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Author |
Alexandra Scott |
Date |
03/25/2022 |
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Reviewer |
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Edited |
A primary care ambulance resource in Greater Vancouver responds to a 2-year-old presenting with a fever and cough. His parents are concerned and state that he is more tired than usual and seems short of breath. Upon assessment, paramedics find the patients vitals to be as follows: RR 42, HR 140, SPO2 98%, GCS 15, and temperature 38.0°C axilla. It has been several months since they have assessed a pediatric patient and they are having a hard time contextualizing the vital signs and remembering normal ranges. The paramedics discern that the child is slightly tachycardic and tachypneic for his age group, but they are not confident on how high their index of concern should be for this child. Could a Pediatric Early Warning System (PEWS) supplement pediatric patient assessments to aid in appropriate clinical decision making?
“Can PEWS identify pediatric patients at risk of clinical deterioration in a prehospital setting?”
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Population |
Pediatric patients in a prehospital setting |
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Intervention |
Utilization of a Pediatric Early Warning System (PEWS) |
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Control |
Current practice with no system in place |
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Outcome(s) |
Early identification of pediatric patients at risk of clinical deterioration |
PubMed: (PEWS OR pediatric early warning) AND (prehospital OR paramedic OR ambulance OR pre-hospital)
PubMed: ("PEWS" OR "pediatric early warning") AND ("British Columbia”)
The first PubMed search yielded 7 results (3 relevant, 2 additional) on 2022-03-13. The second PubMed search yielded 11 results (1 relevant) on 2022-03-13
A Pediatric Early Warning System (PEWS) is an age-specific assessment tool, providing categories to fill in with vital signs and clinical observations. These categories have an associated score for each finding, and the scores are intended to demonstrate to the provider whether the child presents with expected findings for their age or if they have a variance, with higher scores indicating more concerning variances. Although PEWS has been well-established in many hospitals, research regarding the utility of PEWS in a prehospital environment is still emerging. A retrospective cohort study was conducted with a sample of 21,202 medical records of children 0-16 years old conveyed by the Scottish Ambulance Service from 2011-2015.1 It was found that applying an 8-point PEWS (Scotland) to prehospital data was useful for predicting the primary outcomes of ICU admission within 48 hours or death in 30 days.1 Further, a PEWS (Scotland) score of 5 demonstrated optimal sensitivity and specificity and could be utilized as a cut-off for hospital pre-notification or diversion to a higher level resource, although it was emphasized that PEWS only had utility as a supporting criteria.1 Proper assessment and clinical judgement is essential.1 A retrospective cohort study analyzed records of 8,889 patients 0-18 years old transferred by air and land ambulance in Ontario to determine if their Transport PEWS (TPEWS) predicted in-transport critical events.2 Critical patient events had a wide definition, capturing events like hypotension, hypoxia, tachycardia, and bradycardia.2 A higher TPEWS was associated with critical events during transport but demonstrated low sensitivity and was a poor independent predictor.2 In addition, a retrospective case-control study was conducted with a sample of 386 patient records of pediatric patients 0-18 years old conveyed by 3 EMS agencies in the USA from April 2013-2015.3 Both Brighton PEWS and Bedside PEWS were applied and it was found that neither demonstrated sufficient sensitivity to accurately identify pediatrics at risk of clinical deterioration and therefore in need of a higher-level pediatric hospital resource.3 Despite this finding, some individual items from the scores were found to be associated with the outcome, suggesting the possibility of a modified score having utility.3 Further, 298 patient records were found to not contain enough data to complete the 7-component BPEWS, compared to the more streamlined 5-component Brighton PEWS.3 Shifting focus to the British Columbia context, a pilot study with mixed-methods analysis was conducted during the implementation of a 5-component PEWS in Richmond Hospital ED.4 Common themes among staff respondents following PEWS implementation included provider knowledge, documentation of assessments, and communication was improvement when caring for pediatric emergency patients.4 It was also found that as expected, PEWS and CTAS were inversely correlated.4 This study advised a provincial roll-out of PEWS into BC pediatric-receiving emergency departments.4
Although there is a moderate association between higher PEWS scores and negative outcomes, it is unclear from the limited research available whether PEWS has utility in a prehospital setting at predicting clinical deterioration. PEWS was initially formulated and studied in a hospital context, therefore extrapolating this score to a different environment may generate issues with predictive ability. In addition, depending on the score system utilized, different iterations of PEWS had varying levels of complexity and components. Some complex multi-perameter scores like BPEWS proved difficult to retrospectively calculate due to missing prehospital data, which may highlight either the need for improved patient assessment and documentation or the lack of practicality of certain components in a prehospital setting. Pediatrics make up a small percentage of prehospital patients so having a score like PEWS could suggest the possibility of clinical deterioration and highlight abnormal vital signs, reducing cognitive load. This may be beneficial when paramedics are making decisions such as hospital choice, when to pre-notify, and whether to drive routinely or with lights and sirens. PEWS could also improve communication between paramedics and receiving hospitals, as PEWS is becoming widespread among BC emergency departments. Despite these potential benefits, available research has made it clear that PEWS is not a substitute for good assessment and clinical judgement, as the scores are not infallible.