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Dr John Fitzsimons
Consultant Paediatrician and Clinical Director for Quality Improvement
HSE
Wednesday November 26th 2014
National Clinical Guidelines
– a System to Support Clinical Decisions
The National Paediatric Early Warning Score (PEWS) System
More than a number
National Clinical Excellence Symposium
Dublin Castle, November 26th 2014
Dr John Fitzsimons on behalf of the PEWS Working Group
Drogheda PEWS 2010
Version 4
PTO
Paediatric Observation Chart & PEWS
Te
en
ag
e
r!
Ove
r 1
2
ye
ars
!
!OLOLH Drogheda
PEWS
Name: Hospital Number: Date of Birth:
1. Record observations. 2. Add up shaded boxes (1 point each). 3. Enter Total PEWS 4. Act on Total PEWS (PTO)
Date
Time
! if concerned about patient
Temperature
Temperature is not used
To calculate PEWS
40
39
38
37
36
35
Heart Rate
Blood Pressure
BP is not used to calculate
PEWS
140+
130
120
110
100
90
80
70
60
50
0-49
Heart rate (number)
Respiratory Rate
40+
30
20
10
0
Respiratory rate (number)
Respiratory Distress
Mod-Severe
Mild
None
Oxygen saturation %
! if receiving Oxygen
Oxygen flow rate
! if Stridor / Apnoea
Consciousness normal (A)
Conscious decreased (VPU)
BO PU
Blood Sugar
Pain Score (0-10)
Total PEWS 0-2
3-4
5-7
Initials
Weight:
_____
KG
Version 4
PTO
Paediatric Observation Chart & PEWS
Te
en
ag
e
r!
Ov
er
12
yea
rs!
!OLOLH Drogheda
PEWS
Name: Hospital Number: Date of Birth:
Please record call when PEWS 3 or more Please record review & action taken
Date Time PEWS Print Name (nurse in charge)
Date Time Print Name
(doctor)
Action
PEWS ACTION TO BE TAKEN MONITORING
Continue monitoring 4 Hourly
Nurse in Charge review 2 Hourly
Nurse in Charge & SHO review
Hourly
Nurse in Charge & SHO review & Registrar review
Hourly
Paediatric & anaesthetic registrar review.
Inform Consultant
Continuous
Remember: If you feel you need more help at any time, call for help – regardless of PEW Score
Irish PEWS So Far…
• Jan 2014 Project initiated
• Feb 2014 Working Group Established
Project aims agreed
• Mar 2014 PEWS literature review commissioned by NCEC
Call for international examples of PEWS in practice
• April 2014 Review of international PEWS systems
• May 2014 PEWS literature review awarded to DCU
Irish PEWS So Far…
• June 2014 Parameters & cut offs selected
• Aug 2014 Draft PEWS literature completed
• Sept 2014 PEWS co-ordinator appointed
Parameters finalised – Version 1
Testing on draft observation charts begins (add 5th)
• Oct 2014 Pilot sites selected
• Nov 2014 Version 5
Compass adapted
Project Aims
• To design and support the implementation of a national PEWS system as per the National Clinical Excellence Committee guidelines for all children in hospital.
• To trial the PEWS system in ED settings
Current Working Group Claire Browne Paediatric Programme Manager Suzanne Dempsey Director of Nursing, Temple St. Demot Doherty Paediatric Anaesthetist and Intensivist John Fitzsimons (Chair) Paediatrician, Drogheda & QPS Mary Gorman Resuscitation Officer, Crumlin Rachel MacDonell (PEWS Co-ordinator) Resuscitation Officer, Crumlin Ciara Martin Paediatric ED consultant, Tallaght Alf Nicholson Paediatrician, Temple St. & National lead Marina O’Connor ADON, Drogheda Carmel O’Donnell Nurse Education Crumlin Previous Members Ethel Ryan Paediatrician & Neonatologist, Galway Anthea Savage Resuscitation Officer, Temple St Grace Turner Paediatric Programme Manager
The ideal PEWS would….
• Be easy to use
• Be sensitive and specific
• Improve prediction and situation awareness
• Prompt and direct early action
• Be reliable & reproducible
• Be appropriate across all care environments(pre-hospital, ED, Ward)
• Be used in every hospital that cares for children
• Integrate with other EWS’s and communication tools
• Be easy to evaluate
• Be easily adapted to electronic format
PEWS would also help with latent deteriorations…
• Sepsis
• Cardiomyopathy
• End stage respiratory failure
Situation Awareness
Perception Gather the information
Comprehension Recognise and Understand
Projection Anticipate/Predict/Mitigate/Escalate
PEWS Project Overview
Design • Project team
• Detection & Response system
• Education
Test • Can it work?
• Findings from review
Pilot • Does it work?
Spread
Evaluate
Train the trainers
Does it improve care?
PEWS Project Overview
Design • Project team
• Detection & Response system
• Education
Test • Can it work?
• Findings from review
Pilot • Does it work?
Spread
Evaluate
Train the trainers
Does it improve care?
DCU Systematic Review
• Systematic review of 11 clinical guidelines & 70 research articles
• Grey literature review & interviews
• Review of detection & response systems as well as implementation & economic impact.
DCU Systematic Review
“positive directional trends in improving clinical based outcomes”
“there is no consensus and limited evidence about which PEW system is most useful or ‘optimal’ for paediatric contexts”
DCU Systematic Review
“The consequence of not investigating PEW systems as complex interventions is that... we are still unclear on what the true “active ingredients” of the PEW systems are”
Triggers
Baseline Observations Score
1.Nurse or family concerns 0, 1
2.Heart rate 0, 1, 2, 3
3.Respiratory rate 0, 1, 2, 3
4.Respiratory effort 0, 1 or 3
5.Oxygen use 0, 1, 2
6.AVPU 0, 1 or 3
Add-on Observations if PEWS > 3 (Prompting & Amplifying)
7.SpO2 0, 1, 2, 3
8.Blood Pressure 0, 1 or 3
9.Capillary refill time 0 or 1
PEWS Chart Design
Front Page
• Observation Chart
- Immediate triggers
- Aggregate scores
- Limited weighting
• Room for trigger modifications
Back Page
• Escalation plan
• ISBAR Prompts
• Sepsis plan
• GCS & Neuro Chart
• Pain chart
• Room For local additions
Paediatric Sepsis 6
Get 3 Give 3 • IV or IO access and take bloods - Blood Culture & PCR - FBC - Glucose & treat if low - Blood Gas - Lactate • Urine output measure
• Early Senior input
• High flow Oxygen • IV fluids - Aim to restore circulating volume - Titrate 20mls/kg isotonic fluid over 5-10 mins. - Repeat if necessary. - Caution for fluid overload. or hepatomegaly. • Broad spectrum IV Antibiotics
PEWS Project Overview
Design • Project team
• Detection & Response system
• Education
Test • Can it work?
• Findings from review
Pilot • Does it work?
Spread
Evaluate
Train the trainers
Does it improve care?
PEWS Project Overview
Design •Detection & Response system •Project team reviews •DCU report
Test • Can it work?
• Findings from review
Pilot • Does it work?
Spread
Evaluate
Train the trainers
Does it improve care?
Pilot Plan
• Four paediatric sites selected: OLCH Crumlin, CUH Temple St, University Hospital Limerick & Portiuncula.
• Training using adapted Compass training programme
• Train the trainers in December 2014
• Training of local staff & launch in January 2015
• Plan to run for 6 weeks and then to analyse before finalising the PEWS observation charts and other system elements.
Compass Training
• Paediatric version available from Australia. Only slight modifications from Adult version.
• Kept structure (mostly) but adapted the content to our needs
• Main purpose is to introduce the PEWS observation chart and the other system elements
• Refresher in paediatric resuscitation with ABCDE approach to assessment.
PEWS Project Overview
Design • Project team
• Detection & Response system
• Education
Test • Can it work?
• Findings from review
Pilot • Does it work?
Spread
Evaluate
Train the trainers
Does it improve care?
PEWS Project Overview
Design • Project team
• Detection & Response system
• Education
Test • Can it work?
• Findings from review
Pilot • Does it work?
Spread
Evaluate
Train the trainers
Does it improve care?
Challenges ahead
• How else might we improve:
- Safety culture
- Situation awareness
- Communication
- Team work
• Measure of outcomes (hard & soft) – need for better data nationally.
Special thanks
• To Rachel MacDonell, Anthea Savage
• To Claire Browne & Paediatric Programme
• To the DCU team
• To the NCEC team
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