1. Tools of the trade Shirley McGrath, Lead for Resuscitation & Clinical Skills Claire Holt, Consultant Paediatrician

2. What is PEWS?
It is known that children who die or deteriorate unexpectedly in the hospital setting will often have observable features in the period before the seriousness of their condition is recognised. A seminal study of paediatric mortality in the UK estimated that approximately one in five children who die in hospital have avoidable factors leading to death and up to half of children have potentially avoidable factors. Early warning scores are generally defined as bedside ‘track and trigger’ tools to help alert staff to clinically deteriorating children by periodic observation of physiological parameters, generation of a numeric score and predetermined criteria for escalating urgent assistance with a clear framework for communication. In using these physiological track and trigger systems, the goal is to ensure timely recognition of patients with potential or established critical illness and to ensure a timely and appropriate response from skilled staff.

4. What was life like pre Paediatric Early Warning Score?
Significant issues in failures to recognise deterioration
Poor communication of observations
Lack of response to that communication
Nurses’ inability to voice concerns, convey urgency about deterioration to Doctors.
Nurses and Doctors speak different languages.
Nurses communicate in a social manner - qualitative.
Doctors use a more quantitative, precise, ‘medical’ style.
Doctors need objective information - to identify urgency & prioritise their work
NPSA

5. Why an early warning score?
Evidence from adults
EWS in use since 90’s
Early detection of deterioration associated with improved outcomes
Tachypnoea, Depressed Consciousness & Tachycardia good indicators of deterioration requiring increased level of care
The Higher The Score The Sicker the Patient
‘Critical Care Without Walls’
A critical care Outreach Team using a MEWS introduced to the Royal Berkshire Hospital’s Surgical Service in 2002
MEWS validated. Correlation between high MEWS and Mortality
National- CEMACH Recommendation
Local
Nationally- Early warning scoring used by adult outreach teams to identify deterioration in wards at an early stage, allow proactive management, reduce emergency resuscitation and ICU admission (Coombs & Dillon, 2002)
Obvious signs of deterioration prior to cardiac arrest, that were often missed – suboptimal care
Locally- MEWS in all adult patients 2005

6. Emerging evidence from children Anecdotal & exploratory work suggests the same potential for suboptimal care exists National interest group- affiliated to PICS Brighton PEWS introduced to Wexham Park 2005 A&E audit of paediatric assessment skills 2006 Trial Brighton PEWS Children’s Hospital Oxford CEMCH Child Death Review – Why Children Die? 2008 For paediatric care in hospital we recommend a standardised and rational monitoring system with imbedded early identification systems for children developing critical illness Local Adverse Clinical Incident Invitation to Institute of Innovation to review learning 2007 introduction in RBH driven by failure to recognise deterioration in child with pneumococcal disease – morbity rather than mortality
No studies describe suboptimal care in children
Development of outreach and early warning for children is in its infancy

7. Which tool & Why
Two PEW tools published and in use in practice in the UK – Brighton and Bristol
Bristol PEWS
validated single parameter track & trigger tool for use in a tertiary centre with an outreach team
Brighton PEWS
easy to use and suited to adaptation for our service
Children’s Service in a large DGH no PICU – paediatric outreach unlikely

8. Will PEWS recognise all sick children?
Professional curiosity
Children not always in normal parameters
Track and trigger

9. Tools only as good as person using them
Clinicians working in inpatient paediatric units, and management at unit and organisational levels, need to recognise that the early detection of a deteriorating child is much more than identifying and responding to a score. Instead, through creation of a common language, PEWS should stimulate a heightened sense of situation awareness and open communication among clinicians about children at risk of clinical deterioration, thereby supporting, not replacing, clinical judgement. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.

10. Moving forward Multifaceted ‘system’ approach
four integrated components which work together to provide a comprehensive safety system
component which detects clinical deterioration and triggers an appropriate response
component which consists of the personnel and resources providing the response
component containing elements such as auditing/monitoring/evaluation
governance/administrative component
Critically Ill Children Network
mortality reviews to provide additional scrutiny and their newsletter to allow lessons learnt to be communicated.
Paediatric hand book on line
clinical protocols developed jointly by the Royal Berkshire Paediatric Department and local GPs
National PEWS tool
Canadian bedside PEWS