The Irish Paediatric Early Warning System

Rachel MacDonell, National PEWS Coordinator

PEWS

PEWS Paediatric Early Warning Score

PEWS Paediatric Early Warning Score System

PEWS Project Plan

Design

• Project team

• Detection & Response system

• Education

Test • Can it work?

• Findings from review

Pilot • Does it work?

• Why does it work?

Spread

Evaluate

Train the trainers

Does it improve care?

Irish PEWS …2014

• Jan Project initiated

• Feb Working Group Established

• April International PEWS tool review

• Aug PEWS literature review

• Sept PEWS co-ordinator, charts Version 1

• Nov Version 5, Compass adapted

• Dec Train the trainer, site visits

Irish PEWS …2015

• Feb Pilot launch- Version P7

• Mar Pilot complete, audits/ focus groups

• April Revision of parameters

• May Retesting - Version P13

• June Roll out to pilot sites

• July Compass ‘PEWS Education’

• Sept Version N2

• Nov NCG No. 12 PEWS

Design

Design

“positive directional trends in improving clinical based outcomes” “there is no consensus and limited evidence about which PEW system is most useful or ‘optimal’ for paediatric contexts”

Test

Pilot

Pilot

• 4 sites, 7 wards

• Audit

– Compliance

– Amendments

– Training evaluations

– Staff feedback

– Focus groups

Pilot learning “I think everybody is liking the tool and liking the structure around reporting and who to go to and what to do when something isn't just quite right” (FG3)

“We are seeing children when we should be seeing them early on in illness” (FG3)

“Delegation is easier and maybe the more qualified can look after the sicker patient if necessary” (FG4)

“I think what it has done is given us a more structured way of being consistent in how we communicate” (FG2)

“The consensus from the ward seems to be very positive and the feedback from the staff from the very first day has been very positive” (FG1)

P13 N2

PEW System

Observations abnormal

Observations normal

No concern Concern

PEWS is not…

• Replacement for

– Calling the emergency team in the event of collapse with suspected cardiac or respiratory arrest

– Contacting medical personnel for immediate review of any patient about whom there is clinical concern

Core Observations

1 Nurse or family concerns 0,1,

2 Respiratory Rate 0,1,2,3

3 Respiratory Effort 0,1,3

4 Oxygen therapy (mode + pressure) 0,1,2 + 0,1

5 Heart Rate 0,1,2,3

6 AVPU 0,1,3

Additional observations if clinically required

7 SpO2 0,1,2,3

8 Capillary refill time (central) 0,1

9 Blood Pressure (systolic) 0,1,2,3

10 Skin colour No score

11 Temperature No score

Triggers

PEWS charts

Standardised education

Standardised observations

• A

• B

• C

• D

• E

PEWS does not replace an emergency call

Score Observation

Frequency Minimum Alert Minimum Response

1 4 hourly Nurse in Charge

Any trigger should prompt increase

in observation frequency as

clinically appropriate 2 2-4 hourly

3* 1 hourly Nurse in Charge + 1st on-call

Nurse in charge review

4-5 30 minutes Urgent medical review

6

Continuous

Nurse in Charge + 1st on-call

+ Senior Dr. + Consultant Urgent SENIOR medical review

≥7 URGENT PEWS CALL Immediate local response team

PEWS does not replace clinical concern

Standardised Escalation

Standardised communication

Identify

Situation

Background

Assessment

Recommendations

Standardised approach to sepsis

Paediatric Sepsis 6

Take 3 Give 3 • IV or IO access and take bloods - Blood Culture & PCR - FBC - Glucose & treat if low - Blood Gas - Lactate • Urine output measure

• Early Senior input

• High flow Oxygen • IV fluids - Aim to restore circulating volume - Titrate 20mls/kg isotonic fluid over 5-10 mins. - Consider early innotropes - Caution for fluid overload or hepatomegaly • Broad spectrum IV Antibiotics

Standardised documentation

Parental engagement

What are your clinical concerns or worries? How can we help?

PEWS N2...............N3 (draft)

Paediatric Early Warning System

Team work & Communication

Clear Escalation Guide

ISBAR

Decision aides

Cardiovascular Prompts

Paediatric Sepsis 6

Situation Awareness “It’s more than the score”

“What’s going on & what’s going to happen”

Family Involvement “Are you concerned?”

PEWS observation

chart & score

PEWS Toolkit

• Many tools needed for even a small job

• Need to know how to use each tool

• Sometimes other experts are required

PEWS Lifebuoy

• Need to be spotted

• Need to tell right person

• Right response

PEWS

Governance & Leadership

Teamwork & Communicati

on

Situation Awareness

Family Involvement

Decision Aides

Ability to Respond

PEWS Scoring

Tool

Spread

Quality Framework

Quality

Leadership for quality

Engaging patients

Enabling staff

Systematic approach

Measure and learn

Governance

Quality Framework

PEWS

Leadership for quality

Engaging patients

Enabling staff

Systematic approach

Measure and learn

Governance

Central support

• Briefing meeting

• Train the Trainer x2

• Audit meeting x1

• Site visit as required/conference calls

• Post implementation visit

Hospital Group links to share learning and resources

PEWS package

• NCG No. 12, Implementation & Education guides

• National chart templates

• Manual

• Slide set x2

• Attendance/evaluation/certificate

• Quiz

• Case studies

• Ward resources (parent leaflet, quick reference guide, escalation poster, sepsis 6 poster)

• Audit tools

Evaluate

Evaluation

• Compliance

• Response

• Variance use

• Outcomes

• Satisfaction

• Safety culture

• Metrics/KPI

• HSE/HIQA

In Conclusion

• The Irish PEWS is more than a score

• The detection of sick or deteriorating children is best aided by a system of observations, conversations, projections & interventions focused on the child

• PEWS encourages & supports behaviours that promote patient safety