The Utilization of a Pediatric Early Recognition Tool in Identifying the Deteriorating Pediatric Patient in the Non-ICU Setting

This project seeks to evaluate the effectiveness of an early recognition tool at identifying clinical pediatric patient deterioration. The project includes a retrospective comparison of two early recognition tools in patients who experience clinical deterioration in the Non-ICU setting as well as randomly selected patients who did not experience an event. Various studies have demonstrated that improved recognition of the deteriorating patient improves overall outcomes. (Akre et al., 2010) The Confidential Enquiry into Maternal and Child Health report (2008) suggests that standardized monitoring systems should be embedded into acute care facilities that identify children at risk for critical illness or deterioration (McCabe, Duncan, & Heward, 2009). Early identification systems would assist with bedside nursing and practitioner recognition of a deteriorating patient possibly secondary to sepsis or other etiologies of shock. Early identification of a deteriorating child would help to lower the frequency of cardiac and respiratory arrest in this population, and improve the overall survival rates (Priestly G et al., 2004; Brilli RJ et al., 2007; Sharek PJ, Parast LM, Leong K, & et al, 2007; Hunt EA et al., 2008). There have been several tools developed for the adult population but more research on pediatric early recognition tools needs to be conducted (Parshuram et al., 2011). There have been several modifications of pediatric early recognition tools over the past few years. Two of the most recent revisions to the original Pediatric Emergency Warning Score (Monaghan, 2005) were completed by Texas Children's Hospital and the Hospital for Sick Children in Toronto. The initiation of timely interventions for the clinically deteriorating patient has demonstrated improved outcomes. In order for such interventions to occur, nursing staff and clinicians must first recognize patient deterioration. There currently is no objective tool utilized at Primary Children's Hospital to assist medical staff in recognizing these types of situations. This project has three primary objectives: 1) Compare the effectiveness of the Bedside Pediatric Early Warning System (Parshuram et al., 2011) and the Texas Children's Hospital Pediatric Advanced Warning Score Tool (Bell et al., 2013) at recognizing pediatric patient deterioration at Primary Children's Hospital; 2) Investigate how an early recognition tool can be integrated into the current electronic charting system at Primary Children's Hospital; 3) Disseminate project to inpatient Non-ICU unit directors at Primary Children's to demonstrate the possibility of improved patient outcomes with the use of an early recognition tool. A score for each tool was calculated for every patient that experienced a rapid response initiation, code blue activation, or unplanned transfer to the Pediatric Intensive Care Unit (PICU) up to 24 hours prior to their event. Scores were calculated every four hours, up to 24 hours prior to the event. An additional 20 patients who did not experience an event were randomly selected from each of the Non-ICU units, and scores were calculated for both tools. An addition to the current ECIS system was designed to automatically calculate a recognition score every four hours based on nursing assessment and patient vital signs. Overall, the PEWS tool was more sensitive in recognizing deterioration than the PAWS. The PAWS was more specific but had much lower thresholds of recognition. It is difficult to determine which tool would be more effective as there was a large amount of missing data-particularly for the PAWS calculations. Holes in current nursing documentation were identified and feedback was given to individual directors. The results from this project were presented to the clinical deterioration and quality improvement boards at PCH.