Pediatric Early Warning Scores

Pediatric Early Warning Score a Safety Net for Kids at University of Maryland Children's Hospital

As children with increasingly complex and acute health problems come to University of Maryland Children’s Hospital, aggressive changes to facilities and the care paradigm over recent months have kept apace, extending comfort and peace of mind to the sickest children and their families.

Major upgrades recently completed in an all new 19-bed pediatric intensive care unit (PICU) include private rooms for each patient, with dedicated family sleeping space in each room along with other conveniences. Meanwhile, the simultaneous implementation of Pediatric Early Warning Scores (PEWS) and rapid response team (RRT) initiatives for pediatric inpatients is designed to predict which children are at risk of clinical deterioration and mobilize the resources to treat them before a potentially catastrophic outcome can occur.

Offering all PICU patients private rooms helps protect them against the threat of hospital-acquired infections, says Jason Custer, M.D., assistant professor of pediatrics at University of Maryland School of Medicine. Other new amenities include a dedicated family consultation room and “tot guard” bracelets on children that activate an alarm if children leave the confines of the PICU without the knowledge of staff members.

“We also have the ability to provide complex care in any patient room without moving patients around as frequently as we did,” explains Dr. Custer. “The other nice thing is the aesthetic upgrades that have been made, including pediatric-specific nature themes throughout the unit and Xbox video games in each room with wireless remotes and movies.”

Scorecard Offers Objective Patient Assessment

Dr. Custer and pediatric critical care nurse practitioner Jessica Strohm Farber, D.N.P., C.R.N.P., decided together to explore the implementation of PEWS after learning more about other children’s hospitals across the country who also use the patient safety system. While pediatric code blue events at UMMC are rare — averaging one or two per year — both health professionals became convinced that PEWS was a smart choice because of the increasing complexity of pediatric cases presenting here.

“Most of the time we get a very subjective view of which patients are more worrisome, but we wanted some tools to make our assessment more objective,” Dr. Custer says. “It’s really a safety net for everyone.”

An objective scoring tool that’s based on a patient’s behavior, cardiovascular and respiratory status, PEWS helps to “package” the patient’s physiological data and clearly identifies the patient’s deteriorating status. In research, the tool has been shown to identify patients with at least an hour’s warning prior to a code blue event, creating a situational awareness that reduced the chances for unrecognized deterioration of patients and escalation to a higher level of care.

“The patient’s general neurological behavior — whether they’re irritable, awake and playful, or lethargic — is assessed,” Farber explains, noting that scores are routinely calculated every four hours on patients in acute and intermediate care. “Also, the respiratory perspective — how much oxygen they require, how hard they’re working to breathe, the rate of breathing or if it’s fast or hard. The cardiac perspective includes their perfusions, color and heart rate. It’s to identify patients who are stable at the moment and those more likely to get sicker so we keep a closer eye on them in general. It provides nurses with direction long before rapid response would need to be called.”

Adds Dr. Custer, “It also includes how frequently we’re needing to do interventions to keep them safe, such as how frequently they need suctioning, or to be moved, or to keep oxygen saturations within range.”

Rapid Response Team Implemented

The RRT and PEWS systems are designed to complement each other in pivotal ways, with foreboding PEWS scores and an associated algorithm guiding the mobilization of the RRT. Both were launched at the Children’s Hospital over the first half of 2013, with the three-person RRT team formed last winter. While team members rotate depending on who’s on shift, they always include an ICU physician or nurse practitioner, a respiratory therapist and a nurse. A noteworthy feature of the RRT is parents’ ability to participate in its activation.

“If a family is worried about their son or daughter, they can actually ask the staff to activate the RRT, so if they don’t feel their child is getting the attention they need they can ask for help,” explains Dr. Custer. “We find that families often know their children better than we do. Upon admission, nurses go over the rapid response system with them, and if they want to activate the team, phone calls are made and team members come. Our goal is for this process to take less than five minutes.”

The PEWS initiative began in February 2013 with the creation of an interdisciplinary workgroup created by UMMC pediatric providers. Prior to the formation of the workgroup, a PEWS feasibility study was completed to determine the appropriateness of PEWS for the UMMC inpatient pediatric population and to determine PEWS thresholds for the development of a rapid response algorithm. Later, an interdisciplinary workgroup comprised of physicians, nurses and respiratory therapists was created to implement PEWS.

Less than four months later, in early July, PEWS officially launched, fulfilling additional goals to educate staff about its implementation, undergo a trial period to assess gaps and redundancies, and determine how to perform ongoing monitoring.

“It certainly was a rapid process for the size of the change,” Dr. Custer says. “Part of the goal was to implement it at the start of the academic year with the interns, so that it became part of a culture change.”

‘Overarching Quality of Care’

With so few code blue events among UM pediatric patients each year, it may be difficult to use that statistic as a barometer of the effectiveness of the PEWS system, Farber and Dr. Custer agree. But it will certainly benefit communication among healthcare providers and help empower nurses to ask for help when scores indicate a patient’s imminent deterioration.

“Those two things can be reassuring safety nets,” Farber says. “We’re looking at critical care interventions, and if we get to patients before they deteriorate, we hope they’ll need less intervention.”

With the implementation of PEWS and the RRT, referring physicians have many solid reasons to send their emergent pediatric patients to the University of Maryland Children’s Hospital, Dr. Custer says.

“The reason physicians should send sick children to us is for the overarching quality of care we provide here, and PEWS is one indicator of that care,” he says. “We’re really in this to make sure our outcomes are the best, and as a referring physician, you’d want to make sure your patients are getting the highest quality care.”

To transfer a child to the University of Maryland, please call 1-800-373-4111.