Prospective Observational Study to Develop Paediatric Acute Care Score (PACS) For Early Prediction of Clinical Deterioration in Paediatric Wards Requiring Intensive Care in Children Presenting to Paediatric Emergency Services in A Tertiary Care Hospital
Abstract
Background: All critical inpatient events are preceded by warning signs like change in vital signs such as tachycardia, tachypnoea, hypotension, acute dyspnoea, and change in level of consciousness for an average of 6–8 hours that can be graded into an Early Warning Score.
Objective: To develop and validate a scoring system for early prediction of clinical deterioration requiring intensive care in not unwell children with Comorbid factors admitted to paediatric wards at presentation to the Paediatric emergency department.
Subjects and Methods: This prospective observational study was done in 13987 children with PACS (derived from the PEWS score and indigenously added co-morbidities). The score was developed in the first stage and then validated in the follow-up study. After training the Emergency and ward Medics, all children at presentation were screened, sick children eliminated, and the scores were repeated at the time of deterioration in children needing intensive care.
Results: There was a significant difference in the scores of children between the deteriorated and non-deteriorated groups (P=0.0001) in the parameters of consciousness, breathing, and circulation. When the co-morbid factors are included, the distribution of the scores in the receiver operator curve (ROC) showed a standard error of 0.0122 and an Area under the curve (AUC) of 0.939 with good predictive power.
Conclusion: The PAC score is an easy and accurate scoring system in identifying the risk of clinical deterioration in children with co-morbid factors in the Paediatric wards. At a score of > 4 at presentation, the score has a sensitivity of 83.7% with a specificity of 93.9%, LR+ of 13.8, and AUC of 0.93 of predicting deterioration needing Intensive care.
References
Sperotto F, Daverio M, Amigoni A, Gregori D, Dorste A, Allan C, Thiagarajan RR. Trends in In-Hospital Cardiac Arrest and Mortality Among Children with Cardiac Disease in the Intensive Care Unit: A Systematic Review and Meta-analysis. JAMA Netw Open. 2023 Feb 1;6(2); doi: https://doi.org/10.1001/jamanetworkopen.2022.56178
Mir T, Shafi OM, Uddin M, Nadiger M, Sibghat Tul Llah F, Qureshi WT. Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study. Cureus. 2022 Jul 1;14(7):e26505. doi: https://doi.org/10.7759/cureus.26505
Nadkarni VM, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006 Jan 4;295(1):50-7. doi: https://doi.org/10.1001/jama.295.1.50
Goldhill DR, White SA, Sumner A. Physiological values and procedures in the 24 h before ICU admission from the ward. Anesthesia. 1999; 54:529–34. doi: https://doi.org/10.1001/jama.295.1.50
Hillman KM, Bristow PJ, Chey T, Daffurn K, Jacques T, Norman SL, et al. Duration of life-threatening antecedents before intensive care admission. Intensive Care Med. 2002; 28:1629–34. doi: https://doi.org/10.1007/s00134-002-1496-y
Hodgetts TJ, Kenward G, Vlachonikolis IG, et al. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54: 125–31. doi: https://doi.org/10.1016/s0300-9572(02)00100-4
Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs. 2005; 17(1):32–35. doi: https://doi.org/10.7748/paed2005.02.17.1.32.c964
Duncan HP. Survey of early identification systems to identify inpatient children at risk of physiological deterioration. Arch Dis Child. 2007; 92(9):828. doi: https://doi.org/10.1136/adc.2006.112094
Fuijkschot J, Vernhout B, Lemson J, Draaisma JMT, Loeffen JLCM. Validation of a Paediatric Early Warning Score: first results and implications of usage. Eur J Pediatr. 2015 Jan; 174(1):15–21. doi: https://doi.org/10.1007/s00431-014-2357-8
Chapman SM, Grocott MP, Franck LS. Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration. Intensive Care Med. 2010 Apr; 36(4):600-11. Epub 2009 Nov 26. doi: https://doi.org/10.1007/s00134-009-1715-x
Akre et al, Sensitivity of the paediatric early warning score to identify patient deterioration. Peadiatrics April 2010.Vol125. doi: https://doi.org/10.1542/peds.2009-0338
Duncan H, Hutchison J, Parshuram CS. The paediatric early warning score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care. 2006; 21(3):271–272. doi: https://doi.org/10.1542/peds.2009-0338
Haines C, Perrott M, Weir P. Promoting care for acutely ill children: development and evaluation of a paediatric early warning tool. Intensive Crit Care Nurs. 2006;22(2):73– 81; https://doi.org/10.1016/j.iccn.2005.09.003
Tume L. The deterioration of children in ward areas in a specialist children’s hospital. Nurs Crit Care. 2007;12(1):12–19. doi: https://doi.org/10.1111/j.1478-5153.2006.00195.x
Bell D,Mac et al. The texas Children’s Hospital Paediatric advanced Warning Score as a predictor of clinical deterioration in Hospitalised Infants and children: A modification of PEWS Tool. Journal of Paediatric Nursing. 28:e2-9. doi: https://doi.org/10.1016/j.pedn.2013.04.005
McLellan MC, Gauvreau K, Connor JA. Validation of the Cardiac Children’s Hospital Early Warning Score: an early warning scoring tool to prevent cardiopulmonary arrests in children with heart disease. Congenital Heart Dis. 2014; 9(3): 194-204. doi: https://doi.org/10.1111/chd.12132
Robson MJ, Cooper et al. Comparison of three acute care paediatric early warning scoring tools. Journal of Paediatric Nursing. 28:e33-41. doi: https://doi.org/10.1016/j.pedn.2012.12.002
Oloughlin et al. The effectiveness of the paediatric early warning tool (PEWT) in identifying children requiring admission to a critical care unit. Archives of disease in Childhood, May 2012. doi: http://dx.doi.org/10.1136/archdischild-2012-301885.362
Parshuram, C. S., Hutchison, J., & Middaugh, K. (2009). Development and initial validation of the Bedside Paediatric Early Warning System score. Critical Care, 13(4), R135. https://doi.org/10.1186/cc7998
Skaletzky SM, Raszynski A, Totapally BR (2012) Validation of a modified paediatric early warning system score: a retrospective case-control study. Clin Pediatr (Phila) 51: 431–435. doi: https://doi.org/10.1177/0009922811430342
Tucker KM, Brewer TL, Baker RB, Demeritt B, Vossmeyer MT. Prospective evaluation of a paediatric inpatient early warning scoring system. J Spec Pediatr Nurs. 2009;14; doi: https://doi.org/10.1111/j.1744-6155.2008.00178.x
Panesar R, Polikoff LA. Characteristics and outcomes of paediatric rapid response teams before and after mandatory triggering by an elevated Paediatric Early Warning System (PEWS) score.Hosp Pediatr. 2014 May;4(3):135-40. doi: https://doi.org/10.1542/hpeds.2013-0062
Delia L.Gold,Leslie K Mihalov. Evaluating the Paediatric Early Warning Score (PEWS) System for Admitted Patients in the Paediatric Emergency Department. Acad Emerg Med. 2014 Nov; 21(11): 1249–1256. doi: https://doi.org/10.1111/acem.12514
Sefton G, McGrath C, Tume L, Lane S, Lisboa PJG, Carrol ED. What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study. Intensive Crit Care Nurs. 2015 Apr; 31(2):91–9. doi: https://doi.org/10.1016/j.iccn.2014.01.001
Avent, Johnson et al. Successful use of a rapid response team in a paediatric oncology outpatient setting. The joint Commission Journal on Quality and Patient Safety. 36(1):43-45. doi: https://doi.org/10.1016/s1553-7250(10)36008-9
Bonafide PC, Roberts et al Beyond Statistical prediction: Qualitative Evaluation of mechanisms by which paediatric early warning Scores Impact Patient Safety.Journal of Hospital Medicine.8(5):248-53. doi: https://doi.org/10.1002/jhm.2026
Parshuram, C. S., Hutchison, J., & Middaugh, K. (2009). Development and initial validation of the Bedside Paediatric Early Warning System score. Critical Care, 13(4), R135. doi: https://doi.org/10.1186/cc7998
D Roland et al. Use of paediatric early warning systems in Great Britain:Has there been a change of practice in the last 7 years? Archives of Disease Child 2012-302783; doi: https://doi.org/10.1136/archdischild-2012-302783
Ahmed M.Sobitha Devi D, Burton Paediatric Early Warning system Score. Archives of Disease in Childhood. October 2012. doi: https://doi.org/10.1016/j.jcrc.2006.06.007
Chapman SM, Wray J, Oulton K, et al ‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems. Archives of Disease in Childhood 2017;102:487-495. doi: https://doi.org/10.1136/archdischild-2016-311088
Villa de Villafañe AA, Panattieri ND, Torres S, Bustos FE, Cuencio Rodríguez ME, Vázquez MF, García V, Siaba Serrate A, Rocca Rivarola M. Unplanned transfer of pediatric patients from the general ward to the intensive care unit. Arch Argent Pediatr. 2023 Aug 1;121(4):e202202772. doi: https://doi.org/10.5546/aap.2022-02772.eng
Chong SL, Goh MSL, Ong GY, Acworth J, Sultana R, Yao SHW, Ng KC; International Liaison Committee on Resuscitation (ILCOR) and ILCOR Pediatric Life Support Task Force. Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis. Resusc Plus. 2022 Jun 29;11:100262. doi: https://doi.org/10.1016/j.resplu.2022.100262
Carter B, Saron H, Blake L, Eyton-Chong CK, Dee S, Evans L, Harris J, Hughes H, Jones D, Lambert C, Lane S, Mehta F, Peak M, Preston J, Siner S, Sefton G, Carrol ED. Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals. PLoS One. 2022 Sep 15;17(9):e0273666. doi: https://doi.org/10.1371/journal.pone.0273666
Roland D, Powell C, Lloyd A, Trubey R, Tume L, Sefton G, Huang C, Taiyari K, Strange H, Jacob N, Thomas-Jones E, Hood K, Allen D. Paediatric early warning systems: not a simple answer to a complex question. Arch Dis Child. 2022 Jul 22;108(5):338-43. doi: https://doi.org/10.1136/archdischild-2022-323951
Jacob N, Moriarty Y, Lloyd A, Mann M, Tume LN, Sefton G, Powell C, Roland D, Trubey R, Hood K, Allen D. Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development BMJ Open. 2019 Nov 14;9(11):e028796. doi: https://doi.org/10.1136/bmjopen-2018-028796
Thomas-Jones E, Lloyd A, Roland D, Sefton G, Tume L, Hood K, Huang C, Edwards D, Oliver A, Skone R, Lacy D, Sinha I, Preston J, Mason B, Jacob N, Trubey R, Strange H, Moriarty Y, Grant A, Allen D, Powell C. A prospective, mixed-methods, before and after study to identify the evidence base for the core components of an effective Paediatric Early Warning System and the development of an implementation package containing those core recommendations for use in the UK: Paediatric early warning system - utilisation and mortality avoidance- the PUMA study protocol. BMC Pediatr. 2018 Jul 25;18(1):244. doi: https://doi.org/10.1186/s12887-018-1210-z
Chapman SM, Oulton K, Peters MJ, Wray J. Missed opportunities: incomplete and inaccurate recording of paediatric early warning scores. Arch Dis Child. 2019 Dec;104(12):1208-1213. doi: https://doi.org/10.1136/archdischild-2018-316248
McElroy T, Swartz EN, Hassani K, Waibel S, Tuff Y, Marshall C, Chan R, Wensley D, O'Donnell M. Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up BMC Emerg Med. 2019 Nov 27;19(1):74. doi: https://doi.org/10.1186/s12873-019-0287-5
Corfield AR, Silcock D, Clerihew L, Kelly P, Stewart E, Staines H, Rooney KD. Pediatric early warning scores are predictors of adverse outcome in the pre-hospital setting: A national cohort study. Resuscitation. 2018 Dec;133:153-159. doi: https://doi.org/10.1016/j.resuscitation.2018.10.010
Sefton G, McGrath C, Tume L, Lane S, Lisboa PJ, Carrol ED. What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study. Intensive Crit Care Nurs. 2015 Apr;31(2):91-9. doi: https://doi.org/10.1016/j.iccn.2014.01.001
Chapman SM, Maconochie IK. Early warning scores in paediatrics: an overview Arch Dis Child. 2019 Apr;104(4):395-399. doi: https://doi.org/10.1136/archdischild-2018-314807
Chong SL, Goh MSL, Ong GY, Acworth J, Sultana R, Yao SHW, Ng KC; International Liaison Committee on Resuscitation (ILCOR) and ILCOR Pediatric Life Support Task Force. Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis.Resusc Plus. 2022 Jun 29;11:100262. doi: https://doi.org/10.1016/j.resplu.2022.100262
Lambert V, Matthews A, MacDonell R, Fitzsimons J. Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review. BMJ Open. 2017 Mar 13;7(3):e014497. doi: https://doi.org/10.1136/bmjopen-2016-014497
Roland D, Stilwell PA, Fortune PM, Alexander J, Clark SJ, Kenny S. Case for change: a standardised inpatient paediatric early warning system in England. Arch Dis Child. 2021 Jul;106(7):648-651. doi: https://doi.org/10.1136/archdischild-2020-320466
Pereira MP, Poção P, de Castro Faria H. Pediatric Early Warning System in the Short Stay Unit. Gaz Med [Internet]. 2023 Sep. 15 [cited 2024 Jan. 6];10(3):188-95. https://www.gazetamedica.pt/index.php/gazeta/article/view/539
Breslin K, Marx J et al. Pediatric early warning score at time of emergency department disposition is associated with level of care. Journal of Investigative Medicine, March 2012. doi: https://doi.org/10.1097/pec.0000000000000063
Chaiyakulsil C, Pandee U. Validation of paediatric early warning score in paediatric emergency department. Pediatr Int. 2015 Jan 30; doi: https://doi.org/10.1111/ped.12595
Joanne Windle, Julie Williams. Early warning scores: are they needed in emergency care? Emergency Nurse. 2009 May 1;17(2):22–6. doi: https://doi.org/10.7748/en2009.05.17.2.22.c6989
Egdell P, Finlay L, Pedley DK. The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department. Emerg Med J. 2008 Nov;25(11):745–9. doi: https://doi.org/10.1136/emj.2007.054965
Seiger, Maconochie et al Validity of different paediatric early warning scores in the Emergency department. Peadiatrics, October 2013. doi: https://doi.org/10.1542/peds.2012-3594
Quist-Therson E and the Hertfordshire Partnership NHS Trust. Acute Children’s Services: Guidelines Services: Guidelines for using paediatric early warning scoring tool. National Health System, Hertfordshire Partnership, England. August 2006.
Vandenberg SD, Hutchinson JS, Parshuram CS. A cross-sectional survey of levels of care and response mechanisms in hospitalized children. Peadiatrics. 2007; 119(4). doi: https://doi.org/10.1542/peds.2006-0852
Edwards ED, Powell CV, Mason BW, Oliver A. Prospective cohort study to test the predictability of the Cardiff and Vale paediatric early warning system. Arch Dis Child. 2009; 94(8):602– 606. doi: https://doi.org/10.1136/adc.2008.142026
Bradman et al Can paediatric early warning score be used as a triage tool in Peadtric accident and Emergency? Eur Journal of emergency medicine. Dec 2008 15/6 359-360. https://doi.org/10.1097/mej.0b013e3283026208
Branes H, Solevåg AL, Solberg MT. Pediatric early warning score versus a paediatric triage tool in the emergency department: A reliability study. Nurs Open. 2021 Mar;8(2):702-708. doi: https://doi.org/10.1002/nop2.675
Soeteman M, Lekkerkerker CW, Kappen TH, Tissing WJ, Nieuwenhuis EE, Wösten-van Asperen RM. The predictive performance and impact of pediatric early warning systems in hospitalized pediatric oncology patients-A systematic review Pediatr Blood Cancer. 2022 May;69(5):e29636. doi: https://doi.org/10.1002/pbc.29636
Agulnik A, Mora Robles LN, Forbes PW, Soberanis Vasquez DJ, Mack R, Antillon-Klussmann F, Kleinman M, Rodriguez-Galindo C. Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital Cancer. 2017 Aug 1;123(15):2965-2974. doi: https://doi.org/10.1002/cncr.30664
Mills D, Schmid A, Najajreh M, Al Nasser A, Awwad Y, Qattush K, Monuteaux MC, Hudgins J, Salman Z, Niescierenko M. Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine BMC Health Serv Res. 2021 Oct 26;21(1):1159. doi: https://doi.org/10.1186/s12913-021-07157-x
Agulnik A, Méndez Aceituno A, Mora Robles LN, Forbes PW, Soberanis Vasquez DJ, Mack R, Antillon-Klussmann F, Kleinman M, Rodriguez-Galindo C. Validation of a pediatric early warning system for hospitalized pediatric oncology patients in a resource-limited setting. Cancer. 2017 Dec 15;123(24):4903-4913. doi: https://doi.org/10.1002/cncr.30951
