The ROHNHSFT Experience:

Implementing BWCH PEWS

Alison Warren
Clinical Matron for Children and Young
Peoples Services
The Royal Orthopaedic Hospital NHS
Foundation Trust
RGN, RSCN, ENB 415 & 998
PG Cert (HE) MA Ed (cand)
APLS,EPALS,PHPLS, GIC & pILS Instructor

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 Background
• BWCH PEWS working group since first introduced in 2006
• Involved in a number of iterations of charts and policy (Working
Group)
• Data collection for unplanned PICU admissions
• SIM scenario training Wards / NQN programme
• Development of the BWCH Moodle E learning Package 2013
• Incorporated into Skills and Simulation training for BCU Student
Nurses
• UoB Student PEWS simulation Day
• Robust working knowledge of PEWS and PEWS education

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 Review of existing ROH Early Warning System
• Chart adapted from: Stanmore/Oswestry/BCH
• No Policy to support
• Score 0-4, escalation excluded senior medical
staff/KIDS
• 4 Triggers HR, RR, Temp and CRT
• Numeric recording (unable to see trends) included
components of fluid balance
• 3 age related parameters 2-5; 5-12; 12-16
• First time user impression, supportive reason to
change

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 Rationale for Change
• Potential Clinical Risk
• Supported by RCPCH
recommendation
• But…be careful!!!

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 What the Papers say:
• The recommended standards for measurement of vital
signs and observations: UK Royal College of Nursing
Standards for Assessing, Measuring and Monitoring Vital
Signs in Infants, Children and Young People (2013).
• The baseline frequency of observations depend on the
child’s individual clinical circumstances (range: daily-
continuous monitoring) regardless of reason for admission
• The escalation guide details the minimum observation
frequency for any child triggering PEWS
• It is essential to note any individual outlying parameters,
observe trends and be aware that a child showing no signs
of improvement may quickly lose the ability to compensate.

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 What the Papers say:

• Team members should be appropriately trained and maintain

their competency in the management of an acutely ill child
https://www.resus.org.uk/quality-standards/acute-care-quality-
standards-for-cpr/ NHS England ReACT (Response to ailing
children tool)
http://www.england.nhs.uk/ourwork/patientsafety/re-act/
• PEWS should complement care, not replace clinical judgement
• Clinician or family concern is a core parameter and an
important indicator (PEWS score should never undermine the
intuition of the child’s family or clinician)
• Observations and monitoring of vital signs should be
undertaken in line with recognised, evidence-based standards

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 What the Papers say:
• Hospitals should support additional safety practices that enhance
the Paediatric Early Warning System and lead to greater situation
awareness among clinicians and multidisciplinary teams.
• Paediatric Early Warning System’s should be supported through the
application of quality improvement methods, such as engagement
strategies, testing, and measurement to ensure successful
implementation, sustainability and future progress.
• Communication between all multidisciplinary team members is
essential for the effective interpretation of clinical concern.
Clinicians should use their clinical judgement when determining the
level of response required to the concern expressed and act
accordingly

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 Drivers for ROHNHSFT Change
• Paediatric early warning scores need to be part of a system
of in-hospital care but also link with tertiary centres
• The identification of evolving critical illness and escalation
of concerns then allows experienced clinical staff to
respond quickly to assess and stabilise patients in a timely
manner using the same language
• Communication between all multi-professional team
members is essential for the effective interpretation of
clinical concern
• Give clear escalation guidance for transfer or retrieval to an
area of higher dependency (CYPHDU) or intensive care at
Birmingham Women’s and Children’s Hospital (BWCH)

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 Exploring Risk and Gaining Support
• Champion the cause!
• Presenting the facts and
identifying the risks
• Scoping other centres and best
practice examples
• Senior Nurse support

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 PEWS at ROHNHSFT:
Applying the BWCH Model
• The Paediatric Early Warning Scoring (PEWS) System
at ROHNHSFT consists of the following 5 components:
• An Observation, Monitoring and Escalation Policy
• Standardised Observation Sheets with an embedded,
validated age-related Paediatric Early Warning Scoring
System and standardised fluid balance charts
• The PEWS Response referral algorithm including SBAR
communication
• Audit of unplanned admissions to the CYPHDU or
retrieval to BWCH from ward 11, CYPHDU or theatres
• An education and learning package

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 PEWS Implementation

Audit of unplanned
CYPHDU admissions/ Education and learning
KIDS Referrals package
/Retrievals

Score 1-4 or ↓ in GCS of 1 Score of 5-8 or ↓ in GCS of Score ≥ 9, GCS ≤ 11 or

point 2 points or concern VERY concerned
Discuss with nurse in Inform nurse in charge, call Call Anaesthetist / Critical
Care Outreach / call KIDS for
charge and consider pt’s own team (day) +/-
urgent referral / retrieval
increasing frequency of Anaesthetist/Critical Care 0300 200 1100
observations. Outreach/call KIDS for
clinical advice
03002001100
LIFE THREATENING - CALL 2222

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 The Learning Resource

No E Learning Platform!

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 Paediatric Early Warning Systems
Self Guided Learning and Assessment

The “How to” guide

and assessment

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Calculation and recording of
bedside PEWS

Bedside
PEWS
Score

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PEWS Response Algorithm

Ensure early escalation. Remember

KIDS offer clinical advice, they also like
to be aware if there are any CYP within
region that are showing signs of
deterioration

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 Patient Specific Parameters
Ensure the following before charting the patient’s observations and
calculating the PEWS score :

• The correct age chart is being used

• The patient name and details (demographics) are correctly recorded
• Patient specific parameters are documented at the top of the observation
chart. For many patients, the parameters will be as expected for the age
and this should be documented accordingly. However, discussion with the
medical team may be required as to when to escalate concerns dependent
on individual patient requirements, for example: an infant with chronic
lung disease on home oxygen may have an elevated PEWS score on
admission, which is normal for him/her. Identification of patient specific
parameters will enable you to be record the PEWS score on the
observation chart which will trigger further escalation and review.
• Alarm Limits are documented for any medical device used for monitoring

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 Patient Specific Parameters

A : Record patient specific parameters, these should be advised and documented

by medical staff. This is very important if the patient’s condition deviates from the
PEWS age related physiological parameters.
B : If there is continuous haemodynamic monitoring alarm limits must be recorded

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 Escalating /De-escalating frequency of
Observations
• When escalating or de-escalating the frequency of observations this
should be recorded on the observation chart.
• The date and 24-hour time should then be documented
• If there are any specific parental or nursing concerns then you
should tick the appropriate box and follow the PEWS Response
Algorithm. These concerns should be documented
contemporaneously in the patient healthcare records
• Escalation of concerns should be ticked once the SBAR
communication has occurred
• Any specific events can also be recorded in the Events Box

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 Patient Specific Risks

Any Patient Specific Risk Factors should be circled

at the top of the Observation Chart identifying any
of the following:
• Previous life threatening event (within 48 hours)
• Massive Blood Transfusion policy activated
• Non invasive ventilation
• Major Spinal Surgery
• Immunocompromised

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 Documenting observations
The 7 components of PEWS score:
• Respiratory Rate
• Heart Rate
• Systolic Blood Pressure
• Oxygen Saturations
• Oxygen Requirement
• Respiratory Distress
• Capillary refill time

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 Documenting observations:
Respiratory Rate, Oxygen Saturations, Oxygen Delivery
and Respiratory Distress

Assess patient for signs of respiratory

distress using a structured approach:
• Nasal flaring
• Tracheal tug
• Head bobbing
• Sternal recession
• Intercostal recession
• Subcostal recession

Best Practice Guidance

Use a dot to express the rate
Record the numeric value
Do not join the dots
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 Documenting observations: Heart Rate

•Always count the pulse for one full

minute
•Feel the temperature of the patient’s
hands and feet to check peripheral
circulation
•Consider palpating several sites to
check pulse strength

Best Practice Guidance:

Use a dot to express the rate
Record the numeric value
Do not join the dots
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 Documenting observations : BP
Blood Pressure needs to be recorded on the PEWS
chart using a consistent approach (RCN 2013)
therefore inverted and upright arrows Λ / V must be
used. Do not draw a line between. Use a dot if mean
arterial pressure(MAP)is being recorded. Score
Systolic value.
Λ
. (MAP)

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 Documenting observations:
CRT, PEWS Score, Sepsis 6, Temperature, AVPU,
Blood Sugar, Pain Score

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 Hints and Tips: Non-invasive BP
• Check that the medical device used for
monitoring non invasive BP is working
correctly. Ideally the same cuff should be used
for the duration of the hospital stay
• Choose the correct size BP Cuff for the age of
the child/ young person, align to artery and
ensure within range. Best position for
accuracy is left arm(closest to the heart)

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 Hints and Tips: CRT
• CRT can be assessed either peripherally or
centrally. It is best practice to assess CRT
centrally. If there are some concerns about the
patient an assessment of both peripheral and
central CRT provides more information about
the patient’s haemodynamic status
• Feel: Press on the sternum or forehead for 5
seconds, release and count how long it takes
for the colour to come back. Normal CRT for
the PEWS score at ROH is 2 seconds or less

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Recognition of Sepsis

Guidance is given on the PEWS

chart to escalate concerns if
sepsis is suspected.
The temperature section of the
PEWS chart is also shaded to
identify if patients temperature
trigger a sepsis concern

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 AVPU/Paediatric Coma Scoring

• AVPU-crude tool for rapid assessment

• A coma scale is a tool that instructs the assessor
how to perform and record a series of prescribed
neurological and haemodynamic observations on
a scaled chart
• Neurological observations enable the practitioner
to assess the neurological status of the patient
• Incorporated into PEWS and guidance for use in
Observation, Monitoring and Escalation Policy

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 Hints and Tips: Neurological Assessment

• The mode of painful stimuli used should involve

applying pressure on the side of the finger
sufficient to evoke a rapid response (avoid
pressure on the nail bed).
• If the patient has a significantly reduced
conscious level, use central stimuli by applying
supra-orbital pressure
• Ensure that assessment methods are consistent;
variations can course scoring anomalies.
Consistency is achieved by delivering a concise
and accurate bedside handover.

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 SBAR Communication
Situation
S Hello this is: name , designation and location
I am calling about: ( patients name and location).
The problem I am escalating
I am worried about….. Universal language,
Background ensure succinct
B Brief relevant medical history, i.e. diagnosis and recent events including surgery, etc.
highlighting key
Assessment concerns. Use A-E
A A – Airway
B – Breathing
assessment and
C – Circulation PEWS score.
D – Disability (AVPU and Glucose) Make your
E – Exposure
PEWS Score recommendations
Recommendations clear and document
R I suggest/request that you:
 Attend immediately the time and
 Transfer to HDU communication
 Review within 30 minutes
 Review on the next ward round outcome.
If a change in treatment is required then:
 How often do you want observations
 How long before you want us to get in contact again?
 Is there anything you would like to be performed /set up before you visit? i.e run
through IV infusion , set up for cannulation…..

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 Key Messages
• Early identification of increasing PEWS/
recognition of the sick child
• Understanding the multi-professional team’s role
in the management of deterioration
• Understanding the need to take appropriate
action in line with the PEWS Response algorithm
• Awareness of essential clinical guidelines
(national/ local)
• Early escalation according to PEWS Response
algorithm
• Early referral to KIDS if indicated for
advice/retrieval

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 Clinical Assessment of the use of PEWS
chart, PEWS Response Algorithm and SBAR
communication
Case Study
Baseline Obs
Case progression
PEWS Score, clinical decisions, actions
recommendations, SBAR Handover

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Any Questions?
alisonwarren2@nhs.net

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