Ashley Lynch, BSN, RN, CMSRN Pediatric Early Warning Score Assessment Tool at Beaufort Memorial Hospital Ashley Lynch, BSN, RN, CMSRN

Behavior Score 0 Score 1 Score 2 Score 3 Playing Alert Appropriate At Baseline Sleepy Fussy but Consolable Irritable or Inconsolable Lethargic Confused Reduced Response to Pain

Cardiovascular Score 0 Score 1 Score 2 Score 3 Pink Capillary refill 1-2 seconds Pale Capillary refill 3 seconds Grey Capillary refill 4 seconds Tachycardia 20 BPM above normal rate Mottled Capillary refill 5 seconds or above Tachycardia 30 BPM above normal rate Bradycardia

Respiratory Score 0 Score 1 Score 2 Score 3 Within normal parameters Rate greater than 10 BPM above normal Accessory muscle use 30% + FIO2 3+ L/min. O2 Rate greater than 20 above normal Retractions 40% + FIO2 6+ L/min. O2 O2 saturation 5% below baseline Below normal rate Grunting 50% + FIO2 8+ L/min. o2 O2 Saturation greater than 5% below baseline

What to do next? Score 0-2 Reassess as scheduled & PRN Score 3 Reassess at least Q4 hours & PRN Score 4 Notify CRN CRN assess and calculate PEWS Call RT to bedside PRN Q1 hour Vital Signs until baseline Q1 hour assessment until baseline Notify MD Consider PRR Score >4 or 3 in any Category Q 15 minute Vital Signs Q 15 minute assessments Activate PRR Notify MD Notify RT Provide intervention per Protocol Consider transfer to higher level of care Reassess PEWS following intervention

Did the PEWS positively impact your practice?

Did the PEWS Lead to Earlier Physician Contact or Initiation of PRRT?

References Monaghan, A. (2005). Detecting and managing deterioration in children. Paediatric Care, 17(1), 32-35. doi:10.7748/paed2005.02.17.1.32.c964