Links To And Excerpts From “Bringing Pediatric Early Warning Scores To Your Hospital” From Philips With Links To Additional Resources

Posted on August 9, 2024 by Tom Wade MD

In addition to today’s resource, please see:

All that follows is from Bringing Pediatric Early Warning Scores (PEWS)
to your hospital from Philips. Accessed 8-08-2024.

Undetected deterioration of pediatric patients can have serious adverse outcomes, such as morbidity, long-term disability or even death. The medical community agrees that children who deteriorate unexpectedly will usually have observable signs in the period before the seriousness of their condition is recognized.1 In fact, approximately one in five children who die in hospitals have avoidable factors leading to death, and half of these children have potentially avoidable factors – as shown by a seminal study in the UK.2 Although cardiopulmonary arrests for in-patient pediatric admissions are generally reported as low (0.7-3%),3 survival to discharge for these children is poor (11-37%).3,4 In one review, 61% of pediatric
cardiac arrests were caused by respiratory failure and 29% by shock, which are both preventable and potentially reversible causes.5

The prevention of these events, which can be done via
a systematic assessment of vitals and key symptoms, is a
fundamental element of patient safety. The problem is that
many children appear relatively unaffected until shortly
before respiratory failure or shock. They tend to have a
period of physiological compensation for underlying illness
or injury. Their vitals appear relatively unchanged between
assessments, but change rapidly just before these events. when the compensation mechanisms are overwhelmed. The devastating consequences of cardiopulmonary arrests
on these children, their families and their healthcare providers,
are well proven.6 Moreover, the costs of these events are even
higher than those reported for adults.7 In fact, Bonafide et al.8
estimated that patients who had critical deteriorations cost
$99,773 more during their post-event hospital stay than
transfers to the ICU not fulfilling critical deterioration criteria.

Definition of Pediatric Early Warning Scores (PEWS)

Evidence indicates that prevention of adverse events in pediatrics is possible with early detection, mitigation and
escalation. PEWS are track and trigger tools to help alert
clinicians to deteriorating children by periodic observation
of physiological parameters, calculation of a score (based
on aggregate or individual features), and predetermined
criteria for escalating urgent assistance. Internationally,
PEWS are particularly common throughout the USA, UK, Ireland, Australia, and Canada. Their application is also
gaining momentum in other parts of the world. Initially, PEWS
were developed after carefully examining MEWS (Modified
Early Warning Scores) for adults, using domain knowledge and
incorporating the necessary elements unique to the pediatric
populations5 – shown in Figure 1. This is necessary as the
anatomy and physiology of children differs widely from adults
leading to a higher predisposition for sudden deterioration.9

How well do PEWS perform?

Table 1 shows a number of the most commonly used PEWS,
based on the reviews in References 1, 9 and 10. Note that some
of these scores are trigger scores, where an alert is generated
whenever one of the parameters crosses a threshold, and
others are aggregate scores where an overall score is calculated
and used to generate an alert if it crosses a certain value.
The table also shows performance results in terms of sensitivity
and specificity as measured by different studies.

Key reasons for variations in the performance of different
PEWS scores
• Differences in study cohorts (ages and co-morbidities)
and settings (general wards or ED and other critical areas)
• Customizations in how these scores were applied in
different organizations due to local needs and preferences
• Variations in the definition of clinical deterioration ranging
from unplanned ICU admission to cardiopulmonary arrests

A team from the Great Ormond Street Hospital and UCL
(University College London) compared the predictive
performance of several PEWS on the same data set.15
Their motivation was that, despite the multitude of PEWS
available, only a minority have been evaluated for their
predictive performance. Their data set included patients on
pediatric wards collected over two years. All patients who
suffered a critical deterioration event were designated “cases”
and matched with a control closest in age who was present on
the same ward at the same time. The main outcome measures
were respiratory and/or cardiac arrest, unplanned transfer to
pediatric intensive care, and/or unexpected death.

Although the authors compared more than 12 different
PEWS/trigger systems, focus will be on the most commonly
used scores given in Table 1, which shows results in terms of sensitivity and specificity. The Birmingham Toronto and
C-CHEWS were not used in the comparative study.15
Figure 2 shows the sensitivity and specificity of five of the
PEWS tested on the same data set. The best performer
was the Cardiff and Vale PEWS, followed by the Bedside
PEWS. The authors concluded that overall trigger systems
demonstrated better sensitivity (probability of detection)
than aggregate scoring systems, but worse specificity (true
negative rates).

They also concluded that PEWS demonstrated
the ability to detect children at risk of critical deterioration
at a significant time before the event (Figure 3). Trigger
systems showed a longer time to event, reflecting the
increased sensitivity. In reality, the selection of PEWS by
a clinical team depends on several factors: target sensitivity
and specificity, workflow and ease of use, and the ability
of the team to record measurements.

In practice, the key goal in deploying early warning scores is to
ensure timely recognition of deteriorating patients combined
with a timely and appropriate response from skilled staff.1 EW van der Jagt highlights four important components that
need to go hand-in-hand for a successful implementation
of early warning scores.23

These components, summarized in Figure 4:
• The afferent component: This aims to detect clinical
deterioration in time, and trigger an appropriate response.
Table 1 showed several PEWS that can perform this task.
It is recommended to combine these scores with clear
guidance regarding monitoring type and frequency,
flagging of diagnostic risk factors as well as a mandatory
escalation system.24
• The efferent component: Ensuring access to a medical
emergency team that can respond rapidly, in combination
with a network of clinicians that can provide the response.
The structure and function of the response limb (or the
efferent component) are dependent upon the needs of
the institution. A multidisciplinary team with the skills
and resources to assess and manage emergencies is
recommended.24 Proactive identification through a rover
team or scheduled safety huddles may help with earlier
identification of patients at risk.
• Process improvement: This summarizes the regular use
of auditing, monitoring and evaluation to make sure that
the processes around PEWS implementation are efficient.
This should be designed around the desired outcomes
and identify successes, near misses and failures throughout
the process.
• Governance and administrative component: This highlights
the importance of organizational leadership in addition
to maintaining a safety culture in the hospital. Training
and education play a crucial role here in bringing all
team members on-board and making sure that PEWS are
being implemented and sustained for long periods. This
component should also be designed around the desired
outcomes and key performance indicators.

PEWS outcomes

The use of PEWS has several benefits. Based on the existing
literature, the following are highlighted outcomes:
• Can provide evidence that empowers nurses to overcome
barriers to escalating care25,26
• Provides less-experienced nurses with vital sign reference
ranges25
• Increases the proportion of patients seen by a consultant
from the time of breach to PICU admission – e.g., in Theilen
et al., the proportion increased from 49% to 82%.27
• Decreases late ICU transfers – e.g., the time from breach
to PICU admission fell from 21 h to 10 h27                                          • Identifies deterioration better than a physician’s
opinion alone28
• Earlier detection (with a time period identified) –
i.e., decreasing the time from trigger criteria to clinician
response (by 9.25 hours prior to event)22
• Decreases PICU length of stay, which would have a positive
impact on the children spending less time in critical care,
as well as reducing the associated costs. The decrease of
length of stay was by around two days.27
• Possibly reduces ward cardiac arrests and mortality29
• Decreases in code team activations30
• Compliance and adherence to guidelines31

From a cost-benefit analysis, Bonafide et al. looked into
the advantages of having a medical emergency team (MET)
in a pediatric ward combined with a deterioration score for
over four years.8 The conclusion was that while having MET
teams is costly, the costs are small compared to those of
deteriorations in the ward. In fact, the annual cost of having
a nurse, respiratory therapist and ICU specialists is equivalent
to only a reduction of 3.5 critical deterioration events.
The recommendation from that study is that the use of a
deterioration score combined with a MET has significant
cost reduction benefits to the hospital.

PEWS challenges

Despite showing positive impacts in many studies, the
application of PEWS scores in practice can have many
challenges. Some of these include:
• Compared to adult EWS (Early Warning Score), PEWS needs
a variation in age-specific thresholds.1
• Some children are unable to articulate their level of pain or
discomfort, which makes it more difficult for the clinical team
to document these levels.
• Staff training issues and adherence to new protocols.
• Incomplete measurement of some of the required vital signs.
A Danish study by Jensen et al. proposed a multicenter
randomized trial using Bedside PEWS, deducing that all seven
items in Bedside PEWS are complete in only 5% of the time.19,32
In particular, the study showed that clinicians had difficulty
in measuring blood pressure and consciousness levels.
• The fact that there are many available PEWS scores can be
confusing for hospitals. The lack of large-scale validation
and comparison studies can also be problematic. Unlike
MEWS for adults, there are currently no government or
medical guidelines recommending one score over another.
• As the previous section highlighted, deterioration detection
and response require a comprehensive change management
framework that embodies processes and education as well
as communication. If any of these elements were missing,
hospitals would definitely find it challenging to implement
PEWS and maintain results over time.

How can Philips bring PEWS to your hospital?

Philips Early Warning Scoring System IntelliVue Guardian
Solution (IGS) offers a comprehensive solution to help
address clinical deterioration and patient care. It allows
caregivers to automatically acquire vital signs, automate early
warning scoring (EWS) calculations, aid in identifying early
signs of deterioration, and can inform responsible clinicians
for an efficient intervention. Philips Guardian Software
can be embedded in clinical workflows and automatically
incorporated in electronic health records. For surveying an
adult population, Guardian prospective evaluation in two
general wards of a hospital in the United Kingdom has shown
a 52% increase of rapid response team notifications that
triggered interventions. In addition to that, the evaluation
showed a 20% decrease in mortality, an 86% decrease in
cardiac arrests, a 24% reduction in ICU admission, and a 31%
reduction in the severity of patients admitted to the ICU.33

IGS provides a means of addressing many of the challenges
in deploying PEWS scores, and notifying rapid response
teams when needed:
• Pediatric-specific deterioration detection: Philips offers an
EWS system that recognizes the fundamental physiological
differences between adults and children. Our Pediatric Early
Warning System (PEWS) calculates early warning scores that
take into account the unique patterns of deterioration in
children, placing a greater emphasis on nursing observations
in determining the level of risk.33
• Bringing PEWS scoring to the child’s bedside: This can
simplify workflows by directly uploading the vital signs data
into the EHR to reduce the vital signs collection time and
provide an early patient deterioration score and direction on the monitor. The Philips infrastructure allows the
calculation of PEWS in spot-check or continuous mode
using the Philips Patient Information Center (PIC iX),
if the patient is on continuous monitoring.
• Highly configurable: IGS is highly configurable and able to
accommodate different PEWS such as trigger and aggregate
scores, given in Table 1. The Guardian solution can also be
accessed from different devices and screens to match the
hospital’s workflow.
• Facilitating communication: The Care Event event
management system can be configured to deliver
notifications to the care team’s mobile devices of choice,
aiming to improve communication between care teams
regardless of caregiver location.33
• Running multiple algorithms at once: Guardian supports
more than one scoring algorithm for a single patient at the
same time. This allows clinicians to combine PEWS with
other scores (such as sepsis screening scores) that can be
used on long and short time windows simultaneously to
assess patient risk from multiple points of view.
• Support in workflow integration: As the previous
section highlighted, deterioration detection and efficient
response require a comprehensive change management
framework that embodies processes and education as
well as communication. Philips clinical specialists are
trained to assess current workflows and practices, then
collaborate with clinical teams to identify process changes
that can positively affect RRT activation within customized
configurations. They will plan, validate and test the solution
to facilitate successful workflow transitions.

References
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Study 2006. CEMACH. 2008.
3. Tucker KM, Brewer TL, Baker RB, Demeritt B, Vossmeyer MT. Prospective evaluation
of a pediatric inpatient early warning scoring system. J Spec Pediatr Nurs JSPN.
2009 Apr;14(2):79–85.
4. McLellan MC, Gauvreau K, Connor JA. Validation of the Children’s Hospital
Early Warning System for Critical Deterioration Recognition. J Pediatr Nurs.
2017 Feb;32:52–8.
5. Monaghan A. Detecting and managing deterioration in children.
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Available from https://doi.org/10.7748/paed.17.1.32.s27
6. Pediatric Sudden Cardiac Arrest Section on Cardiology and Cardiac Surgery.
Pediatrics. 2012. http://pediatrics.aappublications.org/content/pediatrics/
early/2012/03/21/peds.2012-0144.full.pdf
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Cost-benefit analysis of a medical emergency team in a children’s hospital.
Pediatrics. 2014 Aug;134(2):235–41.
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