Paediatric Advanced Warning Score (PAWS)

Transcription

1 Paediatric Advanced Warning Score (PAWS)

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3 Prevention is better than cure. Spectrum of critical illness Ward level care HDU Care ICU Care Early admission may improve outcome ICU Outreach teams Medical Emergency teams

4 MEWS Score 1 SCORE Resp Pulse BP GCS AVPU A V P U Urine Temp ( o c) SpO British Journal of Anaesthesia 2000; 84 ( 5) : 663

5 MEWS Actions Total Score 1 3 Increase frequency of observations Any score of 3 in 1 category Increase frequency of observations Call senior nurse Total score 4 Or Increased by 2 points Or GCS fallen by 2 points Or Patient causing concern Increase frequency of observations Call senior nurse Call Critical Care Outreach Team 1 British Journal of Anaesthesia 2000; 84 ( 5) : 663

6 Value of Outreach Emergency admissions 58% vs 43% (p = 0.05). Length of stay 7.4 days vs. 4.8 days Mortality 28.6% vs. 23.5%, (p = 0.05) Readmission rate 5.1% vs 3.3% (p = 0.05). A. J. Pittard Out of our reach? Assessing the impact of introducing a critical care outreach service Anaesthesia (9) 882

7 Paediatric Population Traditional rigid model of care Centralised paediatric intensive care Variable provision of localised high dependency care No outreach service Children at risk of developing critical illness and requiring unplanned admission to PICU Reduced experience of trainees Impact of hospital at night programme

8 Hospital episode statistics (HES) 1 Hospital admissions PICU admissions PICU admissions as % % 0.68% 0.86% 1.05% 1.1% 1 Hospital Episode Statistics Department of Health London 2004

9 Hospital episode statistics (HES) 1 Mortality Planned admissions Mortality unplanned admissions Chi Squared 0 28 days days 1 5 years 6 10 years years years < < < < < Hospital Episode Statistics Department of Health London 2004

10 Unplanned admissions > 80% PICU admissions unplanned >34 % unplanned admissions direct from ward Similar statistically significant increased mortality Extrapolate from Pittard admission year averted Possibly reduce mortality 1 Anaesthesia 2003; 58(9):

11 Track and Trigger Scoring Systems: Improve the quality of patient observation and monitoring Improve communication within the multidisciplinary team Allow for timely admission to intensive care Aid good clinical judgement Aid in securing appropriate assistance for sick patients Give a good indication of physiological trends Are a sensitive indicator of abnormal physiology Are a red flag marker of potential or established critical illness Are not a predictor of outcome Are not a comprehensive clinical assessment tool Are not an indicator for immediate admission to intensive care SHOULD NEVER replace clinical judgement Modernisation Agency, 2003

12 Prototype PAWS Score Other Risk Factors Present No YES Physiological risk factors Normal physiology Low risk Moderately deranged physiology Intermediate risk Highly deranged physiology high risk LOW OVERALL WARNING LEVEL INTERMEDIATE OVERALL WARNING LEVEL HIGH OVERALL RISK LEVEL INTERMEDIATE OVERALL WARNING LEVEL INTERMEDIATE OVERALL WARNING LEVEL HIGH OVERALL RISK LEVEL

13 Delphi Technique Research Methodology process of iteration, controlled feedback and statistical group response, to elicit and refine group judgements where exact knowledge is unavailable 1 Panel 51 consultants Series of questionnaires Continued until convergence of opinion 1 N Crolee-Dalkey, The Delphi Method; An experimental study of group opinion Rand Corporation 1969

14 Irritability Inability to feed Poor Social interaction Urine output Clinical Risk Factors Oxygen Saturation Blood pressure Parental or Nursing suspicion Temperature Skin colour and turgor Signs of Respiratory distress Neurological status Capillary refill time Heart Rate Respiratory Rate Median rank (IQR)

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17 Physiological variables

18 Physiological variables

19 Physiological variables AGE Heart Rate 1 month - 1 year year - 5 year year- 12 year > 12 year Respiratory Rate AGE 1 month - 1 year year - 5 year year- 12 year > 12 year If signs of respiratory distress (unable to complete sentences, use of accessory muscles, subcostal rescission, SaO2<90%) CONSIDER SCORE RED

20 Age (<2yrs) Vaccination history Existing central venous access Time since hospital admission (<48hrs) Co-morbidity Neurological disease Prematurity Haematological/oncological disease Existing cardiac disease Failure to respond to treatment Neutropenia/immunosupression Median rank (IQR)

21 H Livingston JL Luntley, SM Whiteley 2004

22 PAWS Paws Score 2004: H Livingstone, J Luntley, SM Whiteley Instructions for use. Read measured variables against tables (1) and determine if any risk factors are present (2) Combine the two and read response off action area (3) Read observations 1 against age. 2 Are any risk factors present? Cardiac Disease Oncological Disease Central venous access Haematological disease /Ex-Prematurity Neutropenia New admission (<48hrs) Immunosupression No Yes AGE AGE Heart Rate 1 month - 1 year year - 5 year year- 12 year > 12 year Respiratory Rate 1 month - 1 year year - 5 year year- 12 year All Scores Green Any amber scores Continue Current Care Continue Current Care > 12 year If signs of respiratory distress (unable to complete sentences, use of accessory muscles, subcostal recession SaO2<90%) CONSIDER SCORE RED Alert Capillary Refill Time Neurological Status Responsive to vocal stimul Responsive to painfull stimuli Unresponsive Temperature < to ( 36.0 C) 36.1 to to 37.9 >38 Multiple amber ± one red score Multiple Red Scores 3 Summon Urgent Assistance ACTION REQUIRED Summon Urgent Assistance

23 Initial validation study Nov 2005 Kay Rushforth assisted in data collection Data 2000 in patient days Predictive value of individual risk factors Regression analysis to define cuts off Modelling work Modify Score

24 Temperature: PAWS Paed iatric Advance Warning Score PILOT Instructions: 1. Reading from the chart, note which colour the observations fall into 2. Add up the green, amber & red scores 3. Take action as described 4. Complete PAWS chart Less than 35.7 C C More than 38 C Heart Rate: /12-1 yr All scores green Continue current care Score = yrs 5-12 yrs 12+ yrs Respiratory Rate: 1/12-1 yr or 2 amber scores Increase frequency of observations Medical review within 30 minutes Score = yrs 5-12 yrs 12+ yrs Oxygen Saturation: Respiratory Effort: Neurological Status: Alert Capillary Refill Time: 0 Less than 90% in absence of known cyanotic heart disease 1 If signs of Respiratory Distress or Exhaustion Responds to verbal stimuli 2 3 Responds to painful stimuli 4 5 Unresponsive 6 3+ amber or 1 red score 2 or more red scores Increase frequency of observations Medical review within 15 minutes Score = 3 Immediate medical review Consider crash team call Score = 4 This tool is under development. Your clinical judgement is paramount. If you are in any doubt, refer the patient for further assessment

25 Gant Chart Funding Research Nurse Validation study Data analysis Protocol Development MRECly sis Pilot study Steering group Nov 05 Jan 06 Dec 06

26 Gant Chart MREC PIAG Trust R&D Approval Study Period Analysis Jan 07 June 07 Nov 07

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28 Study period Data Collection Analysis RELEASE PAWS Final validation 2 months 1 month 3 months

29 National picture PICS special interest group on Paediatric outreach / early warning scores National agreed data set Bristol / Brighton / Leeds Three differenet approaches!

30 Bristol PEWS. A Acute airway obstruction (1) Child has required nebulised adrenaline (2) Clinically tiring or impending complete airway obstruction B Breathing (1) SaO2 92% in any amount of oxygen (2) SaO2 75% in any amount of oxygen (cyanotic heart disease) (3) Persistent tachypnoea (RR 70 under 6 months; months; years; 25 over 5 years) (4) Apnoea±bradycardia (HR 95 in children under 5 years) C Circulation (1) Persistent tachycardia following one bolus of 10 mls/kg fluid (HR 150 under 5 years; HR years; HR 100 over 12 years) (2) Signs of shock: e.g. prolonged capillary refill (3 s); poor perfusion; ±low BP D Disability (1) GCS 11 or unresponsive or responding only to pain (2) Convulsion unresponsive to anticonvulsant therapy (lasting 30 min) E Others (1) Hyperkalaemia K+ 6.0 mmol/l (2) Any child with suspected meningococcus (3) Any child with diabetic ketoacidosis (DKA) (4) Any child whose condition is worrying

31 Acknowledgments Harvey Livingston Roger Parslow Diana Morgan Paediatric critical care network Kay Rushforth Participating centres

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