The Pediatric Early Warning System (PEWS) is an established tool that aids in the identification of hospitalized patients at risk for clinical deterioration. Many pediatric institutions have adopted the PEWS as a patient safety initiative. At St. Louis Children’s Hospital, it was initially deployed on the oncology unit in June 2011 and then subsequently expanded to a general medical unit in December 2011. It was well received, but it led to numerous Rapid Response Team (RRT) activations triggered by PEWS scores that were only abnormal because of isolated tachycardia and/or tachypnea. These RRT activations often taxed the resources of the Pediatric Intensive Care Unit (PICU). An analysis demonstrated that the normal ranges for heart rate and respiratory rate, which were obtained from Wong’s Essentials of Pediatric Nursing, were overly restrictive. A substitution of the normal ranges with those from American Heart Association Pediatric Emergency Assessment, Recognition and Stabilization Provider Manualwas proposed, but it was recognized that testing of this change before its implementation would be critical.
To ensure that the change would appropriately balance the desire to decrease the number of RRT activations and the requirement to maintain the efficacy of PEWS, a retrospective chart review of 24 affected patients was performed. They were randomly selected from age groups that matched those of the normal ranges from Wong’s: newborn (0 to 1 month), infant (1 month to 12 months), toddler (13 months to 3 years), preschool (4 to 6 years), school age (7 to 12 years), and adolescent (13 to 19 years). New PEWS scores were recalculated using the normal ranges from American Heart Association and then compared to the original PEWS scores that were generated using the normal ranges from Wong’s.
A recalculation of the PEWS scores with normal ranges from American Heart Associationdecreased the number of RRT activations by 50% and did not miss any patients who genuinely needed a RRT evaluation. As a result, this change was approved and made with confidence and without complications.
Modifications of the PEWS must achieve desired outcomes but not compromise patient safety. In this case, a successful change in the normal ranges for heart rate and respiratory rate was accomplished through a systematic review of available clinical data. A prospective analysis of all unplanned transfers to the PICU is currently under way.