- Email: [email protected]
The Use of Pediatric Early Warning Scores in the Emergency Department
CLINICAL NURSES FORUM
THE USE IN
PEDIATRIC EARLY WARNING SCORES THE EMERGENCY DEPARTMENT
OF
Authors: Carol Oldroyd, MSc, BSc (Hons), PGCert, RGN, RNT, and Alison Day, MSc, PGCE, BSc (Hons), RN, RGN, Coventry, United Kingdom Section Editor: Susan McDaniel Hohenhaus, MA, RN, FAEN
Earn Up to 8.5 CE Hours. See page 424. arly warning scores are becoming an integral part of rapid patient assessment in the emergency department and provide a powerful tool when used in conjunction with graded response strategies. The main function of a scoring system is to detect changes in the patient’s physiological status in the context of their vital signs.1 Whereas these scoring systems work well with adults, their application to pediatric patients is more complex because of the variation in vital sign parameters, children’s compensatory mechanisms, and staff training issues. In 2006, almost 20% of the 119 million ED visits in the United States pertained to children.2 However, it is recognized that there is a relative lack of exposure to seriously ill or injured children among some ED nurses in health care facilities in the United States. Surveys indicate that 50% of emergency departments care for fewer than 10 pediatric patients per day, which highlights the difficulties of maintaining clinical competence for skills such as assessment and triage of children.3 The use of a dedicated pediatric early warning score (PEWS) would improve the identification and assessment of seriously ill children, providing objective, standardized care. However, evidence suggests that there is an unplanned approach to the development, implementation, and evaluation of such tools in both the United Kingdom and the United States.4
E
Carol Oldroyd is Senior Lecturer in Adult Nursing, Coventry University, Coventry, United Kingdom. Alison Day is Senior Lecturer in Emergency Nursing, Coventry University, Coventry, United Kingdom. For correspondence, write: Carol Oldroyd, MSc, BSc (Hons), PGCert, RGN, RNT, RC407, Richard Crossman Building, Coventry University, Priory Street, Coventry CV1 5FB, United Kingdom; E-mail: [email protected]. J Emerg Nurs 2011;37:374-5. Available online 19 May 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.03.007
374
JOURNAL OF EMERGENCY NURSING
The Complexities of a Pediatric Warning Score
The literature indicates that no standardized tool covering pediatrics is currently in common use. One of the difficulties in devising a tool for pediatric patients is the differing clinical parameters that are dependent on age. A further concern is that children initially compensate when critically ill before rapidly deteriorating, and thus a tool may not trigger an alert early enough to guarantee a successful intervention. An important parameter for triggering a response for a sick adult is an abnormal blood pressure recording, but this measurement carries more variability among children. Although guidelines indicate that a full set of vital signs, including blood pressure, should be obtained for all children, because of compensatory mechanisms and variability throughout the age continuum, appreciating the significance of the recording can be difficult. In other countries, such as the United Kingdom, blood pressure recording is not always a routine action, and reliance is placed on other circulatory assessment such as skin color and capillary refill time. Initial Assessment and Triage
Assessment carried out at triage needs to be quick but thorough. First impressions should include visual and auditory evaluation as well as the standardized A through E approach. This assessment should encompass obtaining a full set of vital signs (including blood pressure) and the patient’s weight in kilograms. It is vital for the clinical area to have the appropriate equipment to carry out this assessment. The joint policy statement “Guidelines for Care of Children in the Emergency Department” 5 states that equipment, supplies, and medications that are appropriate for children of all ages and sizes must be easily accessible, clearly labeled, and logically organized. This need has training implications for all staff members. Blood pressure cuffs and pulse oximetry probes of various sizes must be available and used according to clinical guidelines. Abnormal parameters for differing age groups should be placed in a prominent position in the emergency department to alert practitioners about when to notify a physician. A PEWS
VOLUME 37 • ISSUE 4 July 2011
Oldroyd and Day/CLINICAL NURSES FORUM
FIGURE 1 Brighton Paediatric Early Warning Score. Score 2 extra for one quarter hourly nebulizers or persistent vomiting following surgery.
FIGURE 2 Brighton Paediatric Early Warning Score. From: Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs 2005;17(1):32-35.
score that indicates a potentially sick child may be the trigger for further invasive investigations and monitoring such as arterial blood gases, a urinary catheter, and an electrocardiogram monitor and may alert staff to the need for a rapid response team.
July 2011
VOLUME 37 • ISSUE 4
Current Practice
A number of scoring tools exist that are aimed at identifying sick children. However, use of many of these tools is complicated and time consuming. The Brighton Pediatric
WWW.JENONLINE.ORG
375
CLINICAL NURSES FORUM/Oldroyd and Day
Early Warning score is an example of one of the simpler versions that is currently in use within the United Kingdom (Figure 1). The score looks at areas of behavior and cardiovascular and respiratory status and is not age specific. It relies on the premise that any scoring system should be easy to use and is not open to different interpretations by various users. The Brighton PEWS is designed to be used without generating too much extra work and without the need for specific equipment. It is designed as a quick preliminary assessment tool that can be used in conjunction with a full standard assessment. Color coding to alert the practitioner of the critically ill child and simple but clear guidance on appropriate actions to take are other features of the tool (Figure 2). Because of the multiplicity of scoring tools available, it is vital that all health care practitioners use the same tool to standardize care between clinical areas. Use of a simple tool such as the Brighton PEWS would enable this goal to be achieved. Summary
Numerous pediatric scoring systems have been produced using varying physiological parameters. These systems have primarily endeavored to predict critical illness in hospitalized children. One study exploring the validation of a PEWS score derived in an emergency department indicated a sensitivity of 70% and specificity of 90% for identifying children requiring intensive care unit admission.6 Clearly these scoring systems have an important role in the early warning of critical illness, but their diagnostic performance
376
JOURNAL OF EMERGENCY NURSING
is likely to be lower in less select populations or for predicting less critical outcomes.7 Although having a PEWS score for identifying sick children, clinical interventions, and transfers is advantageous, implementing a score that is accurate without being too time consuming or complicated to use will be a challenge. REFERENCES 1. Day A, Oldroyd C. The use of early warning scores in the emergency department. J Emerg Nurs. 2010;36(2):154-5. 2. American Academy of Pediatrics. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics. 2009;124 (4):1233-43. 3. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of United States emergency departments: a 2003 survey. Pediatrics. 2007;120 (6):1229-37. 4. McCabe A, Duncan H, Heward Y. Paediatric early warning systems: where do we go from here? Paediatr Nurs. 2009;21(1):14-7. 5. American Academy of Pediatrics. Joint policy statement—guidelines for care of children in the emergency department checklist 2009. http://aappolicy.aappublications.org/cgi/reprint/pediatrics;124/4/1233. pdf. Accessed March 17, 2011. 6. Egdell P, Finlay L, Pedley D. The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department. Emerg Med J. 2008;25:745-9. 7. Thompson M, Coad N, Harnden A, Mayon-White R, Perera R, Mant D. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child. 2009;94:888-93.
Submissions to this column are encouraged and may be sent to Susan McDaniel Hohenhaus, MA, RN, FAEN [email protected]
VOLUME 37 • ISSUE 4 July 2011
THE USE IN
PEDIATRIC EARLY WARNING SCORES THE EMERGENCY DEPARTMENT
OF
Authors: Carol Oldroyd, MSc, BSc (Hons), PGCert, RGN, RNT, and Alison Day, MSc, PGCE, BSc (Hons), RN, RGN, Coventry, United Kingdom Section Editor: Susan McDaniel Hohenhaus, MA, RN, FAEN
Earn Up to 8.5 CE Hours. See page 424. arly warning scores are becoming an integral part of rapid patient assessment in the emergency department and provide a powerful tool when used in conjunction with graded response strategies. The main function of a scoring system is to detect changes in the patient’s physiological status in the context of their vital signs.1 Whereas these scoring systems work well with adults, their application to pediatric patients is more complex because of the variation in vital sign parameters, children’s compensatory mechanisms, and staff training issues. In 2006, almost 20% of the 119 million ED visits in the United States pertained to children.2 However, it is recognized that there is a relative lack of exposure to seriously ill or injured children among some ED nurses in health care facilities in the United States. Surveys indicate that 50% of emergency departments care for fewer than 10 pediatric patients per day, which highlights the difficulties of maintaining clinical competence for skills such as assessment and triage of children.3 The use of a dedicated pediatric early warning score (PEWS) would improve the identification and assessment of seriously ill children, providing objective, standardized care. However, evidence suggests that there is an unplanned approach to the development, implementation, and evaluation of such tools in both the United Kingdom and the United States.4
E
Carol Oldroyd is Senior Lecturer in Adult Nursing, Coventry University, Coventry, United Kingdom. Alison Day is Senior Lecturer in Emergency Nursing, Coventry University, Coventry, United Kingdom. For correspondence, write: Carol Oldroyd, MSc, BSc (Hons), PGCert, RGN, RNT, RC407, Richard Crossman Building, Coventry University, Priory Street, Coventry CV1 5FB, United Kingdom; E-mail: [email protected]. J Emerg Nurs 2011;37:374-5. Available online 19 May 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.03.007
374
JOURNAL OF EMERGENCY NURSING
The Complexities of a Pediatric Warning Score
The literature indicates that no standardized tool covering pediatrics is currently in common use. One of the difficulties in devising a tool for pediatric patients is the differing clinical parameters that are dependent on age. A further concern is that children initially compensate when critically ill before rapidly deteriorating, and thus a tool may not trigger an alert early enough to guarantee a successful intervention. An important parameter for triggering a response for a sick adult is an abnormal blood pressure recording, but this measurement carries more variability among children. Although guidelines indicate that a full set of vital signs, including blood pressure, should be obtained for all children, because of compensatory mechanisms and variability throughout the age continuum, appreciating the significance of the recording can be difficult. In other countries, such as the United Kingdom, blood pressure recording is not always a routine action, and reliance is placed on other circulatory assessment such as skin color and capillary refill time. Initial Assessment and Triage
Assessment carried out at triage needs to be quick but thorough. First impressions should include visual and auditory evaluation as well as the standardized A through E approach. This assessment should encompass obtaining a full set of vital signs (including blood pressure) and the patient’s weight in kilograms. It is vital for the clinical area to have the appropriate equipment to carry out this assessment. The joint policy statement “Guidelines for Care of Children in the Emergency Department” 5 states that equipment, supplies, and medications that are appropriate for children of all ages and sizes must be easily accessible, clearly labeled, and logically organized. This need has training implications for all staff members. Blood pressure cuffs and pulse oximetry probes of various sizes must be available and used according to clinical guidelines. Abnormal parameters for differing age groups should be placed in a prominent position in the emergency department to alert practitioners about when to notify a physician. A PEWS
VOLUME 37 • ISSUE 4 July 2011
Oldroyd and Day/CLINICAL NURSES FORUM
FIGURE 1 Brighton Paediatric Early Warning Score. Score 2 extra for one quarter hourly nebulizers or persistent vomiting following surgery.
FIGURE 2 Brighton Paediatric Early Warning Score. From: Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs 2005;17(1):32-35.
score that indicates a potentially sick child may be the trigger for further invasive investigations and monitoring such as arterial blood gases, a urinary catheter, and an electrocardiogram monitor and may alert staff to the need for a rapid response team.
July 2011
VOLUME 37 • ISSUE 4
Current Practice
A number of scoring tools exist that are aimed at identifying sick children. However, use of many of these tools is complicated and time consuming. The Brighton Pediatric
WWW.JENONLINE.ORG
375
CLINICAL NURSES FORUM/Oldroyd and Day
Early Warning score is an example of one of the simpler versions that is currently in use within the United Kingdom (Figure 1). The score looks at areas of behavior and cardiovascular and respiratory status and is not age specific. It relies on the premise that any scoring system should be easy to use and is not open to different interpretations by various users. The Brighton PEWS is designed to be used without generating too much extra work and without the need for specific equipment. It is designed as a quick preliminary assessment tool that can be used in conjunction with a full standard assessment. Color coding to alert the practitioner of the critically ill child and simple but clear guidance on appropriate actions to take are other features of the tool (Figure 2). Because of the multiplicity of scoring tools available, it is vital that all health care practitioners use the same tool to standardize care between clinical areas. Use of a simple tool such as the Brighton PEWS would enable this goal to be achieved. Summary
Numerous pediatric scoring systems have been produced using varying physiological parameters. These systems have primarily endeavored to predict critical illness in hospitalized children. One study exploring the validation of a PEWS score derived in an emergency department indicated a sensitivity of 70% and specificity of 90% for identifying children requiring intensive care unit admission.6 Clearly these scoring systems have an important role in the early warning of critical illness, but their diagnostic performance
376
JOURNAL OF EMERGENCY NURSING
is likely to be lower in less select populations or for predicting less critical outcomes.7 Although having a PEWS score for identifying sick children, clinical interventions, and transfers is advantageous, implementing a score that is accurate without being too time consuming or complicated to use will be a challenge. REFERENCES 1. Day A, Oldroyd C. The use of early warning scores in the emergency department. J Emerg Nurs. 2010;36(2):154-5. 2. American Academy of Pediatrics. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics. 2009;124 (4):1233-43. 3. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of United States emergency departments: a 2003 survey. Pediatrics. 2007;120 (6):1229-37. 4. McCabe A, Duncan H, Heward Y. Paediatric early warning systems: where do we go from here? Paediatr Nurs. 2009;21(1):14-7. 5. American Academy of Pediatrics. Joint policy statement—guidelines for care of children in the emergency department checklist 2009. http://aappolicy.aappublications.org/cgi/reprint/pediatrics;124/4/1233. pdf. Accessed March 17, 2011. 6. Egdell P, Finlay L, Pedley D. The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department. Emerg Med J. 2008;25:745-9. 7. Thompson M, Coad N, Harnden A, Mayon-White R, Perera R, Mant D. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child. 2009;94:888-93.
Submissions to this column are encouraged and may be sent to Susan McDaniel Hohenhaus, MA, RN, FAEN [email protected]
VOLUME 37 • ISSUE 4 July 2011