Texas Children s Hospital, Houston, TX

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1 Journal of Pediatric Nursing (2013) 28, e2 e9 The Texas Children s Hospital Pediatric Advanced Warning Sce as a Predict of Clinical Deteriation in Hospitalized Infants and Children: A Modification of the PEWS Tool Donnett Bell MS, RN, CNS, PNP-BC, Anh Mac MSN, RN, CPN, Yvette Ochoa BSN, RN, Mary Gdon PhD, RN, CNS-BC, Mary Ann Gregurich PhD, MPH, Tangula Tayl MBA, BSN, RN, NE-BC Texas Children s Hospital, Houston, TX Key wds: Pediatric warning sce; Screening tool; Pediatric clinical deteriation; Early warning sce; Risk assessment; Pediatric safety Purpose: The purpose of this study was to examine the psychometric properties of the Texas Children's Hospital Pediatric Advanced Warning Sce (PAWS) instrument as an indicat of clinical deteriation in infants and children. Design and methods: A retrospective chart review of 150 infants and children was perfmed. Results: The overall Cronbach's alpha sce was The estimate of interrater reliability was Implications: The Texas Children's Hospital Pediatric Advanced Warning Sce instrument was found to be reliable and valid Elsevier Inc. All rights reserved. PEDIATRIC PATIENTS ARE admitted to acute care settings today with higher acuities and combidities than in years past. In der to safely manage me complex patients, acute care nurses have added many new clinical skills into their daily practices. Higher acuity children are sometimes atrisk f deteriation. Therefe, a robust system f early recognition and timely treatment of deteriation is recommended (Haines, Perrott, & Weir, 2006). Thus, nurses routinely assess f clinical deteriation in acute care and successfully manage deteriation by getting help to the bedside f emergency interventions and/ transfer the child to a higher level of care. The goal is to identify deteriation early to prevent a cardiac arrest from occurring in acute care. The tool studied in acute care is the Texas Children s Hospital (TCH) Pediatric Advanced Warning Sce (PAWS). It is a modification of the Pediatric Early Warning Sce (PEWS) tool to assess deteriation in the pediatric Cresponding auth: Donnett Bell, MS, RN, CNS, PNP-BC. address: dxbell@texaschildrenshospital.g patient population. This study examines the psychometric properties of the TCH PAWS tool as an indicat of clinical deteriation in infants and children during hospitalization. This paper does not compare the psychometrics of the TCH PAWS tool to the psychometrics of the PEWS tool. Approximately 3% of children admitted to hospitals require immediate medical assistance f the treatment of actual impending cardiopulmonary arrest (McCabe, Ducan, & Heward, 2009 & Parshuram, Middaugh, & Hutchinson, 2009). Previous studies have highlighted clinical antecedents associated with in-hospital cardiopulmonary arrests such as clinical deteriation involving either respiraty mental function, systolic blood pressure changes, hypoxia, azotemia (Kause, Prytherch, Parr, Flabouris, & Hillman, 2004 & Lee, Bishop, Hillman, & Daffurn, 1995). Significant attention should be given to the fact, that children deteriate quickly and depending on their age and cognitive ability some will not be able to communicate what they are feeling, which adds a layer of complexity to the clinical assessment (Haines et al., 2006) /$ see front matter 2013 Elsevier Inc. All rights reserved.

2 Pediatric Advanced Warning Sce (PAWS) Studies by Tucker, Brewer, Baker, Demeritt, and Vossmeyer (2009) and Monaghan (2005) describe how early warning scing systems allow f prompt identification of deteriation, thus facilitating earlier intervention. The systems have rapid scing capability because of the objectivity and ease-of-use (approximately seconds) and have helped to increase confidence in nurses to recognize children at-risk f deteriation. Additionally, use of early warning tools promotes timely and efficient communication between nurses and physicians (Andrews & Waterman, 2005). Operationally, early warning scing systems include a trigger (algithm) f graded responses so that lower sces suppt minimal frequency of moniting. As sces increase, the frequency of moniting increases, which may trigger activation of the Rapid Response Team (RRT) and/ movement of the patient to higher intensity care areas (Goldhill, McNarry, Mandersloot, & McGinley, 2005). Rapid Response Teams have helped to decrease codes in acute care (Akre et al., 2010). Child Health Cpation of America Collabative In 2007, our hospital joined a one-year collabative with the Child Health Cpation of America (CHCA), which included 19 other hospitals throughout the country. The challenge of the collabative was to eliminate codes in acute care by identifying deteriation earlier and to intervene appropriately. Use of the Pediatric Early Warning Sce (PEWS) was one of many changes that the collabative suggested. The PEWS tool has 3 assessment parameters: behavi, cardiovascular, and respiraty. Each parameter has 4 categies of scing (0 3 points). An additional 2 points may be added f patients receiving every 15 minutes of nebulizer treatment persistent vomiting following surgery. The highest possible cumulative sce is 13. Higher sces indicate poer patient conditions. The PEWS tool was found to be a reliable and valid scing system to identify risk f clinical deteriation. Tucker et al. (2009) found the PEWS tool identified children who needed a higher level of care (area under the curve = 0.89, 95% CI = , p b.001). Also, interrater reliability was assessed with two RNs independently scing patients (intraclass coefficient = 0.92, p =.001). At the time of the collabative, our hospital was not using an early warning-scing tool. Thus the collabative team decided to investigate the PEWS tool f possible implementation in our hospital. The Texas Children s Hospital Pediatric Advanced Warning Sce Tool A multidisciplinary team of physicians, nurses, and respiraty therapists reviewed the PEWS tool (Tucker et al., 2009), and decided to revise it befe implementation because the iginal study was done on a 24 bed general medical unit. Our patient population included patients with cardiac and surgical diagnoses, as well as patients with medical diagnoses. The primary modifications made to the PEWS tool were the wds used to describe deteriation in some of the categies. The team wanted to evaluate the revised tool and its ability to capture deteriation in patients with cardiac, surgical and medical diagnoses. Permission to modify the PEWS tool was received from Tucker et al., The TCH PAWS tool has 3 assessment parameters: behavi, cardiovascular, and respiraty (Figure 1). Each assessment parameter can be sced between 0 3 points depending on the categy of the findings. An additional 2 points may be added to the total sce if respiraty treatments are needed every hour (versus every 15 minutes with PEWS) if there is persistent vomiting following surgery. The rationale f this change was to comply with the routines f acute care policy, which specifies patients who require nebulizer treatments every hour f me than 4 hours require a higher level of care. The highest possible cumulative sce is 13. Higher sces indicate poer patient conditions. A modification was made to the respiraty parameter. Pulse oximetry was added as the monit f breathing instead of the liters of oxygen per minute. No change was made to the respiraty rate criteria. Pulse oximetry is an accurate and reliable indicat of the level of oxygen circulating in the blood. It is widely available and used routinely in acute care, especially in the acute and chronic cardiac patient populations. Pulse oximetry is most helpful when used to trend oxygen saturation over time and also, it is a standard of practice f moniting the respiraty system in our hospital. Therefe, the team changed the respiraty parameter to include changes in oxygen saturations within baseline limits, 5 points below baseline, me than 5 points below baseline. Changes were made to the scing criteria descripts in the behavi parameter (Figure 1). The team removed categy 1 term sleeping as a descript of behavi, because they felt the term did not sufficiently capture early symptoms of deteriation in mental status. Therefe, it was replaced with irritable (consolable). Categy 2 was changed to irritable (inconsolable). The consensus among the team members was that irritable (consolable) behavi usually precedes irritable (inconsolable) behavi and are better descripts of the observed behavi seen during deteriation. Categy 3 descripts remained lethargic/ confused. The reduced response to pain descript in categy 3 was removed because it was considered a late sign of progression toward clinical deteriation. Changes in the Glasgow coma scale (GCS) were initially included as descripts in the behavi categy as an additional marker of neurological deteriation. The team felt GCS was a standard shift assessment parameter and would be easy to capture on the TCH PAWS tool. However, the GCS was not a significant predict in the behavi categy and therefe, it was removed from the final version of the PAWS tool. e3

3 e4 D. Bell et al Behavi Playing/Appropriate Irritable (consolable) Irritable (inconsolable) Lethargic/confused Cardiovascular Pink baseline col and Cap. refill 1-2 seconds Pale Cap. refill 3 seconds Pale & Cap. refill 4 seconds Tachycardia of baseline Diaphesis 20 above Grey Mottled Cap. refill 5 seconds Tachycardia 30 above baseline Bradycardia Green = 0-2 Sce Yellow = 3 Sce Respiraty RR and O2 sats within baseline limits and No signs of increased wk of breathing RR 10 above baseline Mild using accessy muscles RR 20 above baseline O2 sats 5 pts below baseline Moderate use of accessy muscles Slowing of RR below baseline & increased wk of breathing O2 sats > 5 points below baseline Grunting Severe Retractions Orange = 4 Sce Sce 2 extra points f patients who are on every hour respiraty treatments with persistent vomiting following surgery. Review VS at time of scing & repeat if isolated sce of 3 in any categy OR total sce of 4 obtained. Review O 2 requirement & trend at time of scing. Red =5 Sce Figure 1 Texas Children s Hospital (TCH) Pediatric Advanced Warning Sce (PAWS). (Adapted with permission from: Tucker et al. (2009). Prospective Evaluation of a Pediatric Inpatient Early Warning Scing System. Journal f Specialists in Pediatric Nursing). Diaphesis was added to the cardiovascular parameter in categy 2 as an early warning symptom f deteriation (heart failure). This addition to the cardiovascular parameter was made to accommodate deteriation in our large population of cardiac patients. The TCH PAWS tool considers the patients physiological parameters and baseline vital signs, and recommends trending at the time of scing. The healthcare team utilizes the algithm (Figure 2) to provide care by recommending me frequent assessments, medical interventions, initiating a call to the RRT code team. If a sce of 3 (in any one categy) a total sce of 4 higher is reached, the algithm suggests considering a RRT call. The algithm was modified to capture escalation of concern from the intern to the seni resident at a sce of 5 higher. In addition, a code can be activated at a sce of 6 higher. The team felt waiting f a sce of 7 higher would only delay getting help to the bedside. The wd, consider, was used throughout the algithm as the team felt the healthcare provider should use the tool in combination with good clinical judgment. Pri to collecting data, PAWS education was provided to all acute care unit nurses and physicians. The education consisted of a one hour presentation of content and interactive discussion of various patient scenarios. Also stressed was the concept that a RRT code could be initiated at any time based on the healthcare teams' assessment, regardless of TCH PAWS sce. Individuals were trained to use the data collection instruments, at which point they assumed responsibility f training other data collects. A statistician incpated all data into the database. The hospital-wide roll out of RRT was March The pilot study of the TCH PAWS tool was started in July The house-wide rollout of the TCH PAWS tool was done in August Research Design and Methods The purpose of this study was to examine the psychometric properties of the TCH PAWS tool as an indicat of clinical deteriation in infants and children during hospitalization. The Bayl Institutional Review Board (IRB) approved this study. It was anticipated that the TCH PAWS tool could be useful as a reliable and valid indicat of early warning signs of clinical changes that warrant a rapid clinical response. The key psychometric properties to be examined are reliability and validity. Reliability establishes the consistency repeatability of measurements made with the instrument and validity establishes if the instrument measures what it claims to measure. Additional aims f this study included quantifying: (a) the rate of calls made to the RRT, (b) the rate of communication among health care professionals, (c) the crelation between increased TCH PAWS with increased respiraty and heart rates, and (d) the crelation between increased TCH PAWS with decreased GCS sces. Interrater reliability was also established.

4 Pediatric Advanced Warning Sce (PAWS) e5 Figure 2 Texas Children s Hospital (TCH) Pediatric Advanced Warning Sce (PAWS) Algithm. Impending cardiac respiraty arrest is an automatic code red call *9999. If there are criteria f RRT call *9999. (Adapted with permission from: Tucker et al. (2009). Prospective Evaluation of a Pediatric Inpatient Early Warning Scing System. Journal f Specialists in Pediatric Nursing.)

5 e6 Design The study was a non-experimental retrospective research design. Sample Size and Setting The study was conducted with patients admitted to one of three acute care units: General medicine/transplant unit Pulmonary, adolescent, and endocrine unit Cardiology unit These units manage a variety of patients with the following medical disders such as; heart disease, cystic fibrosis, bronchiolitis, asthma, diabetes, seizure disders, liver, kidney, adolescents with eating disders, Crohns, pancreatitis, sickle cell, and cancer patients not receiving chemotherapy. These units also manage a variety of surgical disders such as; heart, liver, kidney and lung pre and post transplant, and general surgical procedures (appendectomy, incision and drainage, and tonsillectomies). It was determined that 286 infants and children were admitted to the acute care settings at the hospital during the month of July 2008 and with the inclusion of cardiology patients this would be a total of approximately 500 patients. The TCH PAWS sces are obtained as part of routine quality care. F a population size of 500 infants and children with similar characteristics, a sample size of 150 patients was needed to make estimates with a sampling err of no me than ±5 percent, at the 95 percent confidence level. Sample size was determined using determinations f simple random and systematic sampling methods f health studies (Lemeshow, Hosmer, Klar, & Lwanga, 1993). Sampling Procedure A retrospective chart review was perfmed f infants and children admitted to one of the three acute care units during the period of January 1, 2009 to June 1, The institution admitted approximately 21,168 patients during the study year. The sample size reflects 0.7 % of the patient population. Fifty infants' and children's charts were randomly selected from each unit f a total of 150 charts. Patients were included in the study if their length of stay was greater than 48 hours. A PAWS data collection tool was designed to recd data f this particular chart review. Results Researchers reviewed the charts of 150 infants and children admitted in three acute care setting units from January 1, 2009 to June 1, The mean age of the infants and children in the review was 6.3 years (range: years), with almost 25% of subjects under one year of age and 50.7% of subjects female. Table 1 presents me detailed patient demographic infmation. Reliability analysis was used to examine the psychometric properties of the TCH PAWS tool. The analysis calculated the reliability of the measurement scales and the relationships between individual items in the scale. The inter-item crelation matrix showed positive crelations among individual items at the final measurement of the 48-hour time period (Table 2). The weakest crelations were with the behavial measure categy (0.414 with cardiovascular, with respiraty). This weak crelation was also observed clinically. F example, when there is rapid deteriation in the respiraty and cardiovascular systems, the behavial changes seem slower to become evident. Internal consistency of the TCH PAWS sces was measured using the Cronbach s alpha coefficient, which is a single summary statistic measuring reliability of all items to predict the acute changes in clinical status of infants and children during hospitalization. The overall Cronbach s alpha reliability coefficient f the TCH PAWS sce at the final measurement was 0.75, indicating adequate reliability of the instrument. In hospitalized infants and children in the acute care setting, an increasing TCH PAWS sce of 5 resulted in calls to the rapid team response 80% of the time. There were a total of five (5) infants and children in the acute care setting whose first occurrence of a TCH PAWS sce was 5 with four (4) calls made to the rapid response team. The majity of these patients were male (75.0%) with a mean age of 8.4 years. The patient with a TCH PAWS sce of 5 that did not result in a call to the rapid response team was a female less than one year of age. When the first occurrence of a TCH PAWS sce was 3 4 f hospitalized infants and children in the acute care setting, communication was established with the patient s physician the health care professionals. The chart review recded on the TCH PAWS assessment data collection tool resulted in 8 team communications established Table 1 Patient Demographics. N D. Bell et al. Percentage Gender Male % Female % Age 1 Year % 1 3 Years % 4 6 Years % 7 12 Years % N12 Years % Diagnosis Respiraty % Surgery % Medical % Cardiology %

6 Pediatric Advanced Warning Sce (PAWS) Table 2 Inter-Item Crelational Matrix: Final Measure of the 48-Hour Time Period. Behavi sce Cardiovascular sce Behavi sce Cardiovascular sce Respiraty sce Respiraty Sce Table 3 PAWS 48-Hour Assessments, Spearmen s Rank Crelation Coefficients, and PAWS Respiraty. Sces and respiraty rates Assessment Spearman s rho p value Time b0.001 Time b0.001 Time Time Time b0.001 Time Time Time Table 4 PAWS 48-Hour Assessments, Spearmen s Rank Crelation Coefficients, and PAWS Cardiovascular Sces and Heart Rates. Assessment Spearman s rho p value Time Time NS Time NS Time NS Time NS Time Time NS Time out of a total of 10 patients having a TCH PAWS sce of 3 4. Therefe the communication rate among health care professionals was 80%. Of these patients there was an equal number of males and females (50.0%) and a mean age of 1.96 years. The mean age of patients with a TCH PAWS sce of 3 4 when health care professionals were not called (20%) was 2.13 years there also were an equal number of males and females. Of those patients when the rapid response and communication teams were not called, the diagnoses were evenly distributed between respiraty disders, medical, and cardiology and no other remarkable differences with regard to their characteristics. Spearman's rank crelation coefficients were computed to evaluate the crelation between (a) increasing TCH PAWS respiraty sces with increasing respiraty rates, and (b) increasing TCH PAWS cardiovascular sces with increasing heart rates in hospitalized infants and children at each recded measure during the 48-hour time period. All crelations were positively crelated, ranging from to 0.406, and were considered statistically significant. Results of the crelation analysis are presented in Table 3. Spearman's rank crelation coefficients were computed between TCH PAWS cardiovascular sces and heart rates of hospitalized infants and children at every recded measure during the 48-hour time period. All crelations were positively crelated, with three statistically significant crelations: the first measure (Time 1), Time 6, and the last measure of the 48-hour time period (Time 8). Results of the crelation analysis are presented in Table 4. To determine if increasing TCH PAWS sces crelated with decreasing GCS, Spearman s rank crelation coefficients were computed between total TCH PAWS sces and GCS of hospitalized infants and children at every recded measure during the 48-hour time period. At Time 1, TCH PAWS and GCS were negatively crelated (rho = 0.240) and statistically significant (p = 0.004). The result of the crelation analysis at Time 2 was negatively crelated (rho = 0.066) but not statistically significant. Results of the remaining crelation analyses (Time 3 Time 8) between the TCH PAWS and GCS were positive and not significant. Therefe, GCS was removed from the final TCH PAWS tool. Interrater reliability of observers' common interpretation of the TCH PAWS was done prospectively by computing the intraclass crelation coefficient (ICC). To capture the consistency of sces among nurses who evaluated the same patient's level of deteriation, two nurse raters assessed each patient s level of deteriation with TCH PAWS at the same time point. There were 58 nurses, including float pool nurses that staff acute care units, who participated in evaluation of the ICC. The TCH PAWS total sce strength of the relationship between both raters simultaneously was 0.851, with a 95% confidence interval Individual items also yielded an acceptable ICC at 0.740, with a 95% confidence interval (Table 5). Typically, TCH PAWS is used with a single observer, therefe the single measure sce was used as a baseline f future interrater reliability studies. The relationship between the nurses sces ascertained that nurse raters dependably gave acceptable ratings. In 2008 (year befe the study began) the rate of the RRT calls from acute care units was 4.88 per 1000 patient days. During the calendar year 2009, the rate of RRT calls from acute care units was 5.85 per 1000 patient days. One outcome goal of the collabative was to minimize the number of codes in acute care. The code events decreased from per 1000 patient days in per 1000 patient days in However, this decreased number of codes is not statistically significant. Pri to the study, the average length of time between codes on the pilot units was 18.1 days. The target goal of the acute care units was to double the number of days between codes, making the target number 36 days. The acute units exceeded their goal by achieving 258 days between codes during the period of 7/12/08 to 3/31/09. e7

7 e8 D. Bell et al. Table 5 Interrater Reliability Assessment with ICC. Intraclass crelation a 95% Confidence interval F test with true value 0 Lower bound Upper bound Value df1 df2 Sig Single measures.740 b Average measures.851 c Two-way random effects model where both people effects and measures effects are random. The Average ICC refers to the interrater reliability of two raters combined. Single ICC refers to the reliability of one nurse. Accding to McCabe, Ducan, & Heward (2009) implementation and reinfcement of an early warning system can take several years to achieve a reduction in code events and improve clinical outcomes. Therefe, the priity hospital-wide goal to decrease/eliminate code events in acute care units continues today. Implications f Practice The TCH PAWS tool was found to be a valid and reliable tool that was incpated into clinical practice throughout the acute care units. During the early stages of the project, TCH PAWS was completed twice per 12-hour shift. After benchmarking with other pediatric hospitals that utilize early warning tools the assessment frequency was changed to every 4 hours. Initially, there was some resistance to the change in practice; however, it has since become a standard of care. Hospital policy has been updated to reflect the 4- hour intervals of patient scing. Tools that helped during the assimilation process included: leadership huddles with staff, and frequent educational opptunities, that assisted in demonstrating the value of TCH PAWS as it related to ensuring safety of hospitalized infants and children. During the pilot study, TCH PAWS was recded on a separate fm that led to po compliance with sce documentation. Since then, TCH PAWS documentation section has been incpated into the electronic medical recd. Texas Children s Hospital Pediatric Advanced Warning Sce as a Communication Tool Pri to transpt to acute care, patients are given a TCH PAWS sce by their transferring departments (emergency services, pediatric intensive care, progressive care, etc.). The sce is used to communicate patients stability. If a patient s sce suggests that the patient may be of higher acuity and require an increase in intensity of services, relevant infmation is given to the charge nurse and the patient s status is investigated by the Nursing Administrative Codinat (House Supervis) to ensure crect patient placement. The TCH PAWS tool is used at initial notification of deteriation and used subsequently after each intervention to determine if a patient s condition has improved. The TCH PAWS tool is also used when a RRT is initiated and is part of the Situation Background Assessment Recommendation (SBAR) communication from bedside nurse to RRT nurse. The TCH PAWS tool is used extensively throughout the ganization and is a vital part of the communication process. Future Implications The assessment of patients using TCH PAWS every 4 hours combined with consistently low sces may carry a risk of fatigue among the nurses. Future studies are needed to further describe this concept. The TCH PAWS tool has been incpated in a new community-based facility within our healthcare system, which opened its inpatient beds in The TCH PAWS tool is included in criteria f transfer from the community hospital to the main hospital in the medical center. How Do I Apply This Infmation to Nursing Practice? The TCH PAWS tool was found to be reliable and valid to detect early clinical deteriation in children admitted to acute care services, thus allowing f early intervention. The TCH PAWS sce can be used to trigger RRT activation. Rapid response team intervention has been associated with decreased code events in acute care areas. The TCH PAWS sce is included in the handoff rept when a patient is transferred to either a higher lower level of care which facilitates discussion of the appropriateness of the transfer. This was noted by receiving nurses to be useful, particularly when a patient should not be transferred to a unit due to a higher TCH PAWS sce. Implementation of TCH PAWS must be housewide and involve all disciplines to be successful as a communication tool among health professionals. Acknowledgments We would like to thank the staff on 12WT, 14WT, 15WT, Larry Jefferson, Moushumi Sur, Jennifer Hudnall, Jennifer Sanders, Shelly Nalbone, Christine Bartlett, Rhonda Wolfe, Cherida Blufd, Susan Iniguez, Rebecca Wolfe, Angela Mgan, Sharon Jacobson, Marilyn Hockenberry, and Julia Kuzin. References Akre, M., Finkelstein, M., Erickson, M., Liu, M., Vanderbilt, L., & Billman, G. (2010). Sensitivity of the pediatric early warning sce to identify patient deteriation. Pediatrics, 125,

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