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Validation of a pediatric early warning system for hospitalized pediatric oncology patients in a resource-limited
Asya Agulnik1,2, Alejandra Méndez Aceituno3, Lupe Nataly Mora Robles4
1Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee.
Insights
Pediatric Early Warning Systems (PEWS) accurately predict the need for pediatric intensive care unit (PICU) transfer in pediatric oncology patients, even in resource-limited hospitals. Higher PEWS scores indicate increased illness severity and mortality risk.
Area of Science:
- Pediatric Oncology
- Critical Care Medicine
- Health Systems Research
Background:
- Pediatric oncology patients face high risks of clinical deterioration, especially in resource-limited settings.
- The effectiveness of Pediatric Early Warning Systems (PEWS) in these environments is largely unassessed.
- This study addresses the need to evaluate PEWS validity for predicting critical events in this population.
Purpose of the Study:
- To evaluate the accuracy of PEWS in predicting unplanned transfers to the pediatric intensive care unit (PICU).
- To assess the utility of PEWS in identifying clinical deterioration among pediatric oncology patients in a resource-limited hospital.
Main Methods:
- Retrospective case-control study design.
- Involved 129 pediatric oncology patients requiring unplanned PICU transfer (cases) and matched controls.
- Analyzed highest documented and corrected PEWS scores prior to PICU transfer.
Main Results:
- PEWS scores demonstrated high accuracy in predicting PICU transfer (AUC 0.940 for documented, 0.930 for corrected).
- PEWS scores increased significantly 24 hours before transfer, correlating with organ dysfunction and higher mortality.
- Elevated PEWS scores (≥4) were linked to higher PIM2 scores, septic shock, and increased need for mechanical ventilation or vasopressors.
Conclusions:
- PEWS accurately predicts the need for PICU transfer in pediatric oncology patients, irrespective of hospital resource levels.
- Abnormal PEWS scores emerge 24 hours before PICU admission, signaling impending deterioration.
- Higher PEWS scores correlate with illness severity, need for interventions, and mortality in the PICU.
Background:
Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource-limited hospital.
Methods:
A retrospective case-control study comparing the highest documented and corrected PEWS score before unplanned PICU transfer in pediatric oncology patients (129 cases) with matched controls (those not requiring PICU care) was performed.
Results:
Documented and corrected PEWS scores were found to be highly correlated with the need for PICU transfer (area under the receiver operating characteristic, 0.940 and 0.930, respectively). PEWS scores increased 24 hours prior to unplanned transfer (P = .0006). In cases, organ dysfunction at the time of PICU admission correlated with maximum PEWS score (correlation coefficient, 0.26; P = .003), patients with PEWS results ≥4 had a higher Pediatric Index of Mortality 2 (PIM2) (P = .028), and PEWS results were higher in patients with septic shock (P = .01). The PICU mortality rate was 17.1%; nonsurvivors had higher mean PEWS scores before PICU transfer (P = .0009). A single-point increase in the PEWS score increased the odds of mechanical ventilation or vasopressors within the first 24 hours and during PICU admission (odds ratio 1.3-1.4).
Conclusions:
PEWS accurately predicted the need for unplanned PICU transfer in pediatric oncology patients in this resource-limited setting, with abnormal results beginning 24 hours before PICU admission and higher scores predicting the severity of illness at the time of PICU admission, need for PICU interventions, and mortality. These results demonstrate that PEWS aid in the identification of clinical deterioration in this high-risk population, regardless of a hospital's resource-level. Cancer 2017;123:4903-13. © 2017 American Cancer Society.
