1. Scoring Systems in Paediatric Emergency Care
Damian Roland

2. Disclaimer
I have developed an Children’s Emergency and Urgent care acuity scoring tool:
The Paediatric Observation Priority Score (POPS) with Dr. Ffion Davies
I am co-director of a Medical Apps firm
quackapps.com

4. Roland D, Shahzad MW, Davies F
Roland D, Shahzad MW, Davies F. The importance of currency in data trends.
Arch Dis Child 2013;98:

6. Definitions
Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel 
Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):

7. Definitions
Triage
Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel 
Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):

9. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:38

10. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:38

11. Serious infection life-threatening
Intermediate infection: longer than 10 days or have a non life-threatening complication
Minor infection: recover without sequelae
Not infection group: NOT an acute infection
Arch Dis Child 2009;94:888–893

12. Illness Identification
Definitions
Illness Identification
Triage
Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel 
Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):

13. Minor infection: recover without sequelae
Arch Dis Child 2009;94:888–893

14. Illness Identification
Definitions
Illness Identification
Triage
EWS
Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel 
Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):

15. Score doesn’t ‘activate’
Score ‘activates’
FLAGS UP DETERIORATING KIDS
POTENTIALLY DRAINS RESOURCES
Not Deteriorating
Deteriorating
FAILS TO RECOGNISE DETERIORATION
MONITORS EFFECTIVELY
Score doesn’t ‘activate’
@damian_roland
Original concept by Akmal Hussein, Royal Berkshire Hospital

16. Concern PEWS may generate work…
O’Leary F and Chayan G. Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department.
Emergency Medicine Australasia (2011) 23, 748–753

17. ..the review activations might have generated an extra 7060 min of additional workload…
O’Leary F and Chayan G. Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department.
Emergency Medicine Australasia (2011) 23, 748–753

18. Physiological Parameters
Junction A
Septic
Thought to have sepsis
Presentation
Physiological Parameters
General Appearance
Not Septic
Not thought to have sepsis
Septic
Not Septic
Concept Tree

19. Optimal Treatment or Outcome Septic
Junction A
Junction B
Optimal Treatment or Outcome
Septic
Thought to have sepsis
Suboptimal Treatment or Outcome
Presentation
Physiological Parameters
General Appearance
Not Septic
Suboptimal Treatment or Outcome
Not thought to have sepsis
Septic
Optimal Treatment or Outcome
Not Septic
Concept Tree

20. Optimal Treatment or Outcome Ill
Junction A
Junction B
Optimal Treatment or Outcome
Ill
Thought to be ill
Suboptimal Treatment or Outcome
Presentation
Physiological Parameters
General Appearance
Not Ill
Suboptimal Treatment or Outcome
Not thought to be ill
Ill
Optimal Treatment or Outcome
Not Ill
Concept Tree

21. Roland D, McCaffery , Davies F
Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

22. High Patient Load
Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

23. High Patient Load Time Pressures
Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

24. High Patient Load Multiple Handovers Time Pressures
Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

25. High Patient Load Inexperienced Staff Multiple Handovers
Time Pressures
Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

26. Diagnostic Uncertainty
High Patient Load
Inexperienced Staff
Multiple Handovers
Diagnostic Uncertainty
Time Pressures
Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

27. Systems should ameliorate..
Failure of…
Diagnostics
Recognition of Severity
Communication

28. An Optimal ED tool should..
Decrease Cognitive Load
Reduce Knowledge Deficit
Escalate Senior Review
Identify both tails of the Distribution curve
Improve Communication

29. The paediatric literature included 7 full papers and 11 abstracts; 7 were prospective studies and 8 examined a score designed for ED use (4 of these assessed the Paediatric Observation Priority Score tool).
Challen K and Roland D. Early Warning Scores: a health warning EMJ doi: /emermed

31. Valid, safe, and user-friendly in pilot testing1,23
Roland D, Lewis G, Davies F. Determining the effect of objective and subjective criteria on a risk assessment tool in a paediatric emergency department. Emerg Med J 2011;28:A12
Roland D, Lewis G and Davies F. Maintaining Safety while reducing admission in a high risk patient group. Poster Presentation at International Forum on Quality and Safety in Healthcare. London April 2013
Roland D, Gareth L and Davies F.  Addition of a subjective nursing assessment improves specificity of a tool to predict admission of children to hospital from an emergency department. e-Poster at European Paediatric Research Society Newcastle October 2011

32. Roland D, Davies F and Coats T
Roland D, Davies F and Coats T. The Paediatric Observation Priority Score (POPS): Outcomes Of Patients Arch Dis Child 2014;99:A24

33. Aggregate Results

34. Relative Results (%)

35. Externality

36. Figure 2 – Triage Assessment Documentation

37. What do we need to know?

38. What do we need to know?
Is the best outcome illness detection or safe discharge?
Is specificity more important that commonality?
Is the ‘score’ more relevant than the system behind it?

39. What do we need to know?
Is the best outcome illness detection or safe discharge?
Is specificity more important that commonality?
Is the ‘score’ more relevant than the system behind it?

40. What do we need to know?
Is the best outcome illness detection or safe discharge?
Is specificity more important that commonality?
Is the ‘score’ more relevant than the system behind it?

41. Thanks Dr. Ffion Davies Prof. Tim Coats
Prof. Andrew Rowlands and colleagues in Manchester
The staff at the Leicester Royal Infirmary

42. Dr. Damian Roland dr98@le.ac.uk @damian_roland
Leicester Emergency Medicine Academic Group (EMAG) Paediatric Emergency Medicine Leicester Academic (PEMLA) East Midlands Emergency Medicine Educational Media (EM3)

44. Systems should amelioriate
Diagnostic failure: Failure to establish the correct diagnosis sufficiently early to permit effective treatment
Failure to recognise illness severity: The correct diagnosis is established but illness severity is underestimated, leading to delayed escalation of support
Failure of communication: Communication between staff may be absent or ineffective. This includes inaccurate medical information as well as human factors

45. Optimal ED tool should..
Reducing Knowledge Deficit: Most tools define an acceptable reference range for each physiological variable commonly measured. This assists junior staff, particularly if inexperienced with children
Decreasing cognitive load: Graphical or numerical display of physiological observations ,whether at the triage stage or repeatedly over time, allows clear identification of sick children.
Escalating seniority of review: Specific scores activate senior clinician involvement
Identifying both tails of the distribution curve: Ability to identify potentially critically unwell children as well as those fit for discharge without hospital admission, is the fundamental purpose of an ED
Improving Communication: Many tools are now integral to the process of patient handover and triage. Handover is well known to be a high-risk transition for patients, and objectivity and alerts are possible using scoring systems.