PEWS Book

PAEDIATRIC EARLY WARNING SYSTEM (PEWS)
EDUCATION PROGRAMME
TRAINING MANUAL
Version 5 (September 2015)
NATIONAL CLINICAL PROGRAMME FOR PAEDIATRICS AND NEONATOLOGY:
PAEDIATRIC EARLY WARNING SYSTEM (PEWS) EDUCATION PROGRAMME MANUAL
CONTENTS PAGE
DISCLAIMER..................................................................................................................................... 2
GLOSSARY OF TERMS, ACRONYMS AND ABBREVIATIONS ............................................................. 3
FOREWORD ..................................................................................................................................... 5
Section 1. INTRODUCTION ............................................................................................................ 7
Section 2. IRISH PAEDIATRIC EARLY WARNING SYSTEM (PEWS) ................................................ 10
Section 3. COMMUNICATION, TEAMWORK AND MANAGEMENT PLANS .................................. 25
Section 4. ‘ABCDE’ STRUCTURED APPROACH TO CLINICAL ASSESSMENT .................................. 30
Section 5. SEPSIS .......................................................................................................................... 40
Section 6. PAEDIATRIC PHYSIOLOGY CONSIDERATIONS ............................................................. 44
Appendix 1. SAMPLE PAEDIATRIC OBSERVATION CHART ........................................................ 54
Appendix 2. ACKNOWLEDGEMENTS ........................................................................................56
REFERENCES, SUPPORTING LITERATURE AND FURTHER LEARNING RESOURCES ........................ 57
DISCLAIMER
The authors, other contributors to the programme, those who modified the training manual,
and the PEWS Steering Group cannot be held responsible for any loss, damage, or injury
incurred by any individual or groups using this programme.
The paediatric observation chart and incorporated Irish Paediatric Early Warning System
(PEWS) has been designed for use with paediatric patients in the hospital setting. It has not
been designed for use with adult patients or neonates under the care of the
neonatal/maternity units.
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GLOSSARY OF TERMS, ACRONYMS AND ABBREVIATIONS
The following definitions apply within the context of this document:
Child Refers to neonate, infant, child and adolescent under 18 years of age unless otherwise
stated
Clinician A health professional, such as a doctor or nurse, involved in clinical practice
Early Warning Score A bedside score and ‘track and trigger’ system that is calculated by clinical
staff from the observations taken, to indicate early signs of deterioration of a patient’s
condition
Family A set of close personal relationships that link people together, involving different
generations, often including (but not limited to) parents and their children. These relationships
are created socially and biologically, and may or may not have a formal legal status.
Infant A child, from birth to one year of age
ISBAR A communication tool, the acronym stands for Identify, Situation, Background,
Assessment, and Recommendation. This technique is used for prompt and appropriate
communication within healthcare organisations.
Neonate A newborn infant, specifically in the first 4 weeks after birth
Nurse in charge A nurse assigned to manage operations within a specific clinical area for the
duration of the shift
Safety pause A short, informal multidisciplinary team meeting which focuses on things
everyone needs to know to maintain safety. Based on one question – ‘what patient safety
issues do we need to be aware of today’ - resulting in immediate actions.
Track and Trigger A ‘track and trigger’ tool refers to an observation chart that is used to record
vital signs or observations graphically so that trends can be ‘tracked’ visually and which
incorporates a threshold (a ‘trigger’ zone) beyond which a standard set of actions is required by
health professionals if a patient’s observations breach this threshold.
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ABG Arterial Blood Gas

ACT Australian Capital Territory
AKI Acute Kidney Injury
ARDS Acute Respiratory Distress Syndrome
ATP Adenosine Triphosphate
AVPU Alert, Voice, Pain, Unresponsive
BP Blood Pressure
BPM Can be used in this document to refer to ‘breaths per minute’ in relation to
respiratory rate, or ‘beats per minute’ in relation to heart rate
CPR Cardiopulmonary Resuscitation
CRT Capillary Refill Time
DCU Dublin City University
DIC Disseminated Intravascular Coagulopathy
DOH Department of Health
ECG Electrocardiogram
GCS Glasgow Coma Scale
HR Heart Rate
HSE Health Service Executive
ICTS Irish Children’s Triage System
IMEWS Irish Maternity Early Warning Score
IO Intraosseus
IV Intravenous
NCEC National Clinical Effectiveness Committee
NEWS National Early Warning Score
NIC Nurse in Charge
O2 Oxygen
O2T Oxygen Therapy
PCR Polymerase Chain Reaction
PEWS Paediatric Early Warning System
PICU Paediatric Intensive Care Unit
RA Room Air
RE Respiratory Effort
RR Respiratory Rate
SD Standard Deviation
SIRS Systemic Inflammatory Response Syndrome
SpO2 Oxygen Saturation
SV Stroke Volume
UK United Kingdom
WBC White Blood Cell
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FOREWORD
For most children being admitted to hospital is a step towards recovery, improvement and
wellness. Children and their families expect hospital to be a safe place, and that being there
ensures the best chance of getting better. Although this is certainly the case for the majority of
paediatric inpatients, it is not the case for all. Clinicians have long recognised that some
children may deteriorate following admission to hospital, even after the initiation of treatment
and despite regular observations, assessment or review. A study from the United Kingdom
(UK), in 2005, which examined paediatric mortality, estimated that 1 in 5 children who die in
hospital have potentially avoidable factors leading to death; most commonly a failure to
recognise how sick they are. Despite the advances of modern medicine we still have room to
learn and improve. This learning has helped us to consider ways to improve our recognition of
the child who is deteriorating in hospital.
Paediatric early warning scores and systems have been in existence for over 10 years, and
continue to evolve. The initial research in this field attempted to find the physiological
parameters that best predicted a child was deteriorating or at risk for deterioration. Changes in
heart rate, blood pressure, skin perfusion, oxygen requirement, pulse oximetry, respiratory
rate, respiratory effort and consciousness level may all be predictors of deterioration. They
may also simply reflect that a child is unwell but not at significant risk. However if these
measurements are converted to a score and combined with the concerns of nurses or family at
the bedside, this information may be used to help clinicians recognise and rescue a sick child,
before they deteriorate. Other features that enhance the score are good teamwork &
communication, observation charts that prompt good decisions, improved situation awareness
and the involvement of families as partners in the monitoring for deterioration. When all these
elements are brought together we have not just a score but a system that generates patient
safety.
A good early warning systems should:

Promote a sense of what is happening as much as what’s going to happen; enhancing
the awareness of frontline healthcare staff as to how the patient is and what their
immediate needs are (situation awareness).
Assist the bedside nurse to raise their concerns to the nurse in charge or the junior
doctor to alert a senior colleague using standardised communication (e.g. ISBAR).
Recognise that the score from physiological measurement is only one element in the
recognition of the deteriorating child and that clinical acumen and “gut feelings” are
often just as important.
Rely on everyone in the child’s environment, especially their family, as those who know
the child best when they are “not right” or “not themselves”.
Allow for the fact that not all alerts will indicate deterioration but some will and that
effective teams accept this and work together to keep this balance right.
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This manual is designed to introduce the user to the Irish Paediatric Early Warning System so
that they may become competent in its use. It is an evolving resource, which will be updated
regularly by the steering group. Users are expected to have an understanding of paediatric
physiology and how it may be used to predict deterioration. There is a section which briefly
reviews this topic in the manual. Users are also expected to have knowledge and skills of
paediatric resuscitation, appropriate to their role, and be up to date with courses. The manual
aligns to resuscitation approaches but is not a resuscitation training programme.
Dr. John Fitzsimons

Chair, PEWS Steering Group
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Section 1. INTRODUCTION
This interdisciplinary education programme is designed to enable our clinicians to recognise the
deteriorating patient and to initiate appropriate and timely interventions. The programme
encourages improved communication between healthcare professionals, and adoption of a
patient-centred, quality-driven approach to enhance timely management of paediatric patients.
This programme has been modified to suit the Irish healthcare system from the COMPASS©
programme with the kind permission of the Health Directorate, ACT Government, Australia.
The Irish Paediatric Early Warning System (PEWS) is designed for use within the hospital setting
to increase patient safety and quality of care, to improve situational awareness of the
healthcare provider, to empower nurses and junior doctors to escalate care when necessary,
and to acknowledge the importance of recognising family concerns when working with this
vulnerable patient population. However, these national paediatric care standards cannot
change practice unless adopted by every hospital and underpinned by ongoing education and
training, evaluation and audit of the process, and necessary revisions as new knowledge and
science becomes available. Individual hospital PEWS governance committees will have
responsibility for local resources and arrangements to facilitate PEWS implementation that will
be guided by the standards and recommendations as set out in the National Clinical Guideline:
Paediatric Early Warning System (pending endorsement November 2015).
NB: PEWS does not replace the emergency call system in any hospital
The values and thresholds chosen for the PEWS triggers were agreed by the PEWS steering
group. This was a consensus process that drew on the systematic review of paediatric early
warning systems and scores carried out by Dublin City University (DCU), other PEWS systems in
use internationally, the Irish Children’s Triage System (ICTS) and published data on physiological
measurements for well children. The most widely validated PEWS triggers came from the
Canadian Bedside PEWS and this was the anchor point for many values. It is the view of the
steering group that there is no exact or ‘perfect’ threshold for any physiological parameter that
identifies deterioration. Combining and monitoring parameters over time creates situation
awareness of a child’s clinical status that can be shared with other team members. In addition,
using triggers from one parameter, e.g. raised heart rate, to promote information seeking from
other parameters, e.g. capillary refill time and blood pressure, enhances the clinical picture.
Following the pilot and consultation with stakeholders, the upper values for blood pressure
were revised down to reflect the possibility that they may be an early warning of a hypertensive
crisis. This is supported with specific guidance in this manual on the interpretation of elevated
blood pressure.
Paediatric Critical Illness

In children, cardiorespiratory arrest is usually hypoxic in origin, reflecting the limit of the body’s
capacity for continued compensation for the effects of underlying illness or injury. Respiratory
problems can quickly progress to severe distress and cardiac arrest. Good outcomes for
7
paediatric patients depend on clinicians completing a thorough clinical assessment, recognising

the progression of illness, accurately recording observations, calculating the total PEWS score,
and appropriately escalating care leading to early medical review.
It is important that all clinicians understand the key components that can lead to failures in
clinical management:
Factors Affecting Accurate and Timely Management

Absent or inaccurate ▪ Equipment not available
observations ▪ Equipment malfunctioning
▪ Inability to use equipment due to lack of knowledge
▪ Inadequate time to perform observations
▪ Inability to make time for performing observations
▪ Lack of understanding of why observations are important
▪ Absence of, or inaccurate, observations preventing
appropriate clinical decision making interpretation
Inability to understand ▪ Unable to trend results and interpret their meaning
observations recorded ▪ Lack of knowledge
Failure to trigger timely ▪ Inability to understand observations recorded
appropriate response ▪ Inability to make a diagnosis
▪ Inability to develop a treatment plan
▪ Failure to escalate if delay to medical review or the child’s
condition fails to improve
Having identified the key components of concern, it is then possible to address those areas that
relate to lack of knowledge. This education package, in conjunction with clearly formatted
observation charts for different age groups and the use of a ‘track and trigger’ system aims to
address these issues.
Rationale for the Irish PEWS Education Programme

The following PEWS education programme has been developed to support the introduction of
the national paediatric observation charts and associated PEWS score for use in Irish hospital
settings. Initially, the Irish PEWS arose from a national initiative aimed at improving the quality
and safety of paediatric inpatient care. It provides a framework for care and empowers
clinicians to act on behalf of any child with signs of deterioration or about whom they have a
clinical concern. The content of this manual is underpinned by evidence from multiple
professional sources: evidence from the literature, expert group consensus and experiential
learning from the pilot of PEWS. The literature review and focus group findings report are
referenced at the end of this manual.
8
Aim of the PEWS Education Programme

This education package is designed to assist the clinician in recognising a deteriorating child and
initiating appropriate and timely interventions while using the Paediatric Early Warning System.
Overall Learning Outcomes of the PEWS Education Programme

At the end of the programme the participant should be able to:
Complete the paediatric observation chart and calculate a PEWS score correctly
Recognise a deteriorating child, and communicate and manage their care appropriately
Identify the appropriate escalation pathway for each total PEWS score
Assist the multidisciplinary team with the development of management plans
Describe the ‘ABCDE’ approach to assessment
Components of the PEWS Education Programme
1. Self-directed learning: the purpose of this PEWS training manual is to detail background
to, and principles of, the Irish Paediatric Early Warning System
2. Attendance at a face-to-face programme
The Irish PEWS National Clinical Guideline (due for endorsement in November 2015)
recommends that all clinicians working with paediatric patients should attend PEWS education
at least every 2 years. In addition, clinicians working with paediatric patients should maintain
knowledge and skills in paediatric life support in line with mandatory or certification standards.
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Section 2. IRISH PAEDIATRIC EARLY WARNING SYSTEM (PEWS)
Aim
The aim of this section is to provide an overview of the national paediatric early warning system
Learning Outcomes
At the end of this section the participant should be able to:
Outline the principles on how to complete the paediatric observation charts and calculate
a PEWS score
Describe the clinician’s responsibilities when a trigger score is met
Describe the theory behind the permitted variances under the Paediatric Early Warning
System
Introduction
The Paediatric Early Warning System (PEWS) is a multifaceted approach to improving patient
safety and clinical outcomes.
PEWS is based upon the use of several complementary quality features, including:
standardised paediatric observation charts,
a Paediatric Early Warning System score (the PEWS score),
escalation guideline,
good communication using the national standard (ISBAR communication tool for
patient deterioration),
and timely clinical intervention and clear documentation of management plans.
Successful implementation of PEWS at institutional level requires a sound education

programme and ongoing audit, evaluation and feedback; and at the individual level, a greater
degree of situational awareness and understanding of the child’s clinical condition and needs.
The PEWS score is embedded within a set of standard national age-specific paediatric
observation charts that allow for greater uniformity of practice in children’s hospital care. A
multi-parameter bedside score and ‘track and trigger’ system is calculated by nursing staff from
the observations recorded, with the aim of detecting early signs of a child’s deterioration. It is
a valuable additional tool to facilitate the detection of deteriorating paediatric patients,
particularly in acute wards where children are often quite unwell and there may be
inexperienced staff.
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Paediatric Observation Chart Design
Front page Middle pages Back page
Escalation guide Amended Parameters Age specific PEWS key
Medical escalation suspension Event record
White space for local

Observation chart
additions, e.g. pain
ISBAR prompt - Immediate triggers
assessment tool, neurological
- Aggregate triggers
assessment tool
Paediatric Sepsis 6
Measurement of Vital Signs and Observations

The ‘ABCDE’ structured approach should be used when assessing, measuring and recording vital
signs (see Section 4). Visual observation, palpation (touch), listening and communication, are
used when assessing and measuring vital signs. This includes taking note of any concern
expressed by the child’s family. Early detection of deranged vital signs is imperative for early
treatment and the prevention of clinical deterioration and even, death.
The PEWS score is calculated via a multi-parameter tool that includes respiratory rate and
effort, inspired oxygen, oxygen saturations, heart rate, systolic blood pressure, capillary refill
time, level of consciousness and family/nurse concern. The child's colour, temperature and
urine output are also considered. The PEWS encourages observation of trends in a child’s
condition. Clinicians should take note of changes in respiratory effort, increased oxygen
requirements or decreasing level of consciousness, for example.
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Some key benefits to be expected (anticipated) under the national Paediatric Early Warning
System:
Benefits of the Paediatric Early Warning System (PEWS)
Child The PEWS increases the potential to identify and review trends in a child’s
condition. If vital signs are outside the expected normal range the PEWS
acts as an early warning alarm or safety mechanism to flag deterioration
in a child’s condition. It will prompt the nurses caring for the child to
monitor him/her more closely, and to seek a medical review if needed. If
there are any signs of clinical deterioration the escalation guidelines
should provide a pathway to enable prompt appropriate review and
intervention. Early detection and management of deteriorating patients
may reduce the incidence of unplanned admissions to the Paediatric
Intensive Care Unit (PICU) and adverse clinical events.
Family The PEWS acknowledges the value of the partnership between clinicians
and family. If a family member expresses concern at the clinical condition
of the child, this increases the weight or significance of the total PEWS
score. In the instance of a low PEWS score but significant family concern,
the clinicians involved should give high regard to the concern expressed
by the family member.
Nurse The PEWS helps to empower nurses to voice their concerns about a child.
Each time the observations are taken the nurse or student nurse should
calculate the total PEWS score. If the child triggers any score, the
escalation guidelines recommend a minimum level of observation
frequency related to the total PEWS score. The nurse is prompted when
to notify the nurse in charge who may then review the child and contact
medical staff as required.
NB: If immediate bedside interventions are appropriate, these should

be carried out including (but not limited to) calling for help,
airway positioning, providing oxygen, suction etc.
Nurse In Charge The nurse or student nurse should discuss specific concerns with the
nurse in charge, if time allows, prior to bleeping or calling for a medical
review of the child. This alerts the nurse in charge and allows him/her to
review the child if needed, and prioritise workload on the clinical area.
Doctor The PEWS assists doctors in planning the management of their patients.
Prompting of timely medical review and treatment of patients due to the
inbuilt escalation guidelines, and empowerment of junior medical staff to
escalate concerns earlier, are key components of this safety system.
Adapted from COMPASS®(2011)
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Calculating the Paediatric Early Warning System Score

To obtain the total PEWS score:
▪ Complete and record the six core parameter observations on the child (concern, respiratory
rate, respiratory effort, O2 therapy, heart rate and AVPU)
▪ Allocate scores for individual observations according to the colour-coded criteria on the child’s
age-specific chart (refer to template in Appendix 1)
▪ Additional parameter observations should be completed and recorded as clinically appropriate
▪ Calculate a total PEWS score by adding the individual scores together
Other charts may still be required in addition to the paediatric observation chart, e.g.
neurological observations, blood transfusion record, weight or fluid balance but use of the
national paediatric observation charts should be the standard. It is suggested that additions to
the paediatric observation chart back page may be determined locally for items such as the
Glasgow Coma Scale (GCS) and/or pain scale.
The following tables show the age-specific criteria for PEWS core and additional parameter
scoring. The values were selected from the best available evidence as examined within the
systematic literature review (Lambert et al., 2014). PEWS parameters underwent pilot,
amendment and further testing across four sites nationally before final confirmation by
consensus at National PEWS Steering Group level.
Table 1: 0-3 Months (inclusive)

From presentation to paediatric unit until the last day of the third month post-birth.
Note: Use corrected age for premature babies up to 3 months
Score 3 2 1 0 1 2 3
Respiratory Rate (bpm) ≤15 16-19 20-29 30-59 60-69 70-79 ≥80
Mild/
Respiratory Effort Severe
moderate
O2 therapy (L) ≤2L >2L
SpO2 (%) ≤85 86-89 90-93 ≥94
Heart Rate (bpm) <80 80-89 90-109 110-149 150-179 180-189 ≥190
Systolic BP (mm Hg) <45 45-49 50-59 60-79 80-99 100-109 ≥110
CRT >2 sec ≤2 sec
Pain /
AVPU Alert Voice
Unresponsive
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Table 2: 4-11 Months (inclusive)

From the 1st day of the fourth month post-birth until the day before the first birthday.
Score 3 2 1 0 1 2 3
Respiratory Rate (bpm) ≤15 16-29 30-49 50-59 60-69 ≥70
Mild / Severe
Respiratory Effort
Moderate
O2 therapy (L) ≤2L >2L
SpO2 (%) ≤85 86-89 90-93 ≥94
Heart Rate (bpm) <70 70-99 100-149 150-169 170-179 ≥180
Systolic BP (mm Hg) <60 60-69 70-79 80-99 100-109 110-119 ≥120
CRT >2 sec ≤2 sec
Pain /
AVPU Alert Voice
Unresponsive
Table 3: 1-4 Years (inclusive)

From the child’s first birthday until the day before the 5th birthday.
Score 3 2 1 0 1 2 3
Mild / Severe
Respiratory Effort
moderate
O2 therapy (L) ≤2 L >2 L
SpO2 (%) ≤85 86-89 90-93 ≥94
Heart Rate (bpm) <60 60-79 80-129 130-149 150-169 ≥170
Systolic BP (mm Hg) <70 70-79 80-89 90-109 110-119 120-129 ≥130
CRT >2 sec ≤2 sec
Pain /
AVPU Alert Voice
Unresponsive
14
Table 4: 5-11 years (inclusive)

From the child’s 5th birthday until the day before the 12th birthday.
Score 3 2 1 0 1 2 3
Mild / Severe
Respiratory Effort
moderate
SpO2 (%) ≤85 86-89 90-93 ≥94
Heart Rate (bpm) <50 50-69 70-109 110-129 130-149 ≥150
Systolic BP (mm Hg) <80 80-89 90-119 120-129 130-139 ≥140
CRT >2 sec ≤2 sec
Pain /
AVPU Alert Voice
Unresponsive
Table 5: 12+ Years (inclusive)

From the child’s 12th birthday onwards.
Score 3 2 1 0 1 2 3
Respiratory Rate (bpm) <10 10-14 15-19 20-24 25-29 ≥30
Mild / Severe
Respiratory Effort
moderate
SpO2 (%) ≤85 86-89 90-93 ≥94
Heart Rate (bpm) <40 40-59 60-99 100-119 120-139 ≥140
Systolic BP (mm Hg) <90 90-109 110-119 120-129 130-149 ≥150
CRT >2 sec ≤2 sec
Pain /
AVPU Alert Voice
Unresponsive
The National Early Warning Score (NEWS) for non-pregnant adult patients should be used
for inpatients in adult ward settings.
The Irish Maternity Early Warning System (IMEWS) is used for the inpatient care of
women with a confirmed clinical pregnancy and up to 42 days in the postnatal period.
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Escalation Guideline
Each PEWS score should prompt consideration of the escalation guideline presented on the
front page of the paediatric observation chart.
Note:
The escalation guideline may only be amended to include local additions, e.g. contact details or
specified team members, under the direction of the PEWS governance committee.
Guidance is provided on:

- the minimum frequency of observation measurement (observation frequency)
- the minimum personnel requiring notification (alert)
- when the child or infant must be reviewed (response)
Each progressive step in the escalation guideline corresponds to an increasing PEWS score, and
a greater level of concern for the condition of the child. The escalation is cumulative: each
increase in PEWS score involves the actions of the previous step, and provides additional
instructions in recognition of the heightened need for urgent medical intervention.
PEWS does not replace an emergency call
Observation
Score Alert Response
frequency
1 4 hourly Any trigger should prompt increase in
Nurse in Charge (NIC) observation frequency as clinically
ESCALATION GUIDELINE
2 2-4 hourly
appropriate
3* 1 hourly NIC review
NIC and 1st Doctor on call (Doc1)
4-5 30 minutes Urgent medical review
NIC and Doc1 and Senior Doc +
6 Urgent SENIOR medical review*
Consultant
Continuous URGENT PEWS CALL
≥7 Senior paediatric + anaesthetic Immediate local response team
staff
*Any single pink trigger on the observation chart warrants an urgent SENIOR medical review
PEWS does not replace clinical judgement, concern or impression
Frequency of Observations
The escalation guidelines set out the expected minimum frequency of assessment and
recording of the child’s vital signs and other observations once they are triggering a PEWS
score.
16
Nurses and medical teams must use discretion in this regard and may increase the frequency
of observations at any time.
Intermittent monitoring is acceptable if the child’s clinical condition is triggering a lower PEWS
score. Continuous monitoring is expected from a PEWS score of ≥6.
Note: use of monitoring technology does not replace the need for frequent nurse-led
assessment of the child and physical checking of pulse volume.
The six core parameters must be completed routinely, and the additional parameters should be
completed as clinically required or appropriate:
Core Parameters Additional Parameters

Concern Oxygen saturation
Respiratory rate Blood pressure
Respiratory effort Capillary refill time (central)
Oxygen therapy Skin colour
Heart rate Temperature
AVPU* Pain / blood glucose / other
*a sleeping child may not require wakening for AVPU assessment (see page 33)
It is important to remember that infants and children tend to have the capacity for a period
of compensation for underlying illness or injury. They may appear to be maintaining their
vital signs relatively unchanged between assessments as they continue to compensate but
this may change quite rapidly once they begin to tire.
It is essential to note any individual outlier parameters, observe trends over the current and
previous shifts, and be aware that a child showing no signs of improvement may quickly lose
the ability to compensate.
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Alerts
Guidance is given on the minimum level of senior clinician to be notified with each increasing
PEWS score. ISBAR is the national standard for effective clinical communication for patient
deterioration and is recommended as part of the PEWS.
Nursing The nurse in charge of the clinical area should be notified of any child triggering
PEWS. This will promote appropriate delegation of care and facilitate effective
interdepartmental communication. Nursing staff should seek guidance from the
nursing site manager or Nursing Administration if required at any time.
Medical The relevant medical or surgical team may be notified at any time due to concern
regarding a child’s condition or PEWS score. The escalation guideline
recommends an alert to the 1st doctor on call when a PEWS score of 3 is reached,
and a senior doctor at a PEWS score of 6. The child’s consultant should be
contacted about any significant changes in a child’s condition. The appropriate
medical response to any call regarding PEWS or concern about a child should be
decided upon by the local PEWS Governance Committee.
Urgent PEWS Call
If a score of ≥7 is triggered then the local PEWS / urgent response team or anaesthetics or other
locally agreed personnel must be alerted. The response may be activated as determined locally
under the PEWS governance committee.
The seniority of the doctor called should be reflective of the condition of the child.
Response
The minimum level of clinical response to a child triggering PEWS should be followed. All PEWS
triggers should be discussed with the nurse in charge, and should prompt increased frequency
of observations as per the escalation guidelines. Medical notification is compulsory once the
PEWS score is ≥3. If the PEWS score is ≥4 a medical review is warranted. Any single parameter
with a score of 3 (pink), or total PEWS score ≥6, warrants a senior medical review. This review
must take place within a timeframe reflective of the urgency of the situation, but must be no
longer than 30 minutes from the time of notification.
If, at any time, there is clinical concern regardless of the PEWS score, a higher level of alert
and response may be activated.
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Variance
Additional considerations relating to the PEWS for individual patients can be charted as a
variance. In some situations clinical judgement may determine that amendments can be made
to:
- the trigger parameters (parameter amendment)
or
- the escalation protocol (medical escalation suspension)
Parameter Amendment
Parameter amendments are applicable to children with a condition that permanently, or for a
fixed period, alters their physiological parameters so that their baseline observations are
significantly different from the expected baseline for age. A parameter amendment should only
be used for chronic and not for acute conditions.
To assign fixed amendments, use the Parameter Amendment Section of the observation chart.
Parameter amendments must only be decided by a doctor of registrar grade or above. A
baseline (usual for this child) range is assigned, along with the expected action if there is
deviation from this. The PEWS score is 0 if the observations fall within the amended range,
however the actual value must still be recorded. Any deviation from the amended parameter
range scores a single 3 (pink). The plan, including a review timeframe, must be documented in
the healthcare record.
Parameter Amendment Key Points

Amendments to acceptable parameters should only be decided by a doctor at registrar
level or above
This section is only to be used for children with pre-existing conditions affecting their
baseline physiological parameters
It is not to be used for children whose current illness is causing the transgression from
their baseline expected ranges
Transgression outside the accepted range scores 3 and requires appropriate clinical
response
Parameter Amendment Example

Consider the example of a child with cyanotic cardiac disease: the medical team may decide on
a trigger score for an oxygen saturation of less than 78%. These alterations need to be
documented by the medical team, and are aimed at preventing falsely triggering a PEWS
response for what is considered usual for that patient. These new limits should be reviewed
periodically. It is possible that following surgery parameters may change and must be updated
accordingly.
Abigail is 12 weeks old with a history of Tetralogy of Fallot, due for a repair procedure at 6
months of age. Her usual SpO2 values are 80-84% (information sourced from parents and
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previous admission charts). Abigail’s consultant may amend her trigger parameters for SpO2 for
the duration of this admission as follows:
Clinical New Acceptable Next Medical

Date/Time Doctor
Parameters Range Review
Date: 1/1/15 Next admission /
SpO2 80-84% in RA JD J.Doe 1234566
Time: 10.15 post-surgery
Medical Escalation Suspension

This is intended for children who are currently unwell, who have observations that deviate from
expected normal limits, and who are triggering PEWS. Some of these children may be stable,
and their increased score will reflect their observed illness as expected. Following assessment
they are considered unlikely to deteriorate if they remain stable in this new range. An example
of this may be an infant with bronchiolitis with an increased respiratory rate, increased
respiratory effort, an oxygen requirement and some parental/nursing concerns: this child may
have a PEWS score of 4-5 that recommends escalation to a medical review on each occasion,
however this child is stable and is not expected to deteriorate further. In this case, the medical
escalation prompt may be conditionally suspended.
Medical escalation suspension must recognise stability in parameters that are triggering, but
continue to monitor for triggering in other parameters. It is important to be aware that
deterioration is always possible.
If the total PEWS score is increasing, if there are changes in any parameters other than
improvement, or there are new concerns then further senior medical assessment is needed.
To assign conditional suspension use the Medical Escalation Suspension Section of the
observation chart. A decision to suspend medical escalation should only be made by a doctor
of registrar grade or above. The agreed plan should state the medical impression and the
actions for escalation, including calling criteria and timeframe for review. This must also be
documented in the healthcare record. These amendments are temporary and must be updated
at least on a daily basis. The child’s observations should be recorded and scored as usual.
The suspension applies only to the medical arm of the escalation guideline.
Any temporary adjustment of escalation guidelines must be overridden at any time if there is
clinical concern.
20
Medical Escalation Suspension Key Points

Suspension of medical escalation guidelines should only be decided by a doctor of
registrar level or above
Child is recognised as unlikely to deteriorate if they remain stable in this new range
Escalation to senior nurse / nurse in charge always applies
Must be frequently reviewed, and must be disregarded at any time if the child’s condition
becomes concerning
Suspension usually applicable for a maximum 24 hour period
Medical Escalation Example

Suzie, a 13year old girl, has a history of asthma and atopy. She has been admitted via the
paediatric emergency department due to an exacerbation of asthma. She has been requiring 2-
hourly nebulised bronchodilators overnight in addition to her 4-hourly prescribed nebulisers.
The admitting registrar has examined and assessed Suzie and has made the clinical decision
that she is stable for the time being. He/she may complete the medical escalation suspension
as follows:
Date/Time Suspension Conditions Next Medical Doctor

Review
Start Date: 1/1/15 Improving asthma exacerbation. RR 31-34 Evening ward JD J.Doe
Time: 10.15 (1), RE wheeze, mild recession (1), 1hourly round 1234566
nebulisers, no O2 requirement, HR 115-124
End Date: (1). Medical review if any disimprovement
Time: or new concerns.
Special Situations
Occasionally children will trigger a PEWS score because they are upset, in pain or are pyrexial
leading to an increased respiratory rate, heart rate or BP. It is important that the score does
not override the nurse’s judgement in these circumstances, but equally it is important that the
nurse recognises the possibility that the PEWS may be indicating that there is cause for concern
and a need for senior input. An experienced nurse, or a student / junior nurse together with
the nurse in charge, may determine that it is appropriate not to escalate until action is taken,
such as working in partnership with the family in calming the child, and treating pain or fever.
The child should be reassessed as appropriate, and recorded in the ‘reassess within’ line on the
chart.
If the PEWS score remains elevated, or there is any uncertainty, it is best to proceed
according to the escalation guideline.
Of note, a child with a valid ‘Do Not Attempt Resuscitation’ order or equivalent who then
triggers a PEWS score on their observations should always receive a nursing / medical response
21
to the change in their condition. A decision not to attempt cardiopulmonary resuscitation (CPR)
applies only to CPR. It does not apply to any other aspect of treatment and all other treatments
and care that are appropriate for the individual should continue.
Nurse or Family Concern

Concern is a core parameter for PEWS and as such must be considered and recorded at each set
of observations. Concern (clinically) on the part of the family and/or nurse is given a score of 1.
Nurse
Occasionally, a child may not display abnormal vital signs or a measurable change in condition
and therefore may be triggering a low or no PEWS score, but a nurse may feel that the child’s
general clinical appearance or symptoms give rise to significant concern. This clinical
judgement represents an aspect of personal situation awareness (see Section 3).
Parent/Family
Similarly, parents and families know their children intimately and can be acutely aware that
their child is unwell or 'just not right', sometimes long before the physiological parameters
become abnormal. If concern is significant, escalation may be initiated sooner, or to a higher
level, than the minimum recommended in the escalation guideline. Parent/family concern may
not be explicit. Open ended questioning techniques may help indicate the presence and degree
of concern for their child. Examples include: How do you feel your child is doing today? Or, how
does your child look to you today?
The PEWS score should never undermine the intuition of the child’s family or nurse.
Clinicians should use their best clinical judgement in determining the level of response
required to the concern expressed and act accordingly.
22
Blood Pressure
Blood pressure is recorded as part of the PEWS score if judged clinically appropriate or if other
cardiovascular parameters are compromised. Systolic blood pressure is a trigger for PEWS at
upper and lower levels. While PEWS is more focused on the detection of low blood pressure, it
may also be useful in the detection of elevated blood pressure as an early warning. The trigger
points (1, 2 or 3) are chosen to reflect the likelihood that the result reflects an abnormality
rather than being thresholds of certainty. Blood pressure readings that trigger PEWS are
abnormal for many children, may be associated with clinical symptoms, and need to be
carefully considered. This is more significant as scores increase.
The interpretation of a single blood pressure reading is limited. If blood pressure is triggering
PEWS then seek evidence of end organ effects, e.g. signs of poor perfusion or evidence of
headache. If the blood pressure reading corresponds with a clinical concern then action should
be taken immediately to deal with this, i.e. manage clinically evident hypotension or
hypertension. If there is no immediate clinical concern, then review the following:
Is the correct cuff size being used?
If there is elevated blood pressure, is the child anxious or in pain?
If the above are addressed do measurements continue to trigger over time? Are they
trending up or down?
If readings remain abnormal then discussion should take place with senior clinical staff.
Completion of the Paediatric Observation Chart

The standardised national paediatric observation charts will be in use in all Irish hospital
settings where children are admitted.
Observations should be transcribed clearly, legibly and alphanumerically (i.e. the letter or
number) onto the paediatric observation chart.
Note: temperature is recorded as a graph.
For each criterion, the score should be noted in the relevant separate grey shaded line.
For every set of observations completed the total PEWS score must be recorded.
For every score of ≥1 the escalation guidelines must be considered.
The planned ‘frequency of observations’ and ‘reassessment within’ boxes are linked and reflect
ongoing critical thinking and clinical judgement on behalf of the nurse.
The ‘frequency of observations’ represents the planned frequency of observation interval
should the child’s condition remain unchanged.
‘Reassessment within’ is included to assist the nurse who makes a clinical decision to
adjust (increase or decrease) the interval of the next observation set for the child
depending on the changes - improvement or deterioration - in the child’s condition.
Should the nurse at the bedside feel that an adjustment to the planned frequency be
23
required, he or she may complete the ‘reassessment within’ (minutes) row under Total
PEWS Score.
Observations During Blood Transfusion

Children undergoing blood or blood product transfusion should continue with their routine
observations recorded on the paediatric observation chart and on the unit’s dedicated blood
transfusion documentation as determined locally.
Section 4 describes each observation individually as part of the ‘ABCDE’ assessment. It is

important to look at all the observations when assessing a child, and not just a single parameter
in isolation.
24
Section 3. COMMUNICATION, TEAMWORK AND MANAGEMENT

PLANS
Aim
The aim of this section is to provide an overview of the national standard for communication
(ISBAR), and documentation of management plans.
Learning Outcomes
Describe the process of communication with other clinicians using a structured tool
(ISBAR)
Appreciate and discuss the importance of teamwork and team participation
Outline other complementary systems that improve situation awareness and patient
safety
Describe the components of management plans
Introduction
An important factor in determining outcome for an acutely ill child is the quality of the
communication among the clinicians involved. In teams, each member has varying
competencies and skills, and different levels of knowledge. The aim in managing the
deteriorating child is to determine the role of each member of the team, identify when support
is required and work together to achieve the best outcome for the child.
The Paediatric Early Warning System is one aspect of the hospital’s safety structures. All PEWS
triggers require interaction between healthcare teams. If a student nurse finds that a child has
an abnormal respiratory rate and increased effort of breathing, he/she must refer this
information to the registered nurse working with them for more guidance on how to proceed.
When a junior doctor is concerned about a deteriorating child, he/she need to discuss the
findings with their registrar or their consultant. The child must be attended to appropriately
and promptly. Timely, accurate and effective communication is vital in improving clinical
outcomes for acutely ill infants or children. Infants and children may deteriorate rapidly and it
is imperative that senior nursing and medical staff are involved early.
Optimal management of the deteriorating child requires:

Gathering as much information as possible
Integrating this information into the presentation of the child
Escalating care to a senior decision maker
Addressing each team member’s concerns or response adequately
Formulating, documenting and communicating a management plan with a provisional
diagnosis
Implementing the management plan
Reassessing for possible re-review and escalation or de-escalation of the management
plan
25
Situation Awareness
Potentially preventable morbidity and mortality from unrecognised deterioration remains a
concern and is often due to a lack or loss of situation awareness. Situation awareness can be
defined as “the perception of elements in the environment within a volume of time and space,
the comprehension of their meaning, and the projection of their status in the near future”
(Endsley & Garland, 2000). Improved situation awareness drives better recognition of early
deterioration and is essential in efforts to reduce poor outcomes from significant deterioration
or cardiorespiratory arrest outside of the PICU.
There are three elements to situation awareness:

1 Perception: Gather Information
Each member of the team (including the child and/or family) has information about the child’s
current situation (individual situation awareness), which may be facilitated by tools such as
PEWS scoring and the ISBAR structured communication tool.
2 Comprehension: Recognise and Understand the Information

The next step is to integrate the information gathered to fully understand the current situation
of the child, e.g. the need to understand why a heart rate or respiratory rate has risen.
3 Projection: Anticipate, Predict, Mitigate and Escalate

Once information has been gathered and analysed the next step is working out what to do with
the information. Certain events may be anticipated or predicted with a degree of certainty.
There may also be the opportunity to take action to mitigate further deterioration which
usually involves an escalation to look for extra support and specialist assistance. This requires
concise and precise communication between clinicians to ensure there is shared situation
awareness.
Additional structures and tools that support a sense of shared situation awareness are also
available, including:
Briefings
Briefings are team-based updates given at an allocated time. They are focused and structured
to cover essential information relating to safety over the next 12—24 hours. This may include
current and predicted ward activity, identification of high risk patients or treatments in use,
same name individuals and staffing issues. Briefings are short, usually no longer than 1-2
minutes.
Huddles
Huddles are short meetings (less than 15 minutes – often shorter) that bring key frontline staff
together at fixed times throughout the working day, e.g. morning, afternoon, evening. The
purpose of the huddle is to create shared situation awareness amongst groups that work
together as a system in order to predict and improve safety and patient flow. Huddles can be
adapted to the needs of any team or organisation.
26
Safety Pause
National Clinical Guideline No.5 Communication (Clinical Handover) in Maternity Services
recommended that the ‘Safety Pause’ (HSE, 2013) is adopted nationally into clinical handover.
The safety pause provides an opportunity for staff to pause and highlight safety issues which
may assist them in being proactive about the challenges they face in providing safe high quality
care for patients. Emphasis on the safety pause as part of clinical handover complements the
implementation of PEWS. It is based on one question: What patient safety issues do we need to
be aware of today?; and results in immediate action.
Communicating Information
It is important to recognise when vital signs/observations are abnormal and make sure that
an appropriate referral is made to a senior clinician and that the child is attended to in a
timely and effective manner.
This means clinicians have to:

1. Identify that there is a problem
2. Attempt to interpret the problem in the context of the child they are caring for
3. Communicate the trigger to the appropriate people for further action
ISBAR for Communication of Patient Deterioration

Identify, Situation, Background, Assessment and Recommendation (ISBAR) is an easy,
structured and useful tool to help communicate concerns, and call for help or action. This tool
is used to assist staff in providing focused communication to other healthcare professionals.
Identify You. Recipient of information. Patient.
Situation Why are you calling?

Identify your concerns, PEWS score and parameter triggers.
Background What is the relevant background?

(age, reason for admission, relevant medical/surgical history, relevant
current treatment/interventions)
Assessment What do you think is the problem?

Give relevant ABCDE assessment information.
Recommendation What do you want them to do?
Adopted from National Clinical Guideline No. 5 Communication (Clinical Handover) in Maternity Services (2014)
27
Where a situation is deemed to be critical this must be clearly stated at the outset of the
conversation.
The Paediatric Early Warning System is a package of actions triggered by recognition of an

unwell child and the effective escalation of care leading to timely patient review and
interventions. It is a valuable additional tool to facilitate the detection of deteriorating
paediatric patients, but does not replace clinical judgement. When the PEWS triggers an
escalation of care, communication must describe the vital signs and other observations
triggering the escalation. For a doctor to be able to appropriately triage and advise on a
particular patient, they need to know the parameters that have caused the score rather than
just a score, e.g. when a high PEWS score triggers a communication, describe the observations
that have triggered (3 year old child, total PEWS score 4 due to: parental concern, RR 48, RE
M/M with recession, cough and wheeze, HR 136 and pyrexial at 38.7⁰c).
It is important to escalate care regardless of the PEWS score if there is clinical concern. A low
PEWS score should not be seen as evidence of reassurance if there is significant clinical
concern. In addition to ISBAR, clarification is to be encouraged where appropriate.
Timely, accurate communication is vital in determining the outcome for an acutely ill infant or
child. Infants and children may deteriorate more rapidly than adults and it is imperative that
senior clinicians are involved early.
ISBAR Example
An eight month old male infant with a history of prematurity and extensive bowel resection
secondary to necrotising enterocolitis is admitted to the ward with gastroenteritis. During the
morning shift there were large fluid losses through urine and faeces. The baby is tachypnoeic,
tachycardic, pale, crying and restless. You, as the nurse caring for the child, are concerned that
the baby is acutely unwell. His mother agrees.
IDENTIFY
“This is Sarah Murphy from Paediatrics calling about David Jones on ward B. Is this Dr. Brown,
Paediatric Registrar?”
SITUATION
“He is an eight month old male infant who has significant gastroenteritis and appears
dehydrated. His is total PEWS score is 6. He is tachypnoeic and tachycardic. I am concerned
about him.”
BACKGROUND
“He has a short bowel from extensive resection following necrotising enterocolitis. He came in
with gastroenteritis. He is on maintenance fluids”
ASSESSMENT
“I think he is acutely unwell and may be dehydrated*. He has lost 200grams since admission.
His vital signs are RR 70 with no increased effort, HR 175 with cool peripheries, central CRT 3
seconds and BP 82/60. He is quite unsettled.”
RECOMMENDATION
28
“I think this patient needs an urgent medical review (and he may require more fluids, electrolyte
levels and an arterial blood gas*). Is there anything I should do in the meantime?”
*notes in italics represent a clinical assessment which may be left out if you have not made a
diagnosis
Documentation
Documentation of medical and nursing care has a two-fold purpose:
1. It helps the flow of information from one shift to the next and often helps to clarify
thought processes
2. It is also a medico-legal requirement
You must always identify who needs to be informed about a deteriorating child, communicate
as much as possible and document appropriately.
A PEWS score of single trigger 3 or ≥4 must be documented in the Event Record on the
paediatric observation chart, in the child’s healthcare record, and in the nursing notes where
they are in use. All notifications to senior clinicians regarding concerns about a child’s clinical
condition must be similarly documented in the healthcare and nursing notes section(s)of the
medical chart or nursing kardex.
Event Record
This section on the back page of the observation charts should be completed for any PEWS
single trigger 3 or PEWS Score ≥4. It is designed as a prompt to assist with an audit trail and at
clinical handover.
Teamwork
Good communication is a key feature of effective teamwork and using a structure such as ISBAR
helps to standardise practice. There are other elements of teamwork that may improve patient
care such as debriefings after events.
Documenting and Formulating Management Plans

The quality of patient care may be reflected in the formulation of management plans. To allow
successful flow of information from one team, one shift and one ward to the next, the plan for
care must be documented.
Following clinical review, medical staff should document their impression, which is the
provisional diagnosis, and include directions as to the required frequency of observations,
criteria for escalation of care and guidance from the team as to when to be concerned, or
directions for a medical escalation suspension.
Reassess
It is important to monitor a sick child, and to reassess at regular intervals, particularly if an
intervention has been implemented, to see if they are improving or if further interventions are
required.
29
Section 4. ‘ABCDE’ STRUCTURED APPROACH TO CLINICAL

ASSESSMENT
Aim
The aim of this section is to provide an overview of the ABCDE structured approach to clinical
assessment in relation to PEWS.
Learning Outcomes
Understand the relevance of the ‘ABCDE’ structured approach to clinical assessment, and
its relevance to the PEWS score
Note: This section is intended to complement any of the paediatric life support courses currently
taught nationally. There are many textbooks and paediatric life support courses that
incorporate the ‘ABCDE’ structured assessment. Local resources including texts, annual
CPR updates and advanced paediatric life support courses should be available for further
learning about the assessment of seriously ill or injured children.
Introduction
Children vary in weight, size, shape, intellectual ability and emotional responses. Infants are
particularly vulnerable to insult by illness or injury. Competent management of children in
hospital requires knowledge of the anatomical, physiological and emotional differences in
children as they grow, and a structured approach to assessment and recognition of illness.
In children, cardiorespiratory arrest is usually due to hypoxia. The child has the capacity to
engage compensatory mechanisms to cope with underlying illness or injury for a period of time.
Eventually, profound bradycardia typically deteriorates to pulseless electrical activity or
asystole. Once a child is in cardiorespiratory arrest, outcomes are generally poor. This
secondary cardiorespiratory arrest is rarely a sudden event, but more often a progressive
deterioration, as compensatory respiratory and circulatory mechanisms fail. The Paediatric
Early Warning System (PEWS) aims to detect deterioration in these children at the early stages
of worsening illness, and provide opportunity for timely medical intervention to prevent
significant deterioration.
30
‘ABCDE’ Clinical Assessment

Early recognition of serious illness and effective management of respiratory, circulatory and/or
neurological problems will prevent the majority of paediatric cardiac arrests thus reducing
morbidity and mortality. The structured ‘ABCDE’ approach to assessment establishes situation
awareness among care providers and allows for clear prioritisation of initial management
strategies. The paediatric observation charts follow this structure to facilitate accurate
recording of observations and correct scoring of the PEWS criteria.
The ‘ABCDE’ assessment comprises the following:

Airway > Breathing > Circulation > Disability > Exposure
‘A’ Airway
When assessing the airway, consider the following:
Is the airway: Patent? Maintainable? Compromised?
Is there any difficulty breathing or speaking?
Are there added breath sounds?
Treat airway obstruction as a medical emergency and act immediately. Airway management
involves head positioning, safe clearance of secretions or foreign body, supplementary oxygen
and urgent specialist help.
PEWS Airway Assessment Criteria

Refer to the paediatric observation chart template (Appendix 1) for specific airway criteria.
Call for help immediately if a child’s airway is obstructed or if they are unable to maintain an
adequate airway.
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‘B’ Breathing
The “look, listen, feel” approach is a practical method to quickly determine causes of
abnormalities in breathing:
LOOK:
Count the respiratory rate
Note: Assess breathing for 1 full minute in infants. In an older child it is permissible to
count respirations for 30 seconds and double the value, provided the child appears
otherwise well and respirations are regular. High rates, and especially increasing rates,
are markers of illness and a warning that the child may suddenly deteriorate.
Assess depth, pattern and equality of breaths (respiratory effort):
• Use of accessory respiratory muscles
(sternomastoid muscle use: shoulder shrugging, head bobbing or nasal flaring),
• Recessions / retractions
(can include subcostal, intercostal, suprasternal (tracheal tug))
• Abnormal breathing pattern
(see-saw respirations,abdominal breathing, central cyanosis, unequal chest
movement)
Position
Colour
LISTEN:
Noisy breathing which may indicate secretions in the upper airways
Stridor or wheeze which may indicate partial airway obstruction
Grunting / gasping/ apnoea
FEEL for deformities:

Surgical emphysema / crepitus
Pulse oximetry completes the respiratory assessment. However, oximeters can be unreliable in
certain circumstances, e.g. if peripheral circulation is poor, the environment is cold, if the
patient is suffering a cardiac arrhythmia, convulsing, shivering, in bright overhead light, or if the
patient is wearing nail varnish. If the pulse oximeter does not give a reading, do not assume it
is broken – the patient may be poorly perfused.
Specific breathing management depends on the cause and it is vital to diagnose life threatening
conditions immediately, e.g. acute asthma, severe croup, epiglotittis. All critically ill children
should receive oxygen therapy.
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PEWS Breathing Assessment Criteria

Scoring can be triggered by abnormalities in the expected respiratory rate, any increase in
effort of breathing, presence of inspired oxygen and oxygen saturation readings.
Core Parameters
Respiratory Rate (RR)
Respiratory Effort (RE)
Note: Respiratory effort is recorded as normal (N), mild / moderate (M) or severe (S)
Oxygen therapy (O2T)
Note: O2 therapy is recorded as a numerical value in L/min of flow. Mode of oxygen delivery
should be recorded at each observation.
Respiratory Effort Criteria

Recession Head bobbing*
Stridor/wheeze Grunting*
Accessory muscle use Gasping / apnoea*
Nasal flaring Central cyanosis*
*Call for help immediately there is any head bobbing/grunting/gasping/apnoea/cyanosis
Normal
- absence of any RE criteria
Mild/Moderate
- presence of any degree of any RE criteria
Severe
- generally accepted as the presence of significant respiratory distress or
- 3 or more RE criteria or
- any one of the red/italics RE criteria
It is important to note that breathlessness and cyanosis in infants and children may be a sign
of serious cardiac pathology.
Additional Parameters
SpO2
Note: Sp02 may not need to be assessed for every child at every set of observations. However, it
must be assessed if there are any concerns regarding the child’s breathing or if the child is in any
amount of oxygen. Additional clinical judgement is required when a child is requiring
supplemental O2 to maintain SpO2 within the PEWS 0 range and is a significant clinical event if
the FiO2 increases and/or the SpO2 decreases.
If the pulse oximeter does not give a reading, do not assume it is broken – the patient may be
poorly perfused.
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‘C’ Circulation
Assess the child’s circulation by:
Taking a heart rate
It is not acceptable to record a heart rate from a pulse oximeter. Heart rate must be felt
by palpating a pulse for 1 minute or from an ECG reading.
Note pulse volume - weak, bounding, irregular etc., and compare central and
peripheral pulses
Measure central capillary refill time (CRT)
Measure blood pressure (BP)
Normal central CRT is ≤2 seconds.
Check skin colour and temperature - warm, hot and sweaty, pale and clammy, cool
and mottled
Note any demarcation line between warm and cool as peripheral vasoconstriction and
decreased perfusion improves or deteriorates.
Circulation management involves oxygen therapy (to correct tissue hypoxia), IV / IO fluids
and consideration of inotropic support to help maintain blood pressure, and early senior
input.
Blood Pressure Measurement in Children

Blood pressure (BP) in children increases with growth. The BP cuff should be sized
according to manufacturer instructions, and the correct size recorded on the observation
chart.
All children must have their blood pressure measured:

on admission
when there are signs of hypotension, shock, hypoperfusion, unexplained tachycardia,
hypertension, renal or cardiac disease, diabetes or adrenal disorders, head injury or
trauma
in neonates and infants if coarctation of the aorta is suspected or if there are signs of
hypotension (i.e. increased heart rate, increased respiratory rate, decreased urinary
output or looking unwell)
pre-operatively and on return to ward post-operatively
in critically unwell children
Pain, anxiety, chronic illnesses and certain renal conditions or anatomical anomalies may
give rise to a falsely elevated BP in the first reading (see page 23). It must be repeated at a
later stage. The first BP reading should be interpreted with this in mind.
In most forms of shock, BP is maintained within normal limits for the child until the
compensatory mechanisms fail. Hypotension is a very late stage of shock, and must be
34
recognised quickly and managed appropriately with fluids or inotropic support, as clinically
indicated by senior medical staff.
Bradycardia in Children
Bradycardia is a pre-terminal and ominous sign. Each paediatric observation chart highlights
the lowest acceptable limit for heart rate below which, if there are poor or no signs of life,
CPR should be commenced and the emergency response team call activated. These limits
were determined from consensus opinion of the Steering Group.
Age Specific Range Lower Threshold Limit for HR

(in the absence of signs of life)
0-3 months <80
4-12 months <70
1-4 years <60
5-12 years <60
12+ years <60
PEWS Circulation Assessment Criteria

Heart rate, central capillary refill (CRT) time and blood pressure are entered numerically
onto the paediatric observation chart. It is not essential to record CRT and BP every time on
every child. However, if there is any concern regarding the child’s circulatory status, central
CRT (sternum or forehead) and BP should be checked and recorded. If the total PEWS score
is >3 without inclusion of a systolic BP measurement, or if the heart rate triggers, then
central CRT and BP assessment should be considered. In addition, any heart rate trigger
should prompt referral to the Sepsis Six Protocol (see Section 5).
Core Parameters
Heart Rate (HR)
Additional Parameters
Central Capillary Refill Time (CRT)
Systolic Blood pressure (BP) - systolic BP is scored though systolic/diastolic may be recorded
as per local policy
Colour
Call for help immediately if a child has absent or poor signs of life and an absent, low or
poor pulse volume
35
‘D’ Disability
Assess the child’s neurological status:
Level of consciousness (AVPU)
Pupils
Posture
Glucose
Level of consciousness is assessed using the ‘AVPU’ scale. This grades the level of
consciousness according to the criteria below. If the child is not fully responsive or ‘A’ on
AVPU, consider completing your local unit’s paediatric Glasgow Coma Scale and seek expert
advice. If the child’s observations are within stated parameters and the child is asleep you
may not need to waken them to assess AVPU (see note below).
AVPU Score (Level of Consciousness Score)

0 = Alert
1 = Responds to Voice
3 = Responds to Pain or Unresponsive
Pupils should be checked as part of neurological observations and when there is any
reduction in the child’s level of consciousness. Any change in the size, equality or reactivity
of the child’s pupil is an important clinical sign of a change in neurological condition.
The abnormal posture of a child may reflect underlying brain dysfunction, which may only
be evident when eliciting the pain response. Abnormal postures include the following, and
warrant immediate senior medical review:
- Hypotonic (floppy)
- Hypertonic (stiff and tense)
- Decorticate (stiff with bent arms, clenched fists, and legs held out straight)
- Decerebrate (the arms and legs being held straight out, the toes being pointed
downward, and the head and neck being arched backwards)
- Seizure activity.
Blood glucose level is one of the first things which should be checked in an infant/child with
an altered level of consciousness. The blood glucose level should be ≥3.0mmol/L or
≥3.5mmol/L (as per local laboratory reference ranges).
The anterior fontanelle usually closes by 18 months of age but can close as early as 9
months of age. It is best assessed when the infant is quiet. Normally, the fontanelle is flat.
Crying vigorously can make the fontanelle more prominent. A bulging fontanelle requires
full examination for signs of raised intracranial pressure. A sunken fontanelle requires a
focused clinical examination for dehydration.
36
Disability management involve identification and treatment of the cause of the problem,
airway management as required, oxygen therapy to correct hypoxia, correction of blood
glucose or other electrolyte derangements, and early senior input.
PEWS Disability Assessment Criteria

Level of Consciousness (AVPU)
Note: AVPU is recorded and scored, however if the child is asleep with a normal sleep
pattern and there are no concerns about neurological status, they may not require wakening
to check AVPU. In this instance, a ‘/’ may be marked in the ‘A’ box and the score left blank.
Note: If the child has reduced consciousness (not ‘A’ on AVPU), a full GCS examination should
be considered and advice sought.
37
‘E’ Exposure, Environment and Everything Else

The child should be undressed, as appropriate, to facilitate a focused clinical examination,
examining the face, the trunk (front and back), extremities and the skin for any rashes,
evidence of trauma, bleeding, burns or unusual markings. Hypothermia can be prevented
through the use of heat blankets.
Assess the child for ‘Everything Else’ and note the following:
Temperature - consider core / peripheries
Rash
Skin integrity - blood loss, lesions, wounds, drains
Consider fluid balance.
PEWS Exposure Assessment Criteria

Temperature is not scored and is recorded as a graph. If the core temperature is ≤36 ̊c or
≥38.5 c̊ then sepsis should be considered and the Paediatric Sepsis 6 (PS6) protocol followed
(see Section 5).
Urine output is not scored. Medical advice should be sought if the child’s urine output is
<1ml/kg/hr or in the 12+ age group if output is below 0.5ml/kg/hr.
38
Summary
System Examination Paediatric Observation Chart and
Early Warning Score
Airway Patency
Risk factors
Breathing Respiratory rate RR*
Chest expansion RE*
O2 therapy*
Look: SpO2
Use of accessory muscles / recession /
retractions
Central cyanosis
Listen:
Auscultate / Percuss
Feel:
Palpate
Oxygen saturations and oxygen
delivery
Circulation Heart rate HR *
Pulses (central / peripheral) CRT (central)
Central capillary refill time Systolic BP
Blood pressure Skin colour
Skin temperature and colour
Disability Level of consciousness AVPU**
Pupils
Posturing
Fontanelle
Consider Blood Glucose
Exposure, Temperature Temperature
Environment Rash
and ‘Everything Injuries
Else’ Urine output
* core parameter
** clinical judgement may allow for non-completion of AVPU in the clinically unconcerning
sleeping child
39
Section 5. SEPSIS
Aim
The aim of this section is to provide an overview of the detection and management of
suspected sepsis in children
Learning Outcomes
Define key concepts related to sepsis in children
Utilise PEWS to aid the early recognition of sepsis
Use the Paediatric Sepsis 6 tool from National Clinical Guideline No. 6 Sepsis
Management for early management of sepsis and referral to senior colleagues
Introduction
In childhood, sepsis is defined as evidence of systemic inflammatory response syndrome
(SIRS) in the context of suspected, or confirmed, bacterial, viral or fungal infection. The
diagnosis of SIRS in children has been modified from the diagnostic features in adults and is
dependent on the presence of certain paediatric specific criteria.
SIRS is a response to a stimulus, which results in two or more of the following:

Temperature > 38.5°c or < 36°c
Respiratory rate > two standard deviations above normal (or pCO2 < 4.25Kpa)
Heart rate greater than two standard deviations above normal, or bradycardia in
children less than 1 year old (< 10th centile for age)
Leukocyte count > 12,000 cells/mm3, < 4,000 cells/mm3, or > 10% band forms
Hyperglycaemia, altered mental status, hyperlactaemia, increased central capillary
refill time (CRT)
Other important definitions in paediatric sepsis include:

Infection A suspected or proven (by positive culture, tissue stain, or polymerase chain
reaction test) infection caused by any pathogen or a clinical syndrome associated with a
high probability of infection. Evidence of infection includes positive clinical examination
findings (e.g. peritonitis, purpuric rash, purpura fulminans), radiograph findings (e.g. chest x-
ray consistent with a pneumonia) and positive laboratory tests (e.g. presence of white blood
cells in normally sterile fluid like urine).
Severe sepsis is sepsis and organ hypo-perfusion (raised lactate, oliguria, prolonged CRT,
reduced mental status) or organ dysfunction* (disseminated intravascular coagulopathy
(DIC), acute respiratory distress syndrome (ARDS), acute kidney injury (AKI))
Septic shock is sepsis and cardiovascular organ dysfunction*
*see end of section for definitions of organ dysfunction
40
The Paediatric Early Warning System (PEWS) seeks to improve the management of sepsis
with three approaches:
1. Early Recognition of Sepsis
2. Effective Resuscitation
3. Ease of Referral to senior colleagues and/or PICU
The following guidelines are shared with National Clinical Guideline No.6 Sepsis
Management (DOH, 2014b)
Recognition of Sepsis
The timely recognition of sepsis is a challenge for all paediatric clinicians. However sepsis is
a time critical medical emergency. Clinical history and physical examination may reveal
features in keeping with infection or some of the diagnostic criteria of SIRS. Some groups of
children have an increased risk for sepsis including:
Infants younger than 3 months
Chronic disease or comorbidity (e.g. children with immune deficiency,
immunocompromise, undergoing oncological treatment, asplenia, post-varicella,
indwelling catheters)
Incomplete vaccination record
Recent surgery
Keeping a high index of suspicion for sepsis in all children with signs of infection, risk factors
or criteria of SIRS is the key to early diagnosis. PEWS facilitates early recognition of sepsis by
highlighting and combining some of the SIRS criteria in particular measures such as
tachycardia or hypotension, which may be latent or overlooked in sepsis. PEWS is not
specific to sepsis, however, and acts only as a prompt for clinicians to consider its possibility.
It is also important to recognise that some of the SIRS criteria are not included as part of
PEWS (temperature, WBC).
If sepsis is suspected then tests that may confirm the diagnosis should be performed. In
addition early management should commence as outlined in the Paediatric Sepsis 6 (see
below).
Recognition of Sepsis 2 or more of the following:

- Core temperature <36°c or >38.5°c
- Inappropriate tachypnoea
- Inappropriate tachycardia
- Reduced peripheral perfusion
- Altered mental status
- Consider comorbidities
Sepsis screening should be used on all patients either presenting unwell or deteriorating
whilst an in-patient as evidenced by deteriorating early warning scores or picked up on
routine history and examination or by other means. Sepsis is diagnosed by the presence of
SIRS criteria due to suspected or proven infection.
41
Resuscitation and Completion of the ‘Paediatric Sepsis 6’

Recognition of sepsis should be accompanied by prompt and effective resuscitation. The
Paediatric Sepsis 6 outlines the key priorities for the first hour following the recognition of
sepsis:
Paediatric Sepsis 6
Get 3 Give 3
IV or IO access and take bloods High flow Oxygen

o Blood Culture & PCR
o FBC IV fluids
o Glucose & treat if low o Aim to restore circulating volume
o Blood Gas o Titrate 20mls/kg isotonic fluid over 5-
o Lactate 10 mins
o Repeat if necessary
o Caution for fluid overload
Urine output measure o Monitor for crepitations or
hepatomegaly
Early Senior input Broad spectrum IV/IO Antibiotics
The Paediatric Sepsis 6 represents the minimum intervention. Other blood tests, cultures or
investigations may be required depending on the clinical scenario. Blood tests must be sent
marked ‘urgent’, and must be reviewed and acted upon in a timely fashion. This also applies
to any other investigations ordered.
Once the diagnosis of sepsis has been made the ‘Paediatric Sepsis 6’ must be performed
within one hour.
Referral
The key difference between the Adult and Paediatric Sepsis 6 is the emphasis on early input
from senior clinicians/specialists. Senior paediatric medical staff must be informed early if
there are clinical concerns. Early involvement of PICU support is encouraged where
warranted. Where PICU support is not on site, a national 24-hour hotline is available for
urgent referrals, providing advice and arranging transfer. The national number for PICU
referral is 1890 213 213.
Early input from senior paediatric medical staff is important in the management of
childhood sepsis.
42
Organ Dysfunction Criteria
Cardiovascular Despite administration of isotonic intravenous fluid bolus ≥40

mL/kg in 1 hr:
Decrease in BP (hypotension) <5th percentile for age or
systolic BP >2 SD below normal for age
OR
Need for vasoactive drug to maintain BP in normal range
(dopamine >5μg/kg/min or dobutamine, Adrenaline, or
noradrenaline at any dose)
OR
Two of the following:
- Unexplained metabolic acidosis: base deficit <5.0 mEq/L
- Increased arterial lactate >2 times upper limit of normal
- Oliguria: urine output <0.5 mL/kg/hr
- Prolonged capillary refill ≥5 seconds
- Core to peripheral temperature gap ≥3°C
Respiratory PaO2/FiO2 < 300 in absence of cyanotic heart disease or pre
existing lung disease
OR
PaCO2 > 65 kPa or 20 mm Hg over baseline PaCO2
OR
Proven need for >50% FiO2 to maintain saturation ≥ 92 %
OR
Need for non-elective invasive or non-invasive mechanical
ventilation
Neurological Glasgow Coma Score < 11
OR
Acute change in mental status with a decrease in Glasgow
Coma Score > 3 points from abnormal baseline
Haematological Platelet count < 80,000/mm3 or a decline of 50% in platelet
count from highest value recorded over the past 3 days (for
chronic haematology/oncology patients)
OR
International normalized ratio > 2
Renal Serum creatinine > 2 times upper limit of normal for age or 2-
fold increase in baseline creatinine
Hepatic Total bilirubin >4 mg/dL (not applicable for newborn)
OR
ALT 2 times upper limit of normal for age
Taken from National Clinical Guideline N0.6 Sepsis Management (2014b)
43
Section 6. PAEDIATRIC PHYSIOLOGY CONSIDERATIONS
Note: This section is intended to summarise key physiological considerations in infants and
children, and to complement any of the paediatric life support courses currently taught
nationally.
Aim
The aim of this section is to revise specific considerations in paediatric physiology.
Learning Outcomes
Understand the basic principles of paediatric physiology and the importance of oxygen
delivery
Oxygen Delivery
Background
Oxygen is essential for Adenosine Triphosphate (ATP) production, a source of energy for all
intracellular functions. If there is inadequate oxygen supply, ATP production falls, and
cellular function is then depressed through lack of energy. This can lead to organ failure,
and may result in unplanned admission to an intensive care setting or, at worst, death.
Oxygen supply to the cells can be described by the “oxygen delivery chain”.
Oxygen Delivery = Cardiac Output x Arterial Oxygen Content
Oxygen delivery requires:

A. Arterial Oxygen Content
- haemoglobin concentration
- haemoglobin oxygen saturation
- partial pressure of oxygen
REFER TO SECTION ON AIRWAY AND BREATHING
B. Cardiac Output
REFER TO SECTION ON CIRCULATION
44
Airway Breathing Circulation
Exhaled air
Heart
&
Lungs
Inspired Air
Arterial Oxygen Content Cardiac Output
OXYGEN DELIVERY
ABC – Oxygen Delivery Chain
Airway and Breathing

Introduction
In order for oxygen to reach haemoglobin and be transported around the body to the
tissues, it needs to pass through the upper airways (nose, mouth, trachea) and lower
airways of the lungs (bronchi) to the alveoli. To do this, a patent airway, intact respiratory
nerve and muscle function are required to move air in and out of the lungs. Once oxygen is
in the alveoli, it diffuses across the thin alveolar capillary membrane into the blood, and
attaches to haemoglobin. From here, it is dependent on the pulmonary and then the
systemic blood circulation to move the oxygen to the tissues and cells where it is required.
Airway
Oxygen cannot move into the lower respiratory tract unless the airway is patent. Causes of
airway obstruction can either be mechanical or functional.
Functional airway obstruction may result from decreased level of consciousness, whereby
the muscles relax and allow the tongue to fall back and obstruct the pharynx.
Mechanical airway obstruction may be through aspiration of a foreign body or

swelling/bleeding in the upper airway, e.g. trauma, allergy and infection. Mechanical
obstruction may also be caused by oedema or spasm of the larynx.
45
Specific Considerations: Paediatric Airway

ANATOMICALLY PHYSIOLOGICALLY
The larynx is relatively high and anterior The lower airways are smaller and so
in position compared to the adult are at greater risk from being
airway obstructed by mucous, oedema or
The epiglottis is “U” shaped and active constriction
protrudes into the pharynx Minor decrease in the diameter of the
The trachea is short and soft and can small paediatric airway creates a large
become compressed if the neck is increase in the amount of resistance to
hyper-extended airflow
The narrowest part of the airway in The diaphragm plays a more significant
infants and children <8 years of age is role in the generation of tidal volume of
below the vocal chords at the cricoid infants and children as the cartilage
cartilage supporting the ribs is more flexible
The vocal chords are short and concave. allowing for paradoxical movement of
Large tongue in proportion to the oral the chest wall
cavity The metabolic rate of children is higher
and hypoxaemia can occur more rapidly
Breathing
Breathing is required to move adequate oxygen in and carbon dioxide out of the lungs.
Breathing requires:
- Intact respiratory centre in the brain
- Intact nervous pathways from brain to diaphragm and intercostal muscles
- Adequate diaphragmatic and intercostal muscle function
- Unobstructed air flow (large and small airways)
Importance of Respiratory Rate

An increased respiratory rate can reflect either a drop in arterial blood oxygen saturation
level or reflect compensation for the presence of metabolic acidosis. Respiratory rate may
therefore be an important indicator of inadequate oxygen delivery to the tissues and
therefore a marker of a deteriorating child. As oxygen delivery to the tissues is reduced,
cells revert to anaerobic metabolism. This increases the lactate production, resulting in the
accumulation of acid. This accumulation of lactic acid stimulates an increase in respiratory
rate (tachypnoea).
46
Specific Considerations: Paediatric Breathing

In children, increasing respiratory rate may be an early sign of inadequate oxygen delivery.
It is important to note that the metabolic rate of children is higher than adults. This means
oxygen consumption is higher and hypoxaemia can occur more rapidly.
Inadequate oxygen delivery at tissue level

Anaerobic metabolism

Lactate production

Metabolic acidosis

Stimulates respiratory drive

Increases the respiratory rate
Metabolic acidosis can increase the respiratory rate even though the arterial oxygen
saturation may be normal.
The decrease in oxygen delivery to the tissues, which results in tachypnoea, can be due to
problems at any point in the oxygen delivery chain.
Normal Arterial Saturation and Tachypnoea

There can be falling oxygen delivery despite normal arterial oxygen saturation. Therefore
rises in respiratory rate can occur in children with normal or low arterial oxygen saturation
levels and may well be a better indicator of deterioration than arterial oxygen saturation.
Paediatric Oxygen Delivery Systems

There are many oxygen delivery systems used in paediatrics that are age and/or size
specific. The delivery systems are classified into fixed and variable performance devices and
can deliver a wide range of oxygen concentrations.
Fixed performance devices such as Venturi masks are used in paediatrics, however only
occasionally. Please note that the colours and flow rates vary between companies. Always
read the label.
Variable performance devices such as nasal prongs, simple facemasks, partial rebreather
and non-rebreather masks come in different sizes to suit the individual size of the child.
Nasal prongs come in neonatal, infant, paediatric and adult sizes. These do not provide all
the gas required for minute ventilation, they entrain a proportion of air in addition to the
oxygen supplied.
47
The inspired oxygen concentration will depend on:

a) Oxygen flow rate
b) The child’s ventilatory pattern (if the child has a faster or deeper respiratory rate, more
air will be entrained, reducing the inspired oxygen concentration).
Nasal prongs
The dead space of the nasopharynx is used as a reservoir for oxygen, and when the child
inspires, entrained air mixes with reservoir air, effectively enriching the inspired gas. Use
oxygen flow rates of 2-4L/min.
High flow nasal prongs

These use warm humidified oxygen at higher flow rates 4-8L/min.
Humidification helps to loosen secretions and improve mucocilliary transport, prevent nasal
obstruction from hard dry secretions, and decrease discomfort and irritation. The type of
humidification device selected will depend on the oxygen delivery system in use and the
patient requirements. Cold dry air may increase heat and fluid losses in infants.
This type of therapy is generally suitable for patients with:

Bronchiolitis (usually up to 3 years of age)
Bronchial asthma (usually up to 6 years of age)
Other conditions deemed suitable by the consulting paediatrician
Oxygen facemask
Reservoir volume of oxygen is increased above that achieved by the nasopharynx, thus
higher oxygen concentration can be achieved in inspired gas (max 50-60%).
Oxygen flow rates less than 6L/min for an oxygen face mask should not be used due to
carbon dioxide retention in the mask.
Non-rebreather mask
A simple face mask with the addition of a reservoir bag, with one or two-way valves over the
exhalation ports which prevent exhaled gas entering the reservoir bag (permits inspired
oxygen concentration up to 90%). It has an oxygen flow rate of 12-15L/min.
Monitoring and Titrating Oxygen Therapy

Oxygen therapy can be monitored clinically (child’s colour, respiratory rate, respiratory
effort), or by measuring oxygenation with pulse oximetry or arterial/venous blood gas. The
advantage of measuring an arterial blood gas is that both oxygen and carbon dioxide are
measured, as well as the metabolic status (including lactate).
Oxygen should be prescribed by a doctor. In urgent situations, where oxygen is applied or

the amount increased, a doctor must review the patient.
In an acute setting, when taking an arterial blood gas sample, do not remove the oxygen.
48
As long as the concentration of oxygen being delivered is recorded, the degree of

hypoxaemia can be calculated. The blood gas machine can calculate this for you as long as
the correct inspired oxygen concentration is recorded.
SaO2 refers to directly measured arterial oxygenation usually via the blood gas.
SpO2 refers to oxygen saturation levels using the oximeter.
Directly Measured Arterial Oxygenation

Arterial blood gases can be sampled and analysed in a standard fashion. These provide the
gold standard method of measuring oxygenation. The ratio of oxygen carrying haemoglobin
compared to the total amount of haemoglobin can be accurately measured. This value can
be presented as a percentage which is termed SaO2. Arterial blood gas measurement is
invasive.
Indirectly Measured Oxyhaemoglobin

Pulse oximetry measures the presence of oxyhaemoglobin indirectly by measuring the
absorption of light at certain frequencies. The absorption of light can be related to the
presence of oxyhaemoglobin. This is usually done with a finger probe. It is possible to
provide an estimate of indirectly measured oxyhaemoglobin concentration as a percentage
of total haemoglobin. This is defined as the SpO2. Pulse oximetry is non-invasive but can be
affected by variables such as movement, the presence of unusual haemoglobin varieties,
including carboxyhaemoglobin, and nail varnishes or false nails. Oximeters can be unreliable
in certain circumstances, e.g. if peripheral circulation is poor, the environment is cold,
arrhythmias, or if the patient is convulsing or shivering. Although pulse oximetry provides
good monitoring of arterial oxygenation, it does not measure the adequacy of ventilation, as
carbon dioxide levels are not measured nor does it determine the adequacy of oxygen
delivery to the tissues.
If the pulse oximeter does not give a reading, do not assume it is broken – the child may
have poor perfusion.
Oxygen saturation may be ‘normal’ but the PCO2 may be high which reflects inadequate
minute ventilation and hence respiratory failure.
‘Normal’ arterial oxygen saturation does not rule out acute respiratory failure.
Blood Gases
Arterial blood gas (ABG) remains the gold standard for assessing respiratory failure. It
measures arterial oxygen, arterial saturation and arterial carbon dioxide. It also provides
information on the metabolic system (i.e. bicarbonate concentration, base excess and
lactate), an approximate haemoglobin, electrolytes and blood glucose.
ABGs should be measured in children who:

Are critically ill
Have deteriorating oxygen saturations or increasing respiratory rate
Requires significantly increased supplemental oxygen to maintain oxygen saturation
Have risk factors for hypercapnoeic respiratory failure
49
Have poor peripheral circulation and therefore unreliable peripheral measurements of

oxygen saturation
Circulation
The Importance of Oxygen
Oxygen reaching the cells and mitochondria is dependent upon adequate amounts of
oxygen being delivered via the blood circulation. Without oxygen being delivered to the
mitochondria, inadequate amounts of ATP are generated and cellular dysfunction occurs.
Oxygen Delivery = Cardiac Output x Arterial Oxygen Content
Stroke Volume x Heart Rate Haemoglobin x SaO2
Blood Pressure
Blood Pressure = Cardiac Output x Total Peripheral Resistance
A decrease in blood pressure can reflect a decrease in cardiac output which can lead
to a reduction in the amount of oxygen getting to the tissues
An increase in heart rate may reflect a decrease in stroke volume, which may reflect a
decrease in cardiac output which may lead to inadequate amounts of oxygen getting
to the tissues
Hence, the measurement of pulse and blood pressure are important surrogate markers of
whether there is adequate cardiac output and hence oxygen delivery to the tissues.
High pulse and low blood pressure may reflect inadequate oxygen delivery to the tissues
Blood Pressure and Maintenance of Organ Function

There are some organs that require an adequate blood pressure for their optimal function
as well as adequate oxygen delivery, e.g. brain, kidney.
Possible Causes of Hypotension

If blood pressure is the product of cardiac output and total peripheral vascular resistance,
blood pressure can fall because of either:
a) A fall in cardiac output
b) A fall in peripheral vascular resistance
50
Specific Considerations: Paediatric Blood Pressure

Blood pressure in children increases with growth and maturation.
Hypotension in Paediatrics
An adequate blood pressure is important for the function of vital organs including the brain,
heart and kidneys. Any reduction in blood pressure will trigger the body to respond in order
to maintain homeostasis.
Hypotension is a very late sign in children due to their excellent cardiovascular

compensatory mechanisms. Hypovolaemia causing circulatory collapse is one major
precipitant of cardiac arrest in infants and children. Hypotension in infants and children is
most likely to occur because of fluid loss from conditions such as gastroenteritis,
intussusception, or haemorrhage. Other reasons for hypotension can be from vasodilation
associated with sepsis, anaphylaxis or poisoning.
Infants and children have a greater percentage of body water compared to body weight
than adults. They have the potential for greater insensible losses due to their relatively
large surface area to volume ratio. This may result in more water loss and temperature loss.
Paediatric Compensatory Mechanisms for Hypotension

1. Cardiac Output
Cardiac output is calculated the same way for infants and children as it is for adults. It is the
product of stroke volume and heart rate, i.e. flow is the volume per unit time.
Infants have a smaller stroke volume relative to size than children ≥2 years of age. This
stroke volume is relatively fixed so that cardiac output is directly related to heart rate.
Practically this means that increasing fluid volume only works up to a point as stroke volume
cannot be significantly increased. So an increasing heart rate in children is often an early
sign of falling stroke volume, shock and/or inadequate oxygen delivery. This is
accompanied by peripheral vasoconstriction to maintain blood pressure.
As the ability of the body to compensate for inadequate oxygen delivery decreases, the
signs include:
Altered mental state, in infants fatigue may be an early indication
Central capillary refill longer than 2 seconds
Heart rate and respiratory rate trending down to normal levels without the
infant/child looking any better
Hypotension in infants and children is a late sign. Decompensation often happens quickly,
and if not treated immediately can quickly lead to death.
2. Heart Rate
This is determined by the rate of spontaneous depolarisation at the sinoatrial node. The
rate can be modified by the autonomic nervous system:
Parasympathetic stimulation SLOWS the heart rate via the vagus nerve, e.g.
vasovagal response, parasympathomimetics (anticholinesterases such as
neostigmine).
51
Sympathetic stimulation QUICKENS the heart rate via the sympathetic cardiac fibres,
e.g. stress response, temperature, sympathomimetics (adrenaline, noradrenaline,
isoprenaline).
Any change in heart rate can affect cardiac output. A faster heart rate can increase the
cardiac output and this often occurs when the stroke volume is falling, while any reduction
in heart rate can cause a decrease in cardiac output.
3. Peripheral Vascular Resistance

Changes in peripheral vascular resistance (the cumulative resistance of the thousands of
arterioles in the body) can increase or decrease blood pressure.
Consequences of Hypotension
Inadequate Cardiac Output
Cardiac output is integral to the amount of oxygen being delivered to the tissues. If
the cardiac output falls, it is likely that oxygen delivery will fall.
If there is inadequate oxygen delivery to the tissues, inadequate amounts of ATP can
be generated which is vital for cellular function.
This in turn leads to organ failure, lactate formation and shock.
Disability: Central Nervous System and Urine Output
Central Nervous System

Introduction
Depressed level of consciousness is a common finding in acute illness. It can occur due to
intracranial disease or as a result of systemic insults. Central nervous system (CNS) function
is an important indicator of adequacy of tissue oxygenation called “end-organ function”.
Thus disability assessment is included in the PEWS. CNS depression in itself can also be
associated with life-threatening complications. The most important complication is an
inability to maintain an adequate airway. Loss of the ‘gag’ or cough reflex for a child is
associated with a high risk of aspiration, often resulting in hypoxia and respiratory failure.
Specific Considerations: Paediatric Central Nervous System

It is important to choose the developmentally appropriate tool when assessing the level of
consciousness in infants and children. It can be difficult to assess the early signs of
neurological deterioration (reduced attention and dulled affect) in the infant/young child.
Often the parent is the best resource as they know their child is “just not themselves”. The
child who does not recognise their parent is significantly compromised. In infants and
young children the AVPU scale is most often used as it is more developmentally adaptable
than the Glasgow Coma Scale.
Causes of Loss of Consciousness

Poisoning is a common cause of neurological deterioration especially in the toddler age
range. Depending on the substance ingested the pupils may be small (opiates,
organophosphates) or large (amphetamine, atropine, tricyclic antidepressants). Other
causes can include head injury, infection (meningitis/encephalitis), seizures, haemorrhage or
space occupying lesions.
52
Assessment of Fontanelle
The anterior fontanelle is normally flat. It usually closes by 12-18 months but can close as
early as 9 months of age. It is best assessed when the infant is quiet. Crying vigorously can
make the fontanelle more prominent. A bulging fontanelle is a sign of increased intracranial
pressure from such causes as meningitis, an intraventricular bleed, and hydrocephalus. A
sunken fontanelle usually indicates dehydration.
Specific Considerations: Paediatric Urine Output

Glomerular filtration rate increases throughout the first two decades of life. This means
that infants and children cannot concentrate their urine as efficiently as adults.
Infants and children have a greater percentage of body water compared to body weight
than adults. They have the potential for greater insensible losses due to their relatively
large surface area to volume ratio. This may result in more water loss and temperature loss.
Newborns have larger extracellular fluid levels than infants and older children. This
extracellular fluid decreases over time so that by one year the ratio of extracellular fluid to
intracellular fluid is close to adult levels.
Urine output should be 1-2ml/kg/hour, e.g. 12-24ml/hour for a 12kg child. In the 12+ age
group, urine output should be >0.5ml/kg/hour.
53
Appendix 1. SAMPLE PAEDIATRIC OBSERVATION CHART
54
55
Appendix 2. ACKNOWLEDGEMENTS
PEWS Steering Group:

Dr. John Fitzsimons (Chair), Director for Quality Improvement, Quality and Patient Safety
Division HSE
Ms. Rachel MacDonell, National PEWS Coordinator
Ms. Claire Browne, Programme Manager, National Clinical Programme for Paediatrics and
Neonatology
Ms. Mary Gorman, Resuscitation Officer, Our Lady’s Children’s Hospital Crumlin
Dr. Ciara Martin, Consultant in Paediatric Emergency Medicine, Tallaght Hospital
Prof. Alf Nicholson, Joint Clinical Lead for National Clinical Programme for Paediatrics and
Neonatology and Consultant Paediatrician, Temple Street Children’s University Hospital
Dr. Dermot Doherty, Consultant Paediatric Intensivist, Temple Street Children’s University
Hospital
Dr. Ethel Ryan, Consultant Paediatrician, University Hospital Galway
Ms. Marina O’Connor, Nurse Practice Development, Our Lady of Lourdes Hospital, Drogheda
Ms. Carmel O’Donnell, Director, Centre for Children’s Nurse Education, Our Lady’s Children’s
Hospital Crumlin
Ms. Suzanne Dempsey, Director of Nursing, Children’s Hospital Group
Other Contributors:
Ms. Anthea Savage, National PEWS Coordinator
Dr. John Murphy, Joint Clinical Lead for National Clinical Programme for Paediatrics and
Neonatology
Ms. Celine Conroy, National Lead, National Early Warning Score, National Clinical
Programme for Acute Medicine
Ms. Eilish Croke, Programme Manager for National Clinical Programme for Acute Medicine
Dr. Vida Hamilton, Clinical Lead for Sepsis
Ms. Christina Doyle, Programme Manager for Sepsis
Ms. Geraldine Shaw, Office of the Nursing & Midwifery Services Director / Clinical Strategy &
Programmes Division
Ms. Carmel Cullen, HSE Communications
Ms. Nicole Slater, ACT Health, Australia, for support and advice
Ms. Karen Egan, Parent Representative
Ms. Olive O’Connor, Parent Representative
Dr. Colin Green, Paediatric Tutor, University of Limerick
Ms. Kathleen Fitzmaurice, Nurse Tutor, Centre for Children’s Nurse Education, Our Lady’s
Children’s Hospital Crumlin
Pilot Sites:
Temple Street Children’s University Hospital, Dublin
Our Lady’s Children’s Hospital, Crumlin, Dublin
St. Therese’s Ward (Children’s Ward), Portiuncula Hospital, Ballinasloe, Co. Galway
The Children’s Ark, University Hospital, Limerick
The PEWS steering group are indebted to Australian Capital Territory (ACT) Health,
especially Nicole Slater and Imogen Mitchell, for their advice and sharing of resources.
56
REFERENCES, SUPPORTING LITERATURE AND FURTHER LEARNING

RESOURCES
Advanced Life Support Group (2011) Advanced Paediatric Life Support 5th edition
Oxford: Blackwell Publishing
American Heart Association (2011) Pediatric Advanced Life Support Provider Manual
United States: First American Heart Assocition Printing
Australian Capital Territory. Ayard B., McKay H., Slater N., Lamberth P., Daveson K., Lafferty
T., Darvil J., Chen S., Garret-Rumba R., Mitchell I. (2014) COMPASS Adult / Paediatric /
Maternity
Accessed at: http://www.health.act.gov.au/professionals/compass
Lambert V. (2014) A systematic literature review to support the

development of a National Clinical Guideline – Paediatric Early Warning System (PEWS)
Lambert V. (2015) Baseline Research to support the development of a National Clinical

Guideline on PEWS (Paediatric Early Warning System) for the Irish health system. PEWS
Focus Groups Post-Pilot Implementation
Endsley M.R., Garland D.J. (2000) Situation Awareness: Analysis and Measurement
Mahwah, NJ: Lawrence Erlbaum Associates
Greater Manchester Critical Care Skills Institute (2013) Paediatric Acute Illness
Management-PaedAIM Course Manual
Greater Manchester Critical Care Skills Institute, Manchester
Department of Health (2013) National Clinical Guideline No. 1: National Early Warning Score
(NEWS)
Accessed at: http://health.gov.ie/patient-safety/ncec/national-clinical-guidelines-2/
Department of Health (2014a) National Clinical Guideline No. 5: Communication (Clinical

Handover) in Maternity Services
Department of Health (2014b) National Clinical Guideline No. 6: Sepsis Management

Resuscitation Council UK (2007) Paediatric Immediate Life Support 2nd edition

London: Resuscitation Council
57

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PAEDIATRIC EARLY WARNING SYSTEM (PEWS)

GLOSSARY OF TERMS, ACRONYMS AND ABBREVIATIONS

The following definitions apply within the context of this document:

Clinician A health professional, such as a doctor or nurse, involved in clinical practice

Infant A child, from birth to one year of age

Neonate A newborn infant, specifically in the first 4 weeks after birth

ABG Arterial Blood Gas

A good early warning systems should:

Dr. John Fitzsimons

Paediatric Critical Illness

paediatric patients depend on clinicians completing a thorough clinical assessment, recognising

Factors Affecting Accurate and Timely Management

Rationale for the Irish PEWS Education Programme

Aim of the PEWS Education Programme

Overall Learning Outcomes of the PEWS Education Programme

Components of the PEWS Education Programme

Section 2. IRISH PAEDIATRIC EARLY WARNING SYSTEM (PEWS)

Successful implementation of PEWS at institutional level requires a sound education

Paediatric Observation Chart Design

Front page Middle pages Back page

Escalation guide Amended Parameters Age specific PEWS key

Medical escalation suspension Event record

White space for local

Measurement of Vital Signs and Observations

NB: If immediate bedside interventions are appropriate, these should

Calculating the Paediatric Early Warning System Score

Table 1: 0-3 Months (inclusive)

Table 2: 4-11 Months (inclusive)

Table 3: 1-4 Years (inclusive)

Table 4: 5-11 years (inclusive)

Table 5: 12+ Years (inclusive)

Guidance is provided on:

PEWS does not replace an emergency call

PEWS does not replace clinical judgement, concern or impression

Core Parameters Additional Parameters

Urgent PEWS Call

Parameter Amendment Key Points

Parameter Amendment Example

Clinical New Acceptable Next Medical

Medical Escalation Suspension

Medical Escalation Suspension Key Points

Medical Escalation Example

Date/Time Suspension Conditions Next Medical Doctor

Nurse or Family Concern

Completion of the Paediatric Observation Chart

Observations During Blood Transfusion

Section 4 describes each observation individually as part of the ‘ABCDE’ assessment. It is

Section 3. COMMUNICATION, TEAMWORK AND MANAGEMENT

Optimal management of the deteriorating child requires:

There are three elements to situation awareness:

2 Comprehension: Recognise and Understand the Information

3 Projection: Anticipate, Predict, Mitigate and Escalate

This means clinicians have to:

ISBAR for Communication of Patient Deterioration

Identify You. Recipient of information. Patient.

Situation Why are you calling?

Background What is the relevant background?

Assessment What do you think is the problem?

Recommendation What do you want them to do?

The Paediatric Early Warning System is a package of actions triggered by recognition of an

Documenting and Formulating Management Plans

Section 4. ‘ABCDE’ STRUCTURED APPROACH TO CLINICAL

‘ABCDE’ Clinical Assessment