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

Abstract

ObjectiveTo 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.MethodThe 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.ResultsFrom 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.ConclusionsDespite 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.

Pediatric early warning score and deteriorating ward patients on high‐flow therapy

“…Despite the limitations of PEWS scoring. that is, the lack of international standardization/validation, PEWS education and implementation processes, its utility in the monitoring of changes in respiratory status should be examined further. Not surprisingly, a more thorough and standardized evaluation of respiratory deterioration was identified early as one of the challenges that PEWS could address …”

‘Rational use of high‐flow therapy in infants with bronchiolitis. What do the latest trials tell us?’ A Paediatric Research in Emergency Departments International Collaborative perspective

“…Early warning scores are a numeric score generated from predetermined physiological criteria and observations, are utilised to alert staff to clinically deteriorating patients and are widely used in some countries . Without a better alternative, and until further evidence is available regarding the utility of paediatric early warning scores, utilising these widely used tools, and their components, appears appropriate to define failure.…”

Early warning scores in paediatrics: an overview

“…The first identified 33 distinct PEWS from 55 papers 4. The second identified 38 primary studies on original and/or modified PEWS from 90 papers 2. Both noted considerable variety in the number and type of component parameters and scoring strategies.…”

“…Paediatric Early Warning Scores (PEWS) have been advocated as a mechanism to aid healthcare professional’s recognition of children ‘at risk’, prompting increased monitoring and escalation to staff with the appropriate emergency and critical care skills 2. Although there is no universally agreed definition, PEWS are generally a composite of a number of vital signs and other clinical indicators indicating organ dysfunction.…”