Paediatric Advanced Warning Score (PAWS)
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
MEWS Score 1 SCORE 3 2 1 0 1 2 3 Resp 8 9-10 11-20 21-25 26-30 31 Pulse 40 41-50 51-100 101-110 111-130 131 BP 84 85-89 90-100 101-199 200 GCS 8 9-13 14 15 AVPU A V P U Urine 10 30 Temp ( o c) 35.0 35.1-35.9 36.0-37.4 SpO 2 87 88-91 92-94 95-100 37.5-38.4 38.5 1 British Journal of Anaesthesia 2000; 84 ( 5) : 663
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
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 2003 58(9) 882
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
Hospital episode statistics (HES) 1 Hospital admissions PICU admissions PICU admissions as % 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 1021132 1001604 977123 987927 981347 6540 6808 8428 10375 11201 0.64% 0.68% 0.86% 1.05% 1.1% 1 Hospital Episode Statistics Department of Health London 2004
Hospital episode statistics (HES) 1 Mortality Planned admissions Mortality unplanned admissions Chi Squared 0 28 days 29 364 days 1 5 years 6 10 years 11 15 years 16 19 years 4.66 2.33 1.55 1.43 1.10 1.65 7.64 6.07 5.34 5.18 5.91 0.003 <0.0001 <0.0001 <0.0001 <0.0001 7.27 <0.0001 1 Hospital Episode Statistics Department of Health London 2004
Unplanned admissions > 80% PICU admissions unplanned >34 % unplanned admissions direct from ward Similar statistically significant increased mortality Extrapolate from Pittard 1 350 admission year averted Possibly reduce mortality 1 Anaesthesia 2003; 58(9): 882-885
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
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
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
Irritability Inability to feed Poor Social interaction Urine output 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 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)
Physiological variables
Physiological variables
Physiological variables AGE Heart Rate 1 month - 1 year 40 45 50 55 60 65 70 75 80 85 90 95 100 110 120 130 140 145 150 160 165 170 175 180 185 190 1 year - 5 year 40 45 50 55 60 65 70 75 80 85 90 95 100 110 120 130 140 145 150 160 165 170 175 180 185 190 5 year- 12 year 40 45 50 55 60 65 70 75 80 85 90 95 100 110 120 130 140 145 150 160 165 170 175 180 185 190 > 12 year 40 45 50 55 60 65 70 75 80 85 90 95 100 110 120 130 145 145 150 160 165 170 175 180 185 190 Respiratory Rate AGE 1 month - 1 year 8 101214161820222426283032343638404244464850525456 1 year - 5 year 8 101214161820222426283032343638404244464850525456 5 year- 12 year 8 101214161820222426283032343638404244464850525456 > 12 year 8 101214161820222426283032343638404244464850525456 If signs of respiratory distress (unable to complete sentences, use of accessory muscles, subcostal rescission, SaO2<90%) CONSIDER SCORE RED
Age (<2yrs) Vaccination history Existing central venous access Time since hospital admission (<48hrs) 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Co-morbidity Neurological disease Prematurity Haematological/oncological disease Existing cardiac disease Failure to respond to treatment Neutropenia/immunosupression Median rank (IQR)
H Livingston JL Luntley, SM Whiteley 2004
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 40 45 50 55 60 65 70 75 80 85 90 95 100110120130140145150160165170175180185190 1 year - 5 year 40 45 50 55 60 65 70 75 80 85 90 95 100110120130140145150160165170175180185190 5 year- 12 year 40 45 50 55 60 65 70 75 80 85 90 95 100110120130140145150160165170175180185190 > 12 year 40 45 50 55 60 65 70 75 80 85 90 95 100110120130145145150160165170175180185190 Respiratory Rate 1 month - 1 year 8 101214161820222426283032343638404244464850525456 1 year - 5 year 8 101214161820222426283032343638404244464850525456 5 year- 12 year 8 101214161820222426283032343638404244464850525456 All Scores Green Any amber scores Continue Current Care Continue Current Care > 12 year 8 101214161820222426283032343638404244464850525456 If signs of respiratory distress (unable to complete sentences, use of accessory muscles, subcostal recession SaO2<90%) CONSIDER SCORE RED Alert Capillary Refill Time 0 1 2 3 4 5 6 Neurological Status Responsive to vocal stimul Responsive to painfull stimuli Unresponsive Temperature <35.6 35.6 to ( 36.0 C) 36.1 to 37.5 37.6 to 37.9 >38 Multiple amber ± one red score Multiple Red Scores 3 Summon Urgent Assistance ACTION REQUIRED Summon Urgent Assistance
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
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 35.7-37.9 C More than 38 C Heart Rate: 40 45 1/12-1 yr 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 All scores green Continue current care Score = 1 1-5 yrs 5-12 yrs 12+ yrs Respiratory Rate: 1/12-1 yr 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 1 or 2 amber scores Increase frequency of observations Medical review within 30 minutes Score = 2 1-5 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
Gant Chart 2005-7 Funding Research Nurse Validation study Data analysis Protocol Development MRECly sis Pilot study Steering group Nov 05 Jan 06 Dec 06
Gant Chart 2006-7 MREC PIAG Trust R&D Approval Study Period Analysis Jan 07 June 07 Nov 07
Study period Data Collection Analysis RELEASE PAWS Final validation 2 months 1 month 3 months
National picture PICS special interest group on Paediatric outreach / early warning scores National agreed data set Bristol / Brighton / Leeds Three differenet approaches!
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; 60 6 12 months; 40 1 5 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 120 5 12 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
Acknowledgments Harvey Livingston Roger Parslow Diana Morgan Paediatric critical care network Kay Rushforth Participating centres