Dataset Information

Pediatric Early Warning System Scores: Lessons to be Learned.

ABSTRACT: The objective was to evaluate the use of a pediatric early warning system (PEWS) score in Dutch general and university hospitals, 4 years after the introduction of a national safety program in which the implementation of a PEWS was advised. An electronic cross-sectional survey was used. All general and university hospitals ( n ?=?91) with a pediatric department in The Netherlands were included in the study. The response rate was 100%. Three-quarters of all Dutch hospitals were using a PEWS score in the pediatric department. A wide variation in the parameters was found leading to 45 different PEWS scores. Almost all PEWS scores were invalidated, self-designed, or modified from other PEWS scores. In one-third of the hospitals with an emergency room, a PEWS was used with a wide variation in the parameters leading to 20 different PEWS scores, the majority of which are invalidated. Three-quarters of the hospitals did implement a PEWS score. The majority implemented an invalidated PEWS score. This may lead to a false sense of security or even a potentially dangerous situation. Although these systems are intuitively experienced as useful, the scientific evidence in terms of hospital mortality reduction and patient safety improvement is lacking. It is recommended to establish a national working group to coordinate the development, validation, and implementation of a wide safety program and a PEWS usable for both general and university hospitals.

SUBMITTER: Sambeeck SJV

PROVIDER: S-EPMC6260327 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Pediatric Early Warning System Scores: Lessons to be Learned.

Sambeeck Sam J van SJV Fuijkschot Joris J Kramer Boris W BW Vos Gijs D GD

Journal of pediatric intensive care 20170503 1

The objective was to evaluate the use of a pediatric early warning system (PEWS) score in Dutch general and university hospitals, 4 years after the introduction of a national safety program in which the implementation of a PEWS was advised. An electronic cross-sectional survey was used. All general and university hospitals ( <i>n</i> = 91) with a pediatric department in The Netherlands were included in the study. The response rate was 100%. Three-quarters of all Dutch hospitals were using a PEW ...[more]

PMID: 31073463

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Project description:ImportanceEarly warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services.ObjectiveTo validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances.Design, setting, and participantsThis prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023.Main outcomes and measuresThe primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC).ResultsThere were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission.Conclusions and relevanceThis study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.

Project description:Pediatric early warning systems using expert-derived vital sign parameters demonstrate limited sensitivity and specificity in identifying deterioration. We hypothesized that modified tools using data-driven vital sign parameters would improve the performance of a validated tool.Retrospective case control.Quaternary-care children's hospital.Hospitalized, noncritically ill patients less than 18 years old. Cases were defined as patients who experienced an emergent transfer to an ICU or out-of-ICU cardiac arrest. Controls were patients who never required intensive care. Cases and controls were split into training and testing groups.The Bedside Pediatric Early Warning System was modified by integrating data-driven heart rate and respiratory rate parameters (modified Bedside Pediatric Early Warning System 1 and 2). Modified Bedside Pediatric Early Warning System 1 used the 10th and 90th percentiles as normal parameters, whereas modified Bedside Pediatric Early Warning System 2 used fifth and 95th percentiles.The training set consisted of 358 case events and 1,830 controls; the testing set had 331 case events and 1,215 controls. In the sensitivity analysis, 207 of the 331 testing set cases (62.5%) were predicted by the original tool versus 206 (62.2%; p = 0.54) with modified Bedside Pediatric Early Warning System 1 and 191 (57.7%; p < 0.001) with modified Bedside Pediatric Early Warning System 2. For specificity, 1,005 of the 1,215 testing set control patients (82.7%) were identified by original Bedside Pediatric Early Warning System versus 1,013 (83.1%; p = 0.54) with modified Bedside Pediatric Early Warning System 1 and 1,055 (86.8%; p < 0.001) with modified Bedside Pediatric Early Warning System 2. There was no net gain in sensitivity and specificity using either of the modified Bedside Pediatric Early Warning System tools.Integration of data-driven vital sign parameters into a validated pediatric early warning system did not significantly impact sensitivity or specificity, and all the tools showed lower than desired sensitivity and specificity at a single cutoff point. Future work is needed to develop an objective tool that can more accurately predict pediatric decompensation.

Dataset Information

Pediatric Early Warning System Scores: Lessons to be Learned.

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Pediatric Early Warning System Scores: Lessons to be Learned.

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