Clinical
Detecting and managing
deterioration in
children
CORBIS
Alan Monaghan RN (Child),
RGN, PGCHSCE, Lecturer
Practitioner, Royal Alexandra
Children’s Hospital, Brighton
KEY WORDS
Intensive care: Paediatric
Patient assessment
Outreach
32
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Alan Monaghan describes how the introduction of a critical care
outreach service and a Paediatric Early Warning Score improved
management of acutely ill children
In the past, paediatric intensive care units (PICUs) intensive care and following discharge. Across the UK,
were perceived by many as ivory towers. They often adult critical care services have been setting up teams
had poor relationships with other departments prob- under various titles such as emergency medical team
ably caused by them working in isolation, by poor or emergency outreach team. Despite the various titles
communication and lack of admission and discharge the teams have three shared aims:
planning. Similar issues in adult critical care resulted ❘❚❘ early detection of patients at risk of deterioration
in the Department of Health recommending a hospital- ❘❚❘ support and education of ward staff in caring for
wide approach to the identification and referral of criti- patients at risk of deterioration
cally ill adults (DoH 2000). This led to the development ❘❚❘ improved discharge and follow up after intensive
of critical care outreach teams in adult services and an care.
improvement in interdepartmental working. This article summarises the process of setting up a
The function of these outreach teams is to improve paediatric critical care outreach team at Brighton and
the provision of critical care prior to admission to describes the development of a paediatric early warning
Paediatric
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score (PEWS) to assist in detecting children at risk of
deterioration. The process of implementing change and
the difficulties encountered when implementing new
working practices are briefly considered. Data from a
pilot implementation are presented to provide evidence
for use of a paediatric early warning score in children.
Early detection
Early detection and optimal care in the critically ill adult
is associated with improved outcomes (DoH 2000), an
association that may apply in children. In one review,
61 per cent of paediatric cardiac arrests were caused
by respiratory failure and 29 per cent by shock, both
of which are potentially reversible causes (Reis et al
2002). Early recognition and appropriate intervention
are therefore equally important in children and may
prevent the need for admission to intensive care.
There are a number of scoring systems being used to
identify adults at risk of deterioration but these have yet
to be verified for their transferability to other subjects.
Although there is a strong indication that early warn-
ing scores may have a place in the paediatric setting, a
literature search did not reveal any publications on this
topic. There were scoring systems in use for croup and
meningococcal septicaemia but little evidence on their
use and sensitivity. The use of a paediatric early warn-
ing score seems to be a relatively new concept.
Project development
In February 2001, a working group was established at
Brighton and Sussex University Hospitals NHS Trust
to develop a score modified for children. We also inves-
tigated the possibility of applying the principle of out-
reach within the women and children’s directorate. This
was felt to be a logical way to approach the increasing
problem of caring for highly dependent children in the
ward area. In October 2001 a pilot of outreach began
with a team comprising a clinical nurse educator lead
and anaesthetic staff grades on PICU attachment after
hours.
At first, ward staff referred patients about whom they
had concerns and intensive care staff would attend,
assess and care for these children and arrange trans-
fer to intensive care. At this time there was no formal
assessment tool available. Unfortunately this approach
appeared to result in an element of deskilling among
ward-based staff. Following debriefing sessions, staff
stated that they felt undermined and undervalued as
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Clinical
care responsibilities had been taken away by the out-
reach staff.
After consideration, a more educational-based model
was devised. As the project lead I felt that if education
and support were provided by a team experienced in
caring for acutely ill children (instead of them ‘taking
over’), staff satisfaction would improve. Staff would
become more skilled in caring for these patients and
would ultimately provide good continuity of care to an
appropriate standard.
An educational approach to outreach
There is evidence that outreach teams can have the
adverse effect of deskilling staff resulting in a greater
demand for high dependency facilities as staff become
reluctant to care for these patients (Mercer et al 1999).
With this in mind a series of study days were set up
along with short in-house sessions in ward areas on
aspects of caring for the acutely ill child. Education
of nursing and medical staff was found to be of real
importance in the recognition of critically ill patients by
Franklin and Mathews (1994). Difficulties in recruiting
qualified nurses resulted in a dilution of the skill mix in
many areas in their study. Other factors affecting staff
responses to deterioration were the increasing use of
temporary staff and a reduction of paid study leave to
gain these skills (Franklin and Mathews 1994).
In addition to staff education, we needed to address
approaches to identifying the child at risk of deterio-
ration, particularly in areas that mainly admit adult
patients such as accident and emergency departments
in district general hospitals with limited paediatric facil-
ities.
Developing the early warning score
A multidisciplinary planning group was set up with
representation for all who would be involved in car-
ing for these patients. The group members gave their
ideas on why staff generally had concerns regarding a
patient’s condition and the markers used to judge sever-
ity. It was decided to adopt an early warning score as an
aid to help nurses assess patients objectively using vital
signs. As no paediatric scoring system could be found
at the time, we decided to develop a paediatric score
based on the available adult systems. One concern was
that some adult systems use blood pressure as one of
the main predictors of deterioration. In children, hypo-
tension is associated with late signs of shock and is a
Paediatric
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Clinical

Fig 1. Royal Alexandra Hospital For Sick Children, Brighton – Paediatric Early Warning Score

0 1 2 3 Score
Behaviour Playing/ Sleeping Irritable Lethargic/confused
appropriate Reduced response to pain

Cardiovascular Pink or capillary Pale or capillary Grey or capillary Grey and mottled or
refill 1-2 seconds refill 3 seconds refill 4 seconds. capillary refill 5 seconds
Tachycardia of 20 or above. Tachycardia of
above normal rate 30 above normal rate or
bradycardia.

Respiratory Within normal >10 above normal >20 above normal 5 below normal
parameters, no parameters, using parameters parameters with sternal
recession or accessory muscles, recessing, tracheal recession, tracheal tug or
tracheal tug 30+% Fi02 or 4+ tug. 40+% Fi02 or grunting. 50% Fi02 or 8+
litres/min 6+ litres/min litres/min

Score 2 extra for 1/4 hourly nebulisers or persistent vomiting following surgery

potentially a pre morbid sign: according to Hazinski
(1992) it is a sign of decompensated shock and multi
system failure.
We also realised that if we used a system that relied
on vital signs parameters alone, three or four differ-
ent scores would be needed to allow for different age
variables. The development proved difficult because of
this factor. There is a danger in implementing a very
complex scoring system or a number of systems as staff
would find it difficult and time consuming to carry out
their assessment. Any clinical scoring system should
be easy to use and not open to different interpretation
by different users. It was hoped that the paediatric early
warning system would be used by all grades of staff and
that it would not generate too much extra work.
The scoring system
Each clinical area was assigned a link person from the
planning group to promote the score and give feedback
on its use. This helped in cascading the information
and aided implementation. The scoring system focused
on three components of assessing a child:
❘❚❘ behaviour
❘❚❘ colour/cardiovascular status
❘❚❘ respiratory status.
Behaviour was felt to be an important observation cri-
terion as it is often an early sign of a shocked child and
something the parents may also recognise. Behavioural
signs are scored exactly as observed so the child who
is uninterested in his or her surroundings would score
three – lethargic. We initially considered including
more detail in the behavioural assessment but this
would have made the score too complex and open to
misinterpretation.
Colour and capillary refill were chosen to assess car-
diovascular signs rather than mean arterial blood pres-
sure. Both signs are used as not all staff are skilled in
assessing capillary refill. Respiratory rate was included
along with oxygen demand. Goldhill et al (1999) found
that respiratory rate and adequacy of oxygenation were
important physiological indicators of a critically ill ward
patient and could be assessed without special equip-
ment. This removes any reliance on equipment such as
saturation monitors being available. Mean respiratory
parameters are used in order to increase sensitivity.
Having assessed the parameters (see Figure 1) the
nurse calculates the child’s total score, which dictates
one of four actions:
❘❚❘ informing the nurse in charge
❘❚❘ increasing the frequency of observations
❘❚❘ calling for medical review and informing the out-
reach team
❘❚❘ calling out the full medical team and outreach
team
If the child’s score was in the red column, or greater
than four, the protocol recommends calling out the full

34 Paediatric
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 Clinical

team. This action could be adapted by other units tak- involved the outreach co-ordinator. Eighty three per
REFERENCES
ing into account the local facilities and resources. For cent of the patients improved following intervention;
example in the absence of on-site paediatric intensive 17 per cent deteriorated and required admission to the Department of Health (2000)
care support, a red score or four score could be adapted PICU. Comprehensive Critical Care
– A Review of Adult Critical
to involve consulting a lead centre. Staff identified three children who were unwell and Care Services. London, DoH.
Several studies have found that nurses and junior required medical intervention during the pilot and who Franklin C, Mathews J (1994)
Developing strategies to
medical staff often fail to notify the senior physician of they thought should have scored higher. Analysis of
prevent in hospital cardiac
clinical deterioration leading up to cardiac arrest (for these children’s audit forms and observations showed arrest: analysing responses
of physicians and nurses
example Franklin and Mathews 1994). It was hoped that they had all developed a tachycardia prior to their in hours before the event.
that the paediatric early warning score (PEWS) would deterioration. It was also noted that certain patients, Critical Care Medicine. 22,
244-247.
prompt action. It would also provide an objective assess- such as children who have had a tonsillectomy, may not
Goldhill DR (2000) Medical
ment tool to prevent contributing factors from affect- display classic signs during the early phases of deterio- emergency teams. Care of the
ing judgement – such as a busy ward. The PEWS also ration. Prolonged vomiting was felt to be a more promi- Critically Ill. 16, 209-212.
allows the nurse to call medical staff without having to nent sign of bleeding in these cases and was added as Goldhill DR et al (1999)
Physiological values and
give a lengthy justification over the phone which could a factor to score. procedures in the 24 hours
waste valuable time. A subsequent audit found a direct relationship before ICU admission from
the ward. Anaesthesia. 54,
between the PEWS and the recording of respiratory 529-534.
Implementation and audit rate: 80 per cent of children without a recorded PEWS Hazinski FM (1992) Nursing
The initial introduction of the scoring system was met also had no respiratory rate recorded. Goldhill (2000) Care of the Critically Ill Child.
2nd edition, pg 181. St Louis,
with a variable response. Some staff could not see why states that sensitivity, specificity and usefulness for this Mosby.
we needed a score as they felt they were quite capable of type of score in adults has yet to be demonstrated; it McQuillan P et al (1998)
recognising patients at risk. Staff were also concerned is important to evaluate the validity and reliability of Confidential inquiry into
the quality of care before
about the assessment being time consuming and add- the PEWS. We plan to test inter-rater reliability of the admission to intensive care.
ing extra paperwork. We timed how long it would take PEWS among all grades of staff and a study is under- British Medical Journal. 316,
1853-1858.
to score a patient and found it to be about 30 seconds way to evaluate the sensitivity of the PEWS in reflecting
Mercer M et al (1999) Medical
on top of a standard set of observations. This time was the child’s severity of illness. emergency teams improve
found to decrease as the nurse became more familiar Staff experience of both the PEWS system and the care. British Medical Journal.
318, 54.
with the system. outreach service was very positive: a survey of staff expe-
Reis A et al (2002) A
The standard four-hourly observation charts did not rience found that out of 33 staff on acute medical and prospective investigation
into the epidemiology
allow for different timings of observations and record- surgical wards, 88 per cent felt that the outreach serv-
of in-hospital paediatric
ing of PEWS. Incorporating the score into the stand- ice increased their confidence in caring for the child at cardiopulmonary
resuscitation using the
ard observation chart prevented the need for additional risk of deterioration. Eighty per cent reported that the international ustein reporting
paperwork. This proved to be popular with most staff as PEWS system improved their confidence in recognis- style. Paediatrics. 109, 200-
209.
it provided more flexibility for documentation. ing the child at risk of deterioration.

Pilot
The PEWS was piloted for three months and patients
were reviewed using an audit tool which captured the
patient’s observations, PEWS score, who was called,
what actions were taken and the outcome. We also
audited children who should have scored highly but
did not (such as children who required intensive care
admission with PEWS scores below four).
During the pilot there were 30 patients who scored
four, warranting a call for medical staff to review the
patient’s condition. Ninety six per cent were seen with-
in 15 minutes and the same percentage required med-
ical intervention. In 54 per cent of these cases, care
Conclusion
The use of the Brighton PEWS system is now stand-
ard practice in our trust and we have used it for sev-
eral years to assess acutely ill children. Along with the
development of the outreach team, this has meant that
children showing signs of deterioration are assessed
by appropriate medical and nursing staff and receive
optimum care during their acute episode. As our audits
show, staff in ward areas have an increased level of con-
fidence in caring for the acutely ill child. Further work
is required to show the benefits of the outreach team
in order to secure funding for what staff see as a valu-
able service PN

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