Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children

Abstract

IntroductionThe timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals.MethodsWe performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients.ResultsA total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001).ConclusionsThe Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.

Triaje: instrumentos de priorización de las urgencias pediátricas

“…8 Existen varias versiones pero hay poca información disponible sobre su uso en diferentes contextos. [5][6][7]10,14,15 Encontramos que los niños con puntuación > 4 en triaje mediante Sistema de alerta temprana tuvieron una mediana para la edad menor (3 años) a los pacientes con puntuaciones menores (5 años). Estos hallazgos son congruentes con lo descrito sobre el mayor riesgo de gravedad e incluso de paro cardiorrespiratorio en niños más jóvenes.…”

Development of Heart and Respiratory Rate Percentile Curves for Hospitalized Children

“…Parshuram' s score had a sensitivity of 64% and a specificity of 94% in a validation study. 17 Akre' s score had a sensitivity of 86%; its specificity was not reported. 16 Neither has been evaluated in a clinical trial.…”

“…3 To facilitate the recognition of vital signs consistent with clinical deterioration, clinicians may rely on several afferent tools, including monitor alarms, electronic health record (EHR) vital sign alerts, MET calling criteria, and early warning scores (EWSs) that assign point values to vital signs outside of age-based ranges. [10][11][12][13][14][15][16][17] Limited data are available to inform the development of evidence-based parameters for monitor alarms, EHR alerts, MET calling criteria, and EWSs. Currently available sources to inform the configuration of these parameters include textbook reference ranges and existing EWSs with parameters developed using consensus opinion.…”

“…We aimed to determine the proportion of vital signs in our cohort that fell outside textbook [18][19][20][21] reference ranges and those that would be assigned points using existing EWSs. 16,17 Finally, we aimed to directly compare our HR and RR percentile cut points to those from a recent meta-analysis of vital sign distributions in well children. 22 …”

“…Because children have vital sign ranges that vary by age, tool development in pediatrics is particularly complex. Several pediatric EWSs have been described [10][11][12][13][14][15][16][17] with parameters developed using the consensus of experts. Parshuram' s Bedside Pediatric Early Warning System Score 11,14,17 and Akre' s Pediatric Early Warning Score 16 (adapted from Monaghan' s 10 and similar to Tucker' s 15 ) are the 2 most rigorously studied.…”