Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
Task Force Scoping Review Citation
Ng KC, Vinay N,, Maconochie I, Aicken R, Atkins DL, Bingham R, Couto TB, de Caen A, Guerguerian AM, Nadkarni V, Ng KC, Nuthall G, Ong G, Reis A, Schexynader S, Tijssen J, Van de Voorde P on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Taskforce. Pediatric Early Warning Scores in Infants and Children – A Scoping Review and Task Force Insights from the International Liaison Committee on Resuscitation Pediatric Life Support Taskforce. 09 January 2020 Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review conducted by the ILCOR PLS Task Force Scoping Review team. Evidence for pediatric literature was sought and considered by the Pediatric Life Support Task Force.
Scoping Review
No published review as of yet.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Infants and children in in-hospital setting
Intervention: Pediatric early warning scores (PEWS) with or without rapid response teams/medical emergency teams (RRTs/METs)
Comparators: No PEWS +/- RRTs/METs.
Outcomes: In-hospital deterioration, including mortality.
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.
Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to September 15, 2019.
Search Strategies
PubMed (Jan 2015 – September 2019)
("pediatrics"[mh] OR "pediatric"[ti] OR "paediatric"[ti]) AND ("patient care team"[MeSH Major Topic] OR medical emergency team[ti] OR medical emergency teams[ti] OR pMET[ti] OR rapid response system[ti] OR rapid response team[ti] OR rapid response teams[ti] OR early warning system[ti] OR early warning score[ti] OR early warning scores[ti])
Cochrane Central Register of Controlled Trials /CENTRAL (Jan 2015 to September 2019)
"early warning score*","early warning system*", "early warning tool*", "VitalPAC Early Warning Score", "activation criteria", "Rapid Response Team", "Rapid Response system*", "Track and trigger", "trigger tools", "calling criteria", "Alert criteria", "Rapid Response", pediatric* or paediatric* or infant* or child* or baby or toddler or babies or teen* or adolescent*, "Pediatric Early Warning", "Paediatric Early Warning", "p?ediatric alert", "Pediatric Rapid Response", "Pediatric Advanced Warning Score*", "Paediatric Advanced Warning Score*", "infant early warning", "Bedside PEWS", "Bedside paediatric early warning"
Inclusion and Exclusion criteria
Literature search was updated from January 2015 to September 15, 2019.
Studies which addressed the above PICO were included -
- Infants and children in in-hospital setting
- Pediatric early warning scores (PEWS) with or without rapid response teams/medical emergency teams (RRTs/METs)
- Outcomes: In-hospital deterioration, including mortality.
- Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were included
- All years and all languages were included as long as there was an English abstract;
Exclusion Criteria
- patient population > 18 years
- unpublished studies (e.g., conference abstracts, trial protocols) were excluded.
Evaluation of Included Studies
|
Reference |
Methods |
Participants / Interventions / Comparisons |
Outcomes |
Notes |
|
{Trubey 2019 e022105} |
Systematic Review - British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge. Results were searched through May 2018. |
(1) papers reporting on the development or validation of a Paediatric Track and Trigger Tool (PTTT) or (2) the implementation of a broader early warning system in paediatric units (age 0–18 years), where adverse outcome metrics were reported. Several study designs were considered. Question 1: How well validated are existing PTTT and their component parts for predicting inpatient deterioration? Question 2: How effective are paediatric early warning systems (with or without a PTTT) at reducing mortality and critical events? |
3118 papers were identified & screened. 387 full text articles were reviewed and 66 met the inclusion criteria - 36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. The metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. |
Overall, there was limited evidence that paediatric early warning system interventions lead to reductions in deterioration. |
|
{Lambert 2017 e014497} |
Systematic Review - PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). |
Eligible papers had to refer to PEWS, inclusive of rapid response systems (RRS) and rapid response teams (RRT). Outcomes had to be specific to the identification of and/or response to clinical deterioration in child patients (including neonates) in paediatric hospital settings (including emergency departments). No study design restrictions were applied. The Irish Department of Health commissioned this review & the review questions were: 1. What is the available evidence on the effectiveness of different PEW detection systems? 2. What evidence exists on the effectiveness of PEW response mechanisms, and what interventions are used? 3. What evidence exists on PEWS implementation strategies/interventions? |
2742 papers were identified and 90 papers included. Findings showed that while PEWS are extensively used internationally in paediatric inpatient hospital settings, robust empirical evidence on which PEWS is most effective was limited. |
The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration. |
|
{Chapman 2016 87} |
Systematic Review - AMED, CINAHL,Cochrane Library, EMBASE, and OVID Pubmed were used in the search from 1990. In addition, Google scholar was searched and abstracts from the annual conferences of the Royal Collegeof Paediatrics and Child Health (RCPCH); European Society of Paediatric and Neonatal Intensive Care (ESPNIC) and European Society of Intensive Care Medicine (ESCIM); together with the bi-annual World Congress in Paediatric Intensive Care were hand-searched from 2000 onwards. |
To describe the number and nature of published paediatric track and trigger systems (PTTS) and appraise the evidence on their validity, calibration, and effect on important patient outcomes (death, cardiac and/or respiratory arrest, unplanned transfer to intensive/high dependency care, immediate/urgent request for review, rapid response system activation). GRADE methodology was used with papers identified through electronic database and citation searching. |
There were 55 studies with 33 PTTS identified. There was considerable variety in the number and type of parameters, although all contained one or more vital signs. The evidence to support PTTS implementation was very low and the majority of outcomes did not achieve statistical significance. |
When PTTS was implemented as part of a rapid response system, the evidence was moderate to low but there was some evidence of a statistically significant improvement in outcome. There is some limited evidence for the validity and clinical utility of PTTS scores. The high (and increasing) number of systems is a significant confounder. |
|
{Brown 2019 410} |
Scoping Review - Web of Science, PubMed, Scopus, Cumulative Index of Nursing, and Allied Health Literature (CINAHL), EMBASE, Portal Regional da BVS, and TRIP Database were searched for all entries written in English or Spanish from database inception to November 2017. |
The purpose of this review was to summarize the current evidence for use of PEWS in RLS and identify areas for further research. |
Though there is limited research, eight studies on the use of PEWS, or a PEWS score in a pediatric population in low- or middle-income countries were identified. There were 2 studies that assessed the clinical effect of implementation of PEWS - one reported a reduction in clinical deterioration events and the other a reduction in mortality. The remaining studies assessed the association of a PEWS score with signs of clinical deterioration or mortality without a response algorithm. |
There is some evidence, though limited, which suggests usefulness of PEWS in low- or middle-income countries |
|
{Parshuram 2018 1002} |
Multicenter cluster randomized trial |
EPOCH (Evaluating processes of care and outcomes of children in hospital) study. The 21 participating hospitals were from 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) with inpatient units for infants (gestational age >/= 37 weeks) to teenagers (aged =/< 18 years). Participating hospitals had continuous physician staffing and subspecialty pediatric services. The intervention was the Bedside PEWS in 10 hospitals and this was compared with usual care in 11 hospitals (no severity of illness score;). Enrollment started in February 2011, and ended on June 21, 2015 with follow-up ending on July 2015. The primary outcome was all-cause hospital mortality and the secondary outcome was significant clinical deterioration events, which were defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. |
Among 144 539 patient discharges from 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) who completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with Bedside PEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95%CI, −0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95%CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with Bedside PEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, −0.34 [95%CI, −0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95%CI, 0.61 to 0.97]; P = .03). Implementation of the bedside PEWS compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. |
The EPOCH findings do not support the use of PEWS to reduce mortality, but do support the use of bedside PEWS to decrease clinically important deteriorations on the wards in non-tertiary care / community hospitals. |
Task Force Insights
1. Why this topic was reviewed.
There was a 2015 CoSTR on PLS 818 (PEWS) together with a 2015 CoSTR on PLS 397 (Pediatric RRTs/METs).
2015 CoSTR PEWS (PLS 818)
Treatment Recommendation:
The confidence in the estimate of predictive value is so low that the panel decided a recommendation is too speculative.
Knowledge Gaps :
- Does PEWS, independent of other interventions, have an impact on outcomes?
- A large pediatric, cluster-randomized, multicenter study is currently under way examining the impact of implementing a PEWS.
- Additional outcome measures apart from cardiac arrest rate or hospital mortality are required.
- Future specific research will need to focus on prospective evaluation of different PEWS for identifying and predicting patients at risk for different forms of decompensation, including primary respiratory, circulatory, and neurologic etiologies.
2015 CoSTR RRTs/METs (PLS 397)
Recommendations
We suggest the use of pediatric MET/RRT systems in hospitals that care for children (weak recommendation, very-low quality evidence).
Values, Preferences, and Task Force Insights
In making this recommendation, we place a higher value on the potential to recognize and intervene for patients with deteriorating illness over the expense incurred by a healthcare system committing significant resources to implement a MET/ RRT system. We recognize that the decision to use a MET/ RRT system should be balanced by the existing resources and capabilities of the institution.
Knowledge Gaps
- The amount and quality of evidence in children compared with adults for the role of MET/RRT systems is very low. A major limitation to evaluation of these systems is the low rate of pediatric cardiac arrest and mortality (especially outside the intensive care unit setting), including within the hospitals from which the data in this analysis originate. As such, demonstrating a statistically significant effect after a new implementation is difficult. This is apparent in that most studies demonstrated trends of improving cardiac arrest rate or mortality, although not to statistically significant levels. Use of a more proximate outcome metric, like a critical deterioration event, might further support implementation of a MET/RRT in the pediatric inpatient setting.
- The other major limitation in our analysis is the use of before-and-after studies, with the inherent limitations of unaccounted or confounding variables and inability to develop a comparable control group. Joffe et al {Joffe 2011 419} demonstrated the potential for risk of bias or confounding variables by comparing the mortality rate at their institution, which did not initiate or organize a MET/ RRT, with 5 published studies. The reduction in mortality at their institution over the same time period was similar to the published results, illustrating the problems of confounding variables and contemporaneous trends. Quality improvement methodology could be used to regulate the impact of a series of changes that include educational processes, documentation review with feedback systems, and modification of other factors thought to improve the delivery of care.
This topic was chosen for review by the PLS Taskforce because of the previous weak recommendations in 2015 and to review and update based on new evidence in the published literature.
2. Narrative summary of evidence identified
2019 PLS PEWS Narrative Summary
Since 2015, there was a multicenter cluster randomized trial – the EPOCH (Evaluating processes of care and outcomes of children in hospital) study {Parshuram 2018 1002}.
Participants were from 21 hospitals from 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) with inpatient care for infants (gestational age >/= 37 weeks) to teenagers (aged =/< 18 years).
Participating hospitals had continuous physician staffing and subspecialized pediatric services. The intervention was the Bedside PEWS in 10 hospitals and this was compared with usual care (no severity of illness score; 11 hospitals). Enrollment started on February 2011, and ended on June 21, 2015 with follow-up ending on July 2015.
The primary outcome was all-cause hospital mortality and the secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates.
Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) who completed the trial.
All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with Bedside PEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95%CI, −0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95%CI, 0.61 to 1.69]; P = .96).
Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with Bedside PEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, −0.34 [95%CI, −0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95%CI, 0.61 to 0.97]; P = .03). Implementation of the bedside PEWS compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients.
The EPOCH findings do not support the use of PEWS to reduce mortality, but do support the use of bedside PEWS to decrease clinically important deteriorations on the wards in non-tertiary care / community hospitals.
There have been 3 systematic reviews {Trubey 2019 e022105; Lambert 2017 e014497; Chapman 2016 87} and 1 scoping review {Brown 2019 410} published since 2015 (see summary data in Table above).
3. Narrative Reporting of the task force discussions
Taskforce Insights
While there is limited evidence that pediatric early warning system interventions result in a reduction in in-hospital clinical deterioration, some effectiveness studies, with methodological limitations, appear to show clinical benefits. The use of bedside PEWS should decrease clinically important deteriorations on the wards in non-tertiary care / community hospitals.
There is sufficient evidence to warrant a systematic review.
Values, Preferences, and Task Force Insights
The taskforce considered that implementation of PEWS should be part of an overall clinical response system in the institution. The taskforce placed a high value on the potential to recognize and intervene for patients with deteriorating illness, but recognised the expense incurred by a healthcare system committing significant resources to implement PEWS within such systems. We recognize that the decision to use PEWS within such a system should be balanced by the existing resources and capabilities of the institution.
Knowledge Gaps
- Additional outcome measures apart from cardiac arrest rate or hospital mortality are required. A major limitation in the evaluation of PEWS is the low rate of pediatric cardiac arrest and high mortality (especially outside the intensive care unit setting). As such, demonstrating a statistically significant effect after a new implementation, is difficult. This is apparent in that most studies demonstrated trends of improving cardiac arrest rate or mortality, although not to statistically significant levels. Use of a more proximate outcome metric, like a critical deterioration event, might further support implementation of PEWS in the pediatric inpatient setting.
- Does PEWS, independent of other interventions, indeed have an impact on outcomes? The other major limitation is the use of before-and-after studies, with the inherent limitations of unaccounted or confounding variables and the inability to develop a comparable control group. Joffe et al {Joffe 2011 419} demonstrated the potential for risk of bias or confounding variables by comparing the mortality rate at their institution, which did not initiate or organize a MET/ RRT, with 5 published studies. The reduction in mortality at their institution over the same time period was similar to the published results, illustrating the problems of confounding variables and contemporaneous trends. Quality improvement methodology could be used to regulate the impact of a series of changes that include educational processes, documentation review with feedback systems, and modification of other factors thought to improve the delivery of care.
- A large pediatric, cluster-randomized, multicenter study is currently under way examining the impact of implementing PEWS and pediatric track & trigger tools (PEWS Utilization & Mortality Avoidance/PUMA). {Thomas-Jones 2018 244}
- Future research should focus on prospective evaluation of different PEWS not only for identifying and predicting patients at risk for different forms of decompensation, including primary respiratory, circulatory, and neurologic etiologies but interrogate the role PEWS can play in preventing clinical deterioration. Future research should also look at the impact and role of PEWS in resource-limited countries.
References
- Brown SR, Martinez Garcia D, Agulnik A Scoping Review of Pediatric Early Warning Systems (PEWS) in Resource-Limited and Humanitarian Settings. Front. Pediatr. 2019; 6:410. doi: 10.3389/fped.2018.00410
- Chapman SM, Wray J, Kate Oulton K, Peters MJ. Systematic review of paediatric track and trigger systems for hospitalised children. Resuscitation; 2016: 109:87-109.
- Joffe AR, Anton NR, Burkholder SC. Reduction in Hospital Mortality Over Time in a Hospital Without a Pediatric Medical Emergency Team : Limitations of Before-and-After Study Designs. Arch Pediatr Adolesc Med. 2011;165(5):419-423.
- Lambert V, Matthews A, MacDonell R, et al. Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review. BMJ Open 2017;7:e014497. doi:10.1136/bmjopen-2016-014497
- Parshuram CS, Dryden-Palmer K, Farrell C et al. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients. The EPOCH Randomized Clinical Trial. JAMA. 2018;319(10):1002-1012. doi:10.1001/jama.2018.0948
- Thomas-Jones E, Lloyd A, Roland D, et al. 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 Pediatrics (2018) 18:244; https://doi.org/10.1186/s12887... R, Huang C, Lugg-Widger FV, et al. Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review. BMJ Open 2019;9:e022105. doi:10.1136/bmjopen-2018-022105