Validity of different pediatric early warning scores in the emergency department
Nienke Seiger1, Ian Maconochie, Rianne Oostenbrink
1Department of Pediatrics, Room Sp 1540, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, PO Box 2060, 3000 CB Rotterdam, Netherlands. h.a.moll@erasmusmc.nl.
Insights
Pediatric early warning scores (PEWS) can identify children needing intensive care unit (ICU) admission. Numeric scoring systems outperformed triggering systems in predicting critical illness in the emergency department (ED).
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support Tools
- Healthcare Informatics
Background:
- Pediatric early warning scores (PEWS) are increasingly recommended for emergency department (ED) use.
- The effectiveness of various PEWS in pediatric ED settings requires thorough validation.
Purpose of the Study:
- To compare the diagnostic accuracy of ten different pediatric early warning scores (PEWS).
- To evaluate PEWS' validity in predicting intensive care unit (ICU) admission and hospitalization in a pediatric ED.
Main Methods:
- Prospective cohort study of 17,943 children (<16 years) in a Dutch university hospital ED (2009-2012).
- Ten distinct PEWS were assessed for their ability to predict ICU admission or hospitalization.
- Validity was quantified using the area under the receiver operating characteristic (ROC) curves.
Main Results:
- Areas under the ROC curves for ICU admission prediction ranged from 0.60 to 0.82 (moderate to good).
- Areas under the ROC curves for hospitalization prediction ranged from 0.56 to 0.68 (poor to moderate).
- No PEWS demonstrated consistently high sensitivity and specificity for predicting either ICU admission or hospitalization.
Conclusions:
- PEWS are valuable for identifying pediatric patients requiring ICU admission in the ED.
- Scoring systems that sum parameters to a numeric value are more effective than simple triggering systems.
- Further refinement of PEWS may be needed to improve prediction accuracy for hospitalization.
Objective:
Pediatric early warning scores (PEWS) are being advocated for use in the emergency department (ED). The goal of this study was to compare the validity of different PEWS in a pediatric ED.
Methods:
Ten different PEWS were evaluated in a large prospective cohort. We included children aged <16 years who had presented to the ED of a university hospital in The Netherlands (2009-2012). The validity of the PEWS for predicting ICU admission or hospitalization was expressed by the area under the receiver operating characteristic (ROC) curves.
Results:
These PEWS were validated in 17 943 children. Two percent of these children were admitted to the ICU, and 16% were hospitalized. The areas under the ROC curves for predicting ICU admission, ranging from 0.60 (95% confidence interval [CI]: 0.57-0.62) to 0.82 (95% CI: 0.79-0.85), were moderate to good. The area under the ROC curves for predicting hospitalization was poor to moderate (range: 0.56 [95% CI: 0.55-0.58] to 0.68 [95% CI: 0.66-0.69]). The sensitivity and specificity derived from the ROC curves ranged widely for both ICU admission (sensitivity: 61.3%-94.4%; specificity: 25.2%-86.7%) and hospital admission (sensitivity: 36.4%-85.7%; specificity: 27.1%-90.5%). None of the PEWS had a high sensitivity as well as a high specificity.
Conclusions:
PEWS can be used to detect children presenting to the ED who are in need of an ICU admission. Scoring systems, wherein the parameters are summed to a numeric value, were better able to identify patients at risk than triggering systems, which need 1 positive parameter.
