5-12 Years 5-12 Years

National Paediatric Early 0 Have you set your alarm Does your patient have any additional risk factors? NOT APPLICABLE

tient paediatric patient’s PEWS. The components of

This chart is solely intended for recording an inpa-
limits?
1 Risk Factor THINK!

Warning System Observation 2 RR Baseline vital signs outside

of normal reference ranges
Always score the
relevant PEWS value
Vital
sign:

and Escalation Chart

even if this is normal
4 SpO2
for the patient (e.g.
cardiac patient)
Patient’s
normal value:

the chart should not be amended.

Tracheostomy/Airway Risk Do you need additional help in an airway emergency?
HR Invasive/Non-Invasive Ventilation/High Flow Check oxygen requirement on additional respiratory support. Remember
Patient Name:
High Flow/BiPaP and CPAP score maximum of 4 on oxygen delivery
Hospital No. BP Neutropenic/Immunocompromised Sepsis recognition and escalation has a lower threshold

NHS No. <40 weeks corrected gestation Sepsis recognition and escalation has a lower threshold (beware hypothermia)
Other
Neurological condition (ie meningitis, seizures) Remember to check pupillary response if anything other than Alert on AVPU
Date of Birth:
Neurodiversity or Learning Disability Be aware of the range of responses to pain and physiological changes
Type of monitor
5-12 years Consultant:
Outlier Do you need support from home ward/team?

Carer question: Ask your parent/carer: Date Date

How is your child different since I last saw
them? You decide if their response means: Time Time
W - Worse A – Parent/Carer Asleep Frequency Frequency
S - Same U – Unavailable
B - Better W/S/B/A/U W/S/B/A/U

Respiratory distress Value Value

>50 >50 >50
Mild 50 50 50
• Accessory muscle use 45 45 45
Respiratory Rate

Respiratory Rate
40 40 40
• RR/ min

Moderate 35 35 35
• Tracheal tug 30 30 30
• Intercostal recession
25 25 25
• Inspiratory or expiratory
noises 20 20 20
15 15 15
Severe 10 10
10
• Tripoding <10 <10 <10
Airway and Breathing

• Supraclavicular recession
Severe
Respiratory

• Grunting Severe

Respiratory
Distress

Distress
• Exhaustion Moderate Moderate
• Impending respiratory
arrest Mild Mild
None None
≥95% ≥95%
SpO 2

SpO 2
92% - 94% 92% - 94%
≤91% ≤91%
SpO2 probe
SpO2 probe change ( ) change ( )
RSD CODE RSD CODE
Respiratory support (maximum score is 4) (maximum score is 4)
device (RSD) 100%
HF = High Flow Scores the 90%

(NOT High Flow Delivery)

prescription box, of 100% oxygen

BiP = BiPAP maximum

80% 15

Litres per min (L/Min)

of 4

Oxygen Delivery
and L/min with an ‘X’

CP = CPAP
Oxygen as per PGD or

Mark % with a ‘ ‘

70% 10
Oxygen

60% 8
50% 6

40% 4
30% 2
Other delivery methods
28% 1
NP = nasal prongs
FM = face mask 24% 0.1
Score
HB = head box as per <21% <0.01
NRB = Non- oxygen Document ‘Air’ or Value
Delivery method
rebreather /RSD flow rate
Value Value
>190 >190 >190
190 190 190
180 180 180
170 170 170
160 160 160
150 150 150
140 140 140
Heart Rate

Heart Rate
• HR/ min

130 130 130

120 120 120
110 110 110
100 100 100
90 90 90
80 80 80
70 70 70
Circulation

60 60 60
50 50 50
<50 <50 <50

BP Value or Code BP Value or

Record position of BP taken by Code
< diastolic (no score) • mean systolic >

inserting relavant initials above >150 >150 >150

systolic arrow 150 150 150
140 140 140
LA - Left Arm
RA - Right Arm 130 130 130
(Score systolic only)
Blood Pressure

LL - Left Leg 120 120 120

Blood Pressure

RL - Right Leg 110 110 110

100 100 100
Derogation Code if required: 90 90 90
Not attempted (No concern) 80 80 80
- NCO (this scores 0) 70 70 70

Unsuccessful Attempt (No 60 60 60

Concern) - U0 (this scores 0) 50 50 50
40 40 40
Unsuccessful attempt
30 30 30
(Concern) - U4 (this scores 4) <30 <30 <30
CRT ≥3 secs ≥3 ≥3 secs
Record in
seconds ≤2 secs ≤2 ≤2 secs

PEWS PEWS
If V or less do GCS AVPU AVPU
A = Alert
V = Responsive to voice Blood glucose Blood glucose
P = Responsive to pain
U = Unresponsive Pain score Pain score
Disability and Exposure

(as per local policy) (as per local policy)

If asleep with no reason for
altered conscious state (e.g. Value Value
sepsis) write ‘asleep’.
>39 >39 >39
39 39 39
38.5 38.5 38.5
Temperature ºC

38 38 38
Temperature ºC
T=Tympanic

37.5 37.5 37.5

A=Axilla

S=Skin

37 37 37
36.5 36.5 36.5
36 36 36
35.5 35.5 35.5
35 35 35
34.5 34.5 34.5
<34.5 <34.5 <34.5
New suspicion of sepsis New suspicion of sepsis
or septic shock (Y/N) or septic shock (Y/N)

Clinical intuition Clinical intuition Clinical intuition

(Y/N) (Y/N)
If you’re feeling that the
patient is ‘just not right’ Trigger criteria Trigger criteria
despite a low PEWS or natural
carer concern *(Y/N) Escalation level Escalation level
Escalated (Y/Plan) Escalated
(Y/Plan)
Trigger criteria Time NIC informed Time NIC
informed
Cause(s) for escalation:
Time clinician informed Time clinician
SC = Specific Concern informed
CQ = Carer Question Time clinician arrived Time clinician
CI = Clinical Intuition arrived
P = PEWS PICU/transport team called PICU/transport
team called
0 = None
Signature Signature

ESCALATION LEVEL LOW (L) MEDIUM (M) HIGH (H) EMERGENCY (E) THINK! Could this be sepsis?
TRIGGER Specific concern New suspicion of sepsis AVPU: Change to AVPU - V ‘ AVPU: Change to AVPU - P or U ‘Res-
(neurology, sepsis, or Responsive only to Voice’ or ponsive only to Pain’ or ‘Unresponsive’ Think sepsis if any of the following are present:
CRITERIA:
pre-existing risk factor) New suspicion of septic shock OR Abnormal pupillary response • Neutropenia or immunocompromised (call medical
Respond
Clinical Intuition Nurse/clinician concern that patient Nurse/clinician concern that patient Nurse/clinician concern that patient Nurse/clinician concern that patient professional for immediate review)
as per the • Known or suspected infection
needs increased monitoring despite needs a medical review irrespective of needs a ‘Rapid Review’ irrespective of needs emergency review for
highest • Temperature ≥38°C or <36°C
low PEWS PEWS PEWS life-threatening situation
level
• Increasing oxygen requirement
based on Carer Question Carer uses words that suggests the Carer uses words that suggests the child Carer uses words that suggests the child Carer uses words that suggests the
CHANGE in • Unexplained tachypnoea/ tachycardia
child needs increased monitoring or needs a clinical review irrespective of needs a ‘Rapid Review’ irrespective of child has collapsed or significantly
ANY ONE intervention despite the low PEWS PEWS PEWS deteriorated • Altered mental state (e.g. lethargy/floppy)
of these • Prolonged CRT, mottled or ashen appearance
criteria Paediatric Early 1-4 5-8 9-12 ≥13
Warning Score
If suspicion of sepsis, inform nurse in charge.
Communication & response (use Inform Nurse-in-charge Review by Nurse-in-charge for potential Immediate review by Nurse-in-charge Immediate 2222 call: “Paediatric Medical Escalate to patient’s own or on-call team.
ISBAR Framework) escalation (and/or Outreach nurse or for potential escalation Emergency” and review by Nurse-in-charge
equivalent)
Consultant informed urgently to confirm
Medical plan for stabilisation
Consider Medical Review by ST3+ or Request Medical Review by ST3+ or Call for ‘Rapid Review’: Medical incl. stabilisation plan
Structured medical plan to be
documented including: equivalent equivalent airway skills ST3+ or equivalent and I Hello, I am staff nurse (xx) from Ward (xx), I am
outreach nurse (if available or
Senior nurse to support and feedback to calling about (xx).
1. specific actions to be taken parents
equivalent)
2. expected outcome Stabilisation plan to be considered
[In specialist environments rapid review
S I am calling because (e.g. PEWS increased to
3. outcome deadline Stabilisation plan to be discussed with xx, carer is concerned because xx). The last
4. escalation if outcome not met can replace 2222 but only with prior
consultant observations were (xx).
by deadline. Bedside nurse to feed back plan to Bedside nurse to feed back plan to agreement between consultant and nurse-
parents parents Senior nurse to feed back plan to parents in-charge]
B They are (age), admitted on (date) for (reason).
They recently had surgery (xx); treatment (xx).
Medical review timings As agreed with medical team Within 30 minutes Within 15 minutes Immediate
A I think they are (e.g. hypovolaemic). I don’t
Minimal observations Must reassess within 60 minutes (and Must reassess within 30 minutes (and Every 30 minutes and continuous Every 15 minutes and continuous
then document ongoing plan) then document ongoing plan) monitoring of Respiratory Rate / monitoring of Respiratory Rate /
know what is wrong with them but I am/carer
Repeated escalation if remaining in one is very concerned.
Continuous Oxygen Saturation Oxygen Saturation / ECG Oxygen Saturation / ECG
level not required but ongoing plan
monitoring needed GCS recording if change in AVPU GCS recording if change in AVPU or
must be clearly documented in notes.
abnormal pupillary response R I would like you to (e.g. review in xx minutes
please).
FOR EMERGENCY OR LIFE-THREATENING SITUATIONS: CALL 2222 AND STATE “PAEDIATRIC MEDICAL EMERGENCY”

DATE & TIME COMMENTS DATE & TIME COMMENTS

5-12 Years 5-12 Years

Based on the original design from Birmingham Women’s and Children’s NHSFT with contributions from
other English charts and amendments from National SPOT Programme

CS56015 NHSE 5-12 years PEWS Sept 2023 v2.indd 1 09/11/2023 16:16