Case for change: a standardised inpatient paediatric early warning system in England

Abstract

Most children in hospital who are clinically deteriorating are monitored regularly, and their treatment is escalated effectively. However a small, but significant, number of deteriorating children experience suboptimal outcomes because of a failure to recognise and respond to acute deterioration early enough leading to unintended harm. Tragically this occasionally can have fatal consequences. Investigations into these rare events highlight common themes of missed early signs of deterioration in children, prompting regulatory agencies to suggest paediatric early warning systems (PEWS) to aid clinical practice. In England, track and trigger tools (TTT), which are one facet of PEWS have been widely rolled out but in a heterogeneous fashion. The evidence for TTT is mixed but they are complex interventions and current outcomes do not fully define the entirety of their potential impact. This article explains the rationale behind the decision of the NHS England and NHS Improvement, Royal College of Paediatrics and Child Health and Royal College of Nursing to implement a standardised inpatient PEWS as part of a system-wide paediatric observations tracking system in England and how this fits into a wider programme of activity.

Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis

“…The implementation of a standardised system may also serve to eliminate variations in care, streamline interventions and provide opportunities to investigate “missed” cases of deterioration that are potentially actionable. 46 The PUMA (Paediatric early warning system Utilisation and Morbidity Avoidance) Programme is one such framework that provides not only the PEWS tools but also guidance on implementation to support improvement initiatives. 47 …”

Paediatric early warning systems: not a simple answer to a complex question

“…The English National Health Service has started a schedule of activity to introduce a standardised inpatient PEWS chart. 38 This work is part of an overarching System-wide Paediatric Observation Tracking (SPOT) programme. The utilisation of standardised outcomes and end points, being developed as part of the programme, will hopefully avoid further heterogeneous results which will be difficult to interpret.…”

Health professionals’ initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

“…Paediatric early warning systems (PEWS) [ 1 – 3 ] and PEW scores [ 4 – 6 ] are based on a child’s vital signs and other factors such as parental concern [ 7 , 8 ]. They alert health professionals (HPs) to signs of a child’s deterioration, with the intention of triggering an urgent review and escalating care, as needed [ 9 ], and reducing emergency transfer to critical care, cardiac arrest and death [ 10 – 14 ].…”

“…They alert health professionals (HPs) to signs of a child’s deterioration, with the intention of triggering an urgent review and escalating care, as needed [ 9 ], and reducing emergency transfer to critical care, cardiac arrest and death [ 10 – 14 ]. Recording PEW scores can be paper-based or electronic [ 3 , 9 , 15 ]; e-scoring has advantages in comparison to paper-based scoring in terms of enhanced safety benefits including greater time efficiency, reduction in human error and instant availability of the recorded data [ 16 , 17 ]. There is a drive for PEWS to be embedded in the care of children in hospital [ 13 , 18 ], but in the UK their use is not consistent [ 3 ].…”

“…Recording PEW scores can be paper-based or electronic [ 3 , 9 , 15 ]; e-scoring has advantages in comparison to paper-based scoring in terms of enhanced safety benefits including greater time efficiency, reduction in human error and instant availability of the recorded data [ 16 , 17 ]. There is a drive for PEWS to be embedded in the care of children in hospital [ 13 , 18 ], but in the UK their use is not consistent [ 3 ]. The evidence base for the effectiveness of PEWS and PEW scores is ambiguous [ 18 , 19 ].…”