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Cohort study to test the predictability of the NHS Institute for Innovation and Improvement Paediatric Early Warning
B W Mason1, E D Edwards2, A Oliver3
1Public Health Wales, Cardiff, UK.
Insights
The National Health Service Institute for Innovation and Improvement (NHSIII) Paediatric Early Warning System (PEWS) score has low predictive value for critical illness in children. While sensitive, its low positive predictive value generates many false alarms, requiring careful clinical interpretation.
Area of Science:
- Pediatric critical care medicine
- Clinical risk prediction
- Patient safety systems
Background:
- Early detection of critical illness in children is crucial for timely intervention.
- Paediatric Early Warning Systems (PEWS) aim to standardize the identification of at-risk children.
- The National Health Service Institute for Innovation and Improvement (NHSIII) PEWS score is one such tool used in clinical practice.
Purpose of the Study:
- To evaluate the predictive accuracy of the NHSIII PEWS score.
- To determine if the NHSIII PEWS score can reliably identify children at risk of critical illness.
- To assess the score's sensitivity, specificity, and predictive values for adverse outcomes.
Main Methods:
- A retrospective cohort study was conducted.
- Clinical observations from 1000 children admitted to paediatric wards were analyzed.
- The study assessed the correlation between NHSIII PEWS scores and outcomes like high dependency unit admission, intensive care unit admission, and death.
Main Results:
- The NHSIII PEWS score demonstrated a sensitivity of 73.2% and specificity of 75.2% for predicting critical illness.
- The positive predictive value (PPV) was low at 2.6%, indicating a high rate of false positives.
- A significant proportion of children (37.5%) with adverse outcomes did not have an abnormal PEWS score.
Conclusions:
- The NHSIII PEWS score has limited predictive value due to its low positive predictive value.
- Widespread implementation may lead to an excessive number of false positive alerts.
- Clinical judgment remains essential when interpreting PEWS scores, especially low but raised scores.
Objective:
To test the predictability of the National Health Service Institute for Innovation and Improvement (NHSIII) Paediatric Early Warning System (PEWS) score to identify children at risk of developing critical illness.
Design:
Cohort study.
Setting:
Admissions to all paediatric wards at the University Hospital of Wales between 1 December 2005 and 30 November 2006.
Outcome Measures:
Unscheduled paediatric high dependency unit (PHDU) admission, paediatric intensive care unit (PICU) admission and death.
Results:
There were 9075 clinical observations from 1000 children. An NHSIII PEWS score of 2 or more, which triggers review, has a sensitivity of 73.2% (95% CI 62.2% to 82.4%), specificity of 75.2% (95% CI 74.3% to 76.1%), positive predictive value (PPV) of 2.6% (95% CI 2.0% to 3.4%), negative predictive value of 99.7% (95% CI 99.5% to 99.8%) and positive likelihood ratio of 3.0 (95% CI 2.6 to 3.4) for predicting PHDU admission, PICU admission or death. Six (37.5%) of the 16 children with an adverse outcome did not have an abnormal NHSIII PEWS score. The area under the receiver operating characteristic curve for the NHSIII PEWS score was 0.83 (95% CI 0.77 to 0.88).
Conclusions:
The NHSIII PEWS has a low PPV and its full implementation would result in a large number of false positive triggers. The issue with PEWS scores or triggers is neither their sensitivity nor children with high scores which require clinical interventions who are not 'false positives'; but their low specificity and low PPV arising from the large number of children with low but raised scores.
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