The Brighton Paediatric Early Warning Score. Alan Monaghan Lecturer Practitioner Brighton and Sussex University Hospitals NHS Trust

Transcription

1 The Brighton Paediatric Early Warning Score Alan Monaghan Lecturer Practitioner Brighton and Sussex University Hospitals NHS Trust

2 Aims and Learning Outcomes To have an understanding of what is an Early Warning Tool and why it should be used. To be able to use the Brighton Paediatric Early Warning Score. To be aware of future developments of the score.

3 History First used in adults in the early 90s. Obvious signs of deterioration prior to cardiac arrest. (Franklynn and Mathew 1994) Early detection associated with improved outcomes in adults. (McQuillan 1998) Work needed in education of staff in recognition of the seriously ill patient. (Rouse 2001) 1 st PEWS Brighton based on adult systems (2002) Published Feb 2005 (Monaghan 2005)

4 What is a Paediatric Early Warning Score? A tool to identify patients with serious physiological disturbances at risk of deterioration. It is an objective assessment tool. It is a tool that may give us a numeric trend in the patients condition. Safety Net

5 How the Brighton Pews was designed Interviewed staff Why they call medical staff Examined MEWS Used knowledge experience Examined observation charts. Worked at Home

6 Design

7 Behaviour Playing / Appropriate. 1 ST Draft Score Sleeping. Irritable. Lethargic/ Confused Reduced response to pain. Cardiovascular Pink or Capillary Pale Grey Grey and mottled Respiratory Within normal parameters, no recession or tracheal tug. 10 above Normal Parameters, Using accessory muscles, 30+% Fi02 or 4+ litres/min. >20 above Normal Parameters recessing, tracheal tug. 40+% Fi02 or 6+ litres/min. >30 above or 5 below normal Parameters with sternal recession, tracheal tug or grunting.50% Fi02 or 8 + litres/min.

8 Royal Alexandra Hospital For Sick Children, Brighton Paediatric Early Warning Score. Behaviour Playing / Appropriate Score Sleeping. Irritable or Parents concerned. Lethargic/ Confused Reduced response to pain. Cardiovascular Pink or Capillary refill 1-2 seconds Pale or Capillary refill 3 seconds Grey or Capillary refill 4 seconds. Tachycardia of 20 above normal rate. Grey and mottled or capillary refill 5 seconds or above. Tachycardia of 30 above normal rate or bradycardia. Respiratory Within normal parameters, no recession or tracheal tug. > 10 above mean, Using accessory muscles, 30+% Fi02 or 4+ litres/min. >20 above mean recessing, tracheal tug. 40+% Fi02 or 6+ litres/min. >30 above or 5 below mean with sternal recession, tracheal tug or grunting. 50% Fi02 or 8 + litres/min. Score 2 extra for ¼ hourly nebulisers or persistent vomiting following surgery. PEWS score calculated for all patients All patients must have respiratory rate recorded Heart rate Mean Respiratory Infant <1yrs Toddler 1-2yrs Preschool 3-4yrs School 5-11yrs Adolescent yrs Inform Nurse in charge Continue PEWS monitoring Contact SHO / Registrar Consider Cardiac Arrest Call or Increase of 2 following intervention >4 or any red column Inform nurse in charge increase frequency of PEWS and observations Contact SHO/Reg inform PICU anaesthetist Patient attended within 1 hour Patient attended as soon as possible within 15 minutes Management plan agreed: All patients scoring more than 4 Registrar to inform Consultant Consider referral to PICU / HDU For further support consider contacting the Critical Care Outreach team Extension 2508

9 How to use BPEWS Observe the child objectively. Consult the chart and score what you observe. If their score is usually high keep scoring them so to detect any changes. Record the total in the observation chart. Carry out the actions as dictated.

10 Actions Actions range between informing the nurse in charge to calling out the cardiac arrest team. Main aim to encourage discussion and management with child s own team Response times between 15 minutes and 1 hour. Critical Care Liaison informed if score of 4 or any concerns or queries.

11 Challenges New Concept. Seen by staff as extra work. Staff suspicious of motives. What variables should be used? Sensitivity Verification Fear of deskilling. Change Management. Lack of available evidence. Education of Staff.

12 Common Misconceptions It will get my patient to PICU quicker. Its too much paperwork. Its time consuming. I would recognise any sick patient I don t need a score. Its too sensitive.

13 Make Sure You Score This Valentine s Don t forget this valentine s day is the start of The 2 week pilot (on Taaffe & Casualty) of the EARLY WARNING SCORE. For further information contact Alan Monaghan Bleep

14 Audit and Research Pilot study examined triggers initially only examined score 4. Should have examined all levels. Audit of observations. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

15 Audit Examined standard of observations and the relationship to PEWS. 2 main findings. Relationship between PEWS and quality of observations. Respiratory rate. PEWS and Respiratory rate.

16 Association Between Respiratory Rate and PEWS No Respiratory Rate 12 No Respiratory Rate and No PEWS No Respiratory Rate No Respiratory Rate and No PEWS

17 Research 2 studies submitted to LREC 1. To demonstrate that the Brighton Paediatric Early Warning Score reflects the child s severity of illness. 2. To demonstrate the interuser reliability of the (BPEWS) 1 st study passed 2 nd study to be resubmitted once study 1 is complete Study took 3 and a half years as difficulty recruiting group 3 subjects as scorer had to be the expert.

18 Study Protocol 1. Identify Subject 2. Give patient / carer information 3. Obtain consent 4. Expert observes child 5. Documents what is observed

19 Category 1 Control Group Outpatients No acute Illness Expect score to be between 0-1 Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10 Score 10

20 Group 2 Acutely Ill Child Acute admission within 24 hours Nursed in ward area Expect score to be between 2-4 4% 16% 0% 34% 0% 0% 0% 0% 0% 14% 32% Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10

21 Group 3 Critically Ill Acute onset within 24 hours. Classed as critically Ill by medical and nursing 12% staff. Recruited from PICU Expect score between % 0% 0% 0% 0% 2% 5% Score 1 Score 2 14% Score 3 Score 4 Score 5 Score 6 23% Score 7 Score 8 Score 9 Score 10 25%

22 Interobserver Variability of the Brighton PEWS Score Currently in progress Two nurses or Drs score independently Scores sealed in envelope and sent for analysis.

23 Tucker et al 2008 Examined 2979 Children using Brighton PEWS Evaluated its ability to detect deterioration Relationship between BPEWS and transfer to PICU For each rise of 1 in BPEWS there was a two fold increase in likelihood of transfer. Sensitivity was 90%. Specificity was 75% at score of 3. And specificity was 99% for children scoring 9. Limitation using PICU as an outcome.

24 Discussion

25 Scenario 1 12 Year old Diabetic. Irritable, Heart Rate 100. Capillary refill 2-3 secs. Respiratory Rate 20. Afebrile. Blood glucose 10mmols.

26 Scenario 2 4yr old. Not interested in surroundings or toys. Heart rate 140 bpm. Capillary refill 2-3 seconds. Temperature 40 o C. Respiratory Rate 26. Recession, Tracheal tug.

27 Any Questions