From the 2018 HVPAA National Conference
Therese Canares, MD, Kemi Badaki, MD, Jonathan Eisenberg, MD, Dorte Thorndike, Sapana Edwards, Tamara Pegram, Samuel Gottleib, MD, Aoibhinn Nyhan, MD, Kristen Nelson, MD, Christpher Grybauskas, MD
Pediatric early warning scores (PEWS) have been integrated into children’s hospitals to assess clinical status and determine the need for intervention. Hopkins Pediatric Early Warning Score (HPEWS) is unique as it integrates physical exam findings, applies specific clinical parameters, and uses a maximal score rather than an additive score.
This is a quality improvement study to validate HPEWS in predicting pediatric intensive care unit (PICU) transfer of inpatients following signs of clinical deterioration as well to decrease the rate of PICU transfers with rapid response team (RRT) activation.
HPEWS scores patients on predetermined age-based vital signs and clinical findings, and offers a score of green, yellow, red, for 4 organ systems (neurologic, cardiovascular, respiratory, and gastrointestinal). A new red score is defined as any of the 4 organ systems that changed from green or yellow to red. A new red score prompts the bedside nurse to notify the physician, and physicians are expected to evaluate the patient. HPEWS was implemented on all 5 pediatric inpatient units, for all admissions, August 28-November 30 2017. Control patients were matched by age and admitting service, and scored in the first 24 hours of inpatient admission. Primary outcomes were the sensitivity, specificity, and likelihood ratio (LR) of a new red score within 24 hours prior to a PICU transfer. The secondary outcome was the proportion of RRTs who were transferred to the PICU. Early warning and early interventions are expected to increase the number of RRTs, but decrease the rate of PICU transfer within RRTs.
There were 2,161 patients included during the study period. There were 33 PICU transfers: 29 with a new red score and 4 with no new red score 24 hours prior to transfer. There were 39 control patients not transferred to the PICU: 5 with a new red score and 34 with no new red score. Sensitivity of a new red is 81.6% and specificity is 89.5% for predicting PICU transfer. A new red score correctly identified 85.5% of patients in this sample. LR of a PICU transfer having a new red score is 7.75. The area under the ROC curve is 0.86 (95% CI 0.78 to 0.93) (Figure 1). Proportion of RRT events transferred to the PICU remained unchanged from before implementation (Figure 2)
A new red score in HPEWS has high sensitivity, specificity, and likelihood to predict children transferred to the PICU. HPEWS is a useful tool to predict clinical deterioration on a pediatric inpatient unit. HPEWS provides a common language and communication approach for multi-disciplinary providers to evaluate children with changing clinical status. Next steps include transition of this tool into the electronic medical record, and automated transmission of a new red HPEWS score to providers.
Implications for the Patient
HPEWS offers improvement in communication between nurse and physician providers, allows for prompt interventions with new onset clinical deterioration, and successfully identifies patients who require escalation to PICU level care from a pediatric inpatient unit with a simple to use system.