and adverse events allows for continuous quality improvement
Feedback mechanisms should be established to address challenges and refine the system.
Scoring Systems And Parameters
Common Pews Tools:
Several PEWS tools exist, including the Children's Hospital of Philadelphia (CHOP) PEWS, the modified Early Warning Score (MEWS) adapted for pediatrics, and modified Rush score
Each system uses a set of physiological and behavioral parameters with specific scoring values.
Respiratory Parameters:
Respiratory rate is a key indicator
Elevated rates or the need for increased respiratory support (e.g., supplemental oxygen, high flow nasal cannula, non-invasive ventilation) contribute to the score
Accessory muscle use and grunting are also significant findings.
Cardiovascular Parameters:
Heart rate and blood pressure are crucial
Tachycardia or bradycardia, and hypotension or hypertension relative to age, significantly increase the PEWS
Peripheral perfusion (e.g., capillary refill time) and skin color can also be incorporated.
Neurological Parameters:
Level of consciousness, assessed using scales like AVPU (Alert, Voice, Pain, Unresponsive) or GCS (Glasgow Coma Scale), is important
Changes in alertness, unusual somnolence, or irritability can contribute to a higher score.
Behavioral And Observational Signs:
Changes in behavior such as increased irritability, agitation, or excessive lethargy are often included
Observable signs like cyanosis, pallor, dehydration, or a significant decrease in urine output can also increase the PEWS, reflecting systemic compromise.
Escalation And Response
Thresholds And Triggers:
PEWS typically employs tiered thresholds
A low score may indicate routine care with continued observation
Intermediate scores trigger increased frequency of vital sign monitoring and closer nursing assessment
High scores necessitate immediate physician review and consideration for urgent intervention.
Roles And Responsibilities:
Nurses are usually responsible for initial PEWS calculation and monitoring
They are empowered to escalate care based on predefined triggers
Physicians are responsible for evaluating patients with elevated PEWS, confirming the score, initiating further investigations, and implementing management plans
Rapid response teams or PICU teams are often activated for critically high scores.
Communication Strategies:
Effective communication is paramount
Standardized communication tools, such as SBAR (Situation, Background, Assessment, Recommendation), should be used during escalations to ensure clarity and conciseness
Direct verbal communication with the responsible physician is essential
Documentation of the PEWS score and all subsequent actions is critical.
Rapid Response Teams:
For critically ill children identified by PEWS, activation of a pediatric rapid response team (RRT) or medical emergency team (MET) is crucial
These multidisciplinary teams are trained to rapidly assess and manage deteriorating patients, aiming to prevent cardiac arrest and PICU admission
Their early intervention can significantly improve survival rates.
Documentation:
Thorough and accurate documentation of the PEWS score at regular intervals, any changes in the score, the rationale for escalation, and the interventions performed is vital for legal, medical, and quality improvement purposes
This documentation forms part of the patient's medical record.
Challenges And Solutions
Variability In Scoring:
A common challenge is variability in how scores are calculated or interpreted by different staff members
Solutions include rigorous, standardized training, clear algorithms, and regular competency checks
EHR integration can help standardize calculations.
Alert Fatigue:
Frequent alarms or alerts (alert fatigue) can lead to desensitization and missed critical events
This can be mitigated by optimizing scoring parameters, ensuring specificity, and refining escalation thresholds to reduce false positives while maintaining sensitivity.
Resource Limitations:
Implementation may face challenges related to staffing levels, availability of rapid response teams, or EHR infrastructure
Phased implementation, staff advocacy, and strong administrative support are key
Prioritizing high-risk areas and patient populations can also be effective.
Cultural Barriers:
Resistance to change or a lack of buy-in from staff can hinder implementation
Creating a culture of safety, involving frontline staff in the development process, and demonstrating the benefits of PEWS through data can overcome these barriers.
Interdisciplinary Collaboration:
Ensuring seamless collaboration between nursing and medical teams is crucial
Regular interdisciplinary meetings to discuss PEWS performance, patient cases, and protocol adherence can foster better teamwork and shared understanding.
Key Points
Exam Focus:
Understand the purpose of PEWS, its key physiological and behavioral parameters, common scoring systems, and the critical importance of timely escalation and response
Know the roles of different healthcare professionals in the PEWS process.
Clinical Pearls:
Always reassess the child and the PEWS score frequently, especially if there is a change in clinical status
Do not hesitate to escalate if your clinical judgment suggests deterioration, even if the PEWS score is not yet at a critical threshold
PEWS is a tool to aid, not replace, clinical assessment.
Common Mistakes:
Failing to calculate the score accurately
Delaying escalation based solely on a low or moderate score
Not communicating effectively during escalation
Ignoring behavioral changes that are not captured by physiological parameters
Not performing regular audits to ensure compliance and effectiveness.