Even the concept of PEWS as a system (ie, the application of all four components in parallel as described above) is poorly developed. 10 Finally, although many paediatric early warning systems (PEWS) have been developed and tested, uncertainty remains as to which system, or system feature, is most useful for paediatric patients. There are several reasons for this: variation in age-specific thresholds for normal and abnormal physiology children's inability or difficulty in articulating how or what they feel children's physiological compensatory mechanisms staff training issues and the need for more focused attention on respiratory deterioration. Additionally, the application of early warning scores to paediatric patients is more complex than in adults. This led to a request from the Minister for Health that the Department of Health's National Clinical Effectiveness Committee commission and quality assure a number of National Clinical Guidelines including early warning scores for adult, maternity and paediatric healthcare settings.įor paediatrics, this request presented several design challenges, including the need for an observation tool that would work in all paediatric care settings (secondary and specialist care) and a requirement to align with the Adult and Maternity scores. 9 These included a lack of provision of basic fundamental care, failure to recognise risk of clinical deterioration, failure to act or escalate concerns about deterioration to appropriately qualified clinicians and lack of detail in medical record documentation about clinical status and potential risk of clinical deterioration. In Ireland, a 2013 patient safety review by the Health Information and Quality Authority (HIQA) into the unexpected death of a young woman in a maternity setting identified several care failures. 8 This highlights the need to view early warning tools as more than just a ‘score’, rather, they are part of a multifaceted ‘system’ approach based on the implementation of several complementary safety interventions to improve child patient safety and clinical outcomes. Critical to early warning scores are four integrated components which work together to provide a comprehensive safety system for clinically deteriorating patients and those that are most likely to identify and manage patients at highest risk for cardiac or respiratory arrest (1) the afferent component which detects clinical deterioration and triggers an appropriate response (2) the efferent component which consists of the personnel and resources providing the response (eg, medical emergency team (MET)) (3) the process improvement component containing elements such as auditing/monitoring/evaluation to enhance patient care and safety and (4) the governance/administrative component focusing on the organisational leadership, safety culture, education and processes required to implement and sustain the system. In using these physiological track and trigger systems, the goal is to ensure timely recognition of patients with potential or established critical illness and to ensure a timely and appropriate response from skilled staff. 3, 6Įarly warning scores are generally defined as bedside ‘track and trigger’ tools to help alert staff to clinically deteriorating children by periodic observation of physiological parameters, generation of a numeric score and predetermined criteria for escalating urgent assistance with a clear framework for communication. 2 Although the percentage of paediatric cardiopulmonary arrests for inpatient admissions has been reported as low (eg, 0.7–3%), 6, 7 survival to discharge for children that experience inhospital cardiopulmonary arrest is poor (11–37%). 4, 5 Recent years have also witnessed an increased risk of paediatric cardiopulmonary arrest, and its associated mortality, in acute healthcare settings largely as a consequence of increased acuity of care and higher dependency on technology. 1 Other studies have examined the signs (physiological and behavioural) of deterioration that may be present in the period preceding a cardiopulmonary arrest, 2, 3 and the fact that these features are often not recognised or acted on in a timely fashion by hospital staff. 1 The report concluded that ‘there should be ways of telling if something is wrong with a child as early as possible, for example, an early warning scoring system’. A seminal study of paediatric mortality in the UK estimated that approximately one in five children who die in hospital have avoidable factors leading to death and up to half of children have potentially avoidable factors. It is known that children who die or deteriorate unexpectedly in the hospital setting will often have observable features in the period before the seriousness of their condition is recognised.
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