Paediatric Rapid Response Systems: a literature review

Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review

OBJECTIVE

To systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children.

METHOD

The electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised.

RESULTS

From a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration.

CONCLUSIONS

Despite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. 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.

Validation of the Children's Hospital Early Warning System for Critical Deterioration Recognition

OBJECTIVE

Early warning scores, such as the Children's Hospital Early Warning Score (CHEWS), are used by hospitals to identify patients at risk for critical deterioration and trigger clinicians to intervene and prevent further deterioration. This study's objectives were to validate the CHEWS and to compare the CHEWS to the previously validated Brighton Pediatric Early Warning Score (PEWS) for early detection of critical deterioration in hospitalized, non-cardiac patients at a pediatric hospital.

DESIGN AND METHODS

A retrospective cohort study reviewed medical and surgical patients at a quaternary academic pediatric hospital. CHEWS scores and abstracted PEWS scores were obtained on cases (n=360) and a randomly selected comparison sample (n=776). Specificity, sensitivity, area under the receiver-operating characteristic curves (AUROC) and early warning times were calculated for both scoring tools.

RESULTS

The AUROC for CHEWS was 0.902 compared to 0.798 for PEWS (p<0.001). Sensitivity for scores ≥3 was 91.4% for CHEWS and 73.6% for PEWS with specificity of 67.8% for CHEWS and 88.5% for PEWS. Sensitivity for scores ≥5 was 75.6% for CHEWS and 38.9% for PEWS with specificity of 88.5% for CHEWS and 93.9% for PEWS. The early warning time from critical score (≥5) to critical deterioration was 3.8h for CHEWS versus 0.6h for PEWS (p<0.001).

CONCLUSION

The CHEWS system demonstrated higher discrimination, higher sensitivity and longer early warning time than the PEWS for identifying children at risk for critical 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.

Experience of pediatric rapid response team in a tertiary care hospital in Pakistan

OBJECTIVE

To report our experience before and after implementation of pediatric rapid response team (RRT) in pediatric wards of a tertiary care hospital in Pakistan.

METHODS

An audit of RRT activity from December 2007 to August 2008 was conducted and reviewed patient diagnoses at the time of call placement, interventions done and post-intervention clinical outcomes. Clinical Outcomes in the nine months before RRT implementation were compared with those in the first operational nine months after RRT.

RESULTS

Eighty-three calls were generated during the post-intervention study period of 9-month (21 calls/1000 admissions). The median age of patients was 27 months; 37% calls were for infants. The majority of patients were under care of medical services (93% vs 7% under care of surgical services). Greater numbers of calls were made during 0800-1600 hours (45%). Respiratory issues were the most common reason for activation of RRT. Because of early interventions, majority (61%) of patients avoided unnecessary PICU stay and expenditure; only 17% required mechanical ventilation in PICU. The code rate per 1000 admissions decreased from 5.2 (pre-RRT) to 2.7 (post-RRT) (p=0.08; OR 1.88 (95%Cl 0.9-3.93). The mortality rate of patients admitted in PICU from wards decreased from 50% to 15% (p=0.25; OR 1.64 (95%Cl 0.63-4.29).

CONCLUSION

Our experience with implementation of RRT was associated with reduction in cardiorespiratory arrest, mortality and saved a lot of PICU resource utilization. It is an excellent patient-safety initiative especially in resource-constrained countries by bringing PICU reflexes outside the PICU.

Clinical evaluation of algorithms for context-sensitive physiological monitoring in children

BACKGROUND

Subtle changes in monitored physiological signals might be used to guide clinical actions and give early warning of potential adverse events. Automated early warning systems could enhance the clinician's interpretation of data by instantaneously processing new information and presenting it within the context of previous observations. In this study, we tested algorithms for tracking the behaviour of dynamic physiological systems and automatically detecting key events over time.

METHODS

Algorithms were activated in real-time during anaesthesia to run context-sensitive monitoring of six variables (end-tidal PCO(2), heart rate, exhaled minute ventilation, non-invasive arterial pressure, respiratory rate, and oxygen saturation), alongside standard physiological monitors. The clinical evaluation included real-time feedback on each change point (change in the physiological trend) detected by the algorithms and the completion of a usability questionnaire.

RESULTS

Fifteen anaesthetists completed the evaluation during paediatric surgical cases. A total of 38 cases were evaluated, with a mean duration of 103 (102) min. The mean number of change points per case was 22.8 (23.4). Sixty-one per cent of all rated change points were considered clinically significant, and <7% were due to artifacts.

CONCLUSIONS

The algorithms were able to detect a range of clinically significant physiological changes during paediatric anaesthesia, and were considered useful by participating anaesthetists. These findings indicate that automated detection of context-sensitive changes is possible and could be used by early warning systems during physiological monitoring. Further investigations are required to assess how this information can best be communicated to the anaesthetist.