Systems to prevent in-hospital cardiac arrest

FACTORS ASSOCIATED WITH THE CLINICAL DETERIORATION RECOGNIZED BY AN EARLY WARNING PEDIATRIC SCORE

ABSTRACT Objective: To identify the factors associated with clinical deterioration recognized by a Pediatric Early Warning Score. Method: A cross-sectional study conducted in a tertiary pediatric public hospital with 271 children aged from zero to ten, hospitalized between May and October 2015. For the identification of the children with and without signs of clinical deterioration, the translated, adapted and validated version of the Brighton Pediatric Early Warning Score was applied to the Brazilian context. Logistic regression analysis and prevalence ratio (PR) were used to measure the association between the variables studied. A 95% Confidence Interval (CI) and p value were adopted as a measure of statistical significance to identify potential associated factors. Results: The factors associated with the clinical deterioration of the children studied were age ≤ 2 years old (p=0.000), hospitalization in the emergency unit (p=0.000), comorbidity (p=0.020) and clinical diagnosis of respiratory disease (p=0.000). Conclusion: Children ≤ 2 years old, with comorbidity, diagnosed with respiratory disease and hospitalized in the emergency unit showed an increased likelihood of clinical deterioration. The identification of factors associated with clinical deterioration may alert and direct the health team to children more susceptible to this phenomenon.

Provisional Validation of a Pediatric Early Warning Score for Resource-Limited Settings

BACKGROUND AND OBJECTIVES

The use of Pediatric Early Warning Scores is becoming widespread to identify and rapidly respond to patients with deteriorating conditions. The ability of Pediatric Early Warning Scores to identify children at high risk of deterioration or death has not, however, been established in resource-limited settings.

METHODS

We developed the Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) on the basis of expert opinion and existing scores. The PEWS-RL was derived from 6 equally weighted variables, producing a cumulative score of 0 to 6. We then conducted a case-control study of admissions to the pediatrics department of the main public referral hospital in Kigali, Rwanda between November 2016 and March 2017. We defined case patients as children fulfilling the criteria for clinical deterioration, who were then matched with controls of the same age and hospital ward.

RESULTS

During the study period, 627 children were admitted, from whom we selected 79 case patients and 79 controls. For a PEWS-RL of ≥3, sensitivity was 96.2%, and specificity was 87.3% for identifying patients at risk for clinical deterioration. A total PEWS-RL of ≥3 was associated with a substantially increased risk of clinical deterioration (odds ratio 129.3; 95% confidence interval 38.8-431.6; P <.005).

CONCLUSIONS

This study reveals that the PEWS-RL, a simple score based on vital signs, mental status, and presence of respiratory distress, was feasible to implement in a resource-limited setting and was able to identify children at risk for clinical deterioration.

Comparison of Pediatric Early Warning Score to Physician Opinion for Deteriorating Patients

BACKGROUND

This study compares a Pediatric Early Warning Score (PEWS) to physician opinion in identifying patients at risk for deterioration.

METHODS

Maximum PEWS recorded during each admission was retrospectively ascertained from electronic medical record data. Physician opinion regarding risk of subsequent deterioration was determined by assignment to an institutional "senior sign-out" (SSO) list that highlights patients whom senior pediatric residents have identified as at risk. Deterioration events were defined as intubation, initiation of high flow nasal cannula, inotropes, noninvasive mechanical ventilation, or aggressive fluid resuscitation within 12 hours of transfer to the PICU. We assessed the relationships of sociodemographic variables, PEWS, and SSO assignment with subsequent deterioration events using multivariate regression analysis to control for a number of covariates.

RESULTS

There were 97 patients with nonelective transfers to the PICU who were eligible for placement on the SSO lists before transfer, 51 of whom experienced qualifying deterioration events. Maximum recorded PEWS was significantly higher for patients with a subsequent deterioration event during the first 12 hours after transfer, compared with those who were transferred but did not experience a deterioration event in the first 12 hours (mean [SD]: 3.9 [2.0] vs 2.9 [2.0]; P = .01). This association persisted even after multivariate adjustment. SSO assignment was only marginally associated with risk of deterioration among this patient population, with or without adjustment for covariates.

CONCLUSIONS

The PEWS was significantly associated with ICU deterioration, whereas physician opinion was not. Used alone or in conjunction with physician assessment, PEWS is a valuable tool for identifying patients vulnerable to acute deterioration.

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

OBJECTIVE

To determine the use of paediatric early warning systems (PEWS) and rapid response teams (RRTs) in paediatric units in Great Britain.

DESIGN

Cross sectional survey.

SETTING

All hospitals with inpatient paediatric services in Great Britain.

OUTCOME MEASURES

Proportion of units using PEWS, origin of PEWS used, criterion included in PEWS, proportion of units with an RRT and membership of RRT.

RESULTS

The response rate was 95% (149/157). 85% of units were using PEWS and 18% had an RRT in place. Tertiary units were more likely than district general hospital to have implemented PEWS, 90% versus 83%, and an RRT, 52% versus 10%. A large number of PEWS were in use, the majority of which were unpublished and unvalidated systems.

CONCLUSIONS

Despite the inconclusive evidence of effectiveness, the use of PEWS has increased since 2005. The implementation has been inconsistent with large variation in the PEWS used, the activation criteria used, availability of an RRT and the membership of the RRT. There must be a coordinated national evaluation of the implementation, impact and effectiveness of a standardised PEWS programme in the various environments where acutely sick children are managed.

Republished: paediatric early warning scores: Holy Grail and Achilles' heel

Early Warning Scores (EWS) have become increasingly used by hospitals throughout the world to prevent unexpected admission to intensive care or even death in their inpatient population. It is well known that signs of deterioration are present well before collapse and by a combination of systems, EWS enable healthcare professionals to intervene at an appropriate time. A number of national bodies and regulators in the UK have required the use of Early Warning Scores in locations where children are inpatients. This article attempts to describe the background to their development, identify common problems and provide information for units interested in introducing an EWS into their department.