Performance of seven different paediatric early warning scores to predict critical care admission in febrile children presenting to the emergency department: a retrospective cohort study

Abstract

ObjectivePaediatric Early Warning Scores (PEWS) are widely used in the UK, but the heterogeneity across tools and the limited data on their predictive performance represent obstacles to improving best practice. The standardisation of practice through the proposed National PEWS will rely on robust validation. Therefore, we compared the performance of the National PEWS with six other PEWS currently used in NHS hospitals, for their ability to predict critical care (CC) admission in febrile children attending the emergency department (ED).DesignRetrospective single-centre cohort study.SettingTertiary hospital paediatric ED.ParticipantsA total of 11 449 eligible febrile ED attendances were identified from the electronic patient record over a 2-year period. Seven PEWS scores were calculated (Alder Hey, Bedside, Bristol, National, Newcastle and Scotland PEWS, and the Paediatric Observation Priority Score, using the worst observations recorded during their ED stay.OutcomesThe primary outcome was CC admission within 48 hours, the secondary outcomes were hospital length of stay (LOS) >48 hours and sepsis-related mortality.ResultsOf 11 449 febrile children, 134 (1.2%) were admitted to CC within 48 hours of ED presentation, 606 (5.3%) had a hospital LOS >48 hours. 10 (0.09%) children died, 5 (0.04%) were sepsis-related. All seven PEWS demonstrated excellent discrimination for CC admission (range area under the receiver operating characteristic curves (AUC) 0.91–0.95) and sepsis-related mortality (range AUC 0.95–0.99), most demonstrated moderate discrimination for hospital LOS (range AUC 0.69–0.75). In CC admission threshold analyses, bedside PEWS (AUC 0.90; 95% CI 0.86 to 0.93) and National PEWS (AUC 0.90; 0.87–0.93) were the most discriminative, both at a threshold of ≥6.ConclusionsOur results support the use of the proposed National PEWS in the paediatric ED for the recognition of suspected sepsis to improve outcomes, but further validation is required in other settings and presentations.

Mid-Regional Pro-Adrenomedullin in Combination With Pediatric Early Warning Scores for Risk Stratification of Febrile Children Presenting to the Emergency Department: Secondary Analysis of a Nonprespecified United Kingdom Cohort Study*

“…PEWS were calculated retrospectively from the first recorded observations at triage and biomarkers measured retrospectively on stored plasma samples. N-PEWS and AH-PEWS and were calculated retrospectively from the electronic database as per recently published criteria ( 7 ). Specifically, “work of breathing” was classified as mild in N-PEWS, with “stridor” and “cyanosis” classed as severe.…”

“…Specifically, “work of breathing” was classified as mild in N-PEWS, with “stridor” and “cyanosis” classed as severe. Any missing parameters were assumed to be normal ( 7 ). Although clinicians had access to AH-PEWS at time of patient assessment, clinical decisions were made blind to MR-proADM and procalcitonin results.…”

“…Data analysis was performed using SPSS Version 28 (IBM SPSS Statistics, IBM Corporation) and R Version Corporation, Armonk, NY) and R Version 4.1.0 (R Foundation for Statistical Computing, Vienna, Austria; https://www.r-project.org/ ). Optimal cutoffs for PEWS ( 7 ), MR-proADM, and procalcitonin ( 15 ) were identified using Youden’s J statistic ( 23 ). High N-PEWS was defined as greater than or equal to 6, high AH-PEWS as greater than or equal to 3, high procalcitonin as greater than or equal to 0.5 ng/mL, and high MR-proADM as greater than or equal to 0.7 nmol/L.…”

“…This problem fuels rising rates of antimicrobial resistance, as well as increased risk of adverse effects from antibiotics and fluid overload. To standardize the approach to the unwell child and improve patient safety, a U.K. National Pediatric Early Warning Score (N-PEWS) is being developed and evaluated in United Kingdom ( 5 , 6 ) and has been shown to be a good predictor for PICU or high-dependency unit (HDU) admission ( 7 ) in children presenting to the ED.…”

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

“…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 ].…”