Risk stratification to improve Pediatric Early Warning Systems: it is all about the context
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Published on: June 6, 2025
Lara Teheux1, Carin W Verlaat2, Joris Lemson2
1Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. lara.teheux@radboudumc.nl.
Insights
A new risk stratification system (PRESS) improves early detection of critical illness in children compared to conventional Pediatric Early Warning Systems (PEWS), enabling faster interventions and better patient safety.
Area of Science:
- Pediatric critical care medicine
- Clinical risk stratification
- Patient safety systems
Background:
- Prompt recognition of clinical deterioration is crucial for reducing pediatric morbidity and mortality.
- Conventional Pediatric Early Warning Systems (PEWS) have demonstrated limitations in sensitivity and detection window.
Purpose of the Study:
- To develop and evaluate a novel risk stratification system, the Pediatric Risk Evaluation and Stratification System (PRESS).
- To compare the sensitivity of PRESS with conventional PEWS in identifying critically ill pediatric patients prior to adverse events.
Main Methods:
- A single-center retrospective cohort study involving pediatric intensive care unit (PICU) admissions.
- Inclusion criteria: infants to adolescents (<18 years) with unplanned PICU admission.
- Comparison of PRESS sensitivity against PEWS in detecting clinical deterioration within 24 hours prior to an endpoint.
Main Results:
- PRESS demonstrated significantly higher sensitivity (70%) compared to PEWS (30%) at 2 hours prior to endpoint (p < 0.001).
- Excluding seizure patients, PRESS sensitivity further improved to 75%.
- A majority of patients (66%) scored positive for at least one high-risk factor in the PRESS system.
Conclusions:
- Risk stratification using PRESS appears advantageous for earlier detection of clinical deterioration in pediatric patients.
- The PRESS system offers opportunities for timely intervention, potentially improving patient outcomes.
- Combining risk stratification with continuous monitoring may lead to next-generation warning systems for enhanced patient safety.
Abstract:
Early recognition of critically ill patients is of paramount importance to reduce pediatric mortality and morbidity. We created a risk stratification system combining vital parameters and predefined risk factors aimed at reducing the risk of unrecognized clinical deterioration compared with conventional Pediatric Early Warning Systems (PEWS). This single-center retrospective case cohort study included infants (gestational age ≥ 37 weeks) to adolescents (aged <18 years) with unplanned pediatric intensive care unit (PICU) admission between April 01, 2014, and February 28, 2018. The sensitivity in the 24 h prior to endpoint of the Pediatric Risk Evaluation and Stratification System (PRESS) was compared with that of the conventional PEWS and calculated as the proportion of study patients who received a high-risk score. Seventy-four PICU admissions were included. PRESS and PEWS sensitivities at 2 h prior to endpoint were 0.70 (95%CI 0.59 to 0.80) and 0.30 (95%CI 0.20 to 0.42) respectively (p < 0.001). Excluding patients with seizures, PRESS sensitivity increased to 0.75 (95%CI 0.64 to 0.85). Forty-nine patients (66%) scored positive on at least one high-risk factor, and "worried sign" was scored in 31 patients (42%).Conclusion: Risk stratification seems advantageous for a faster detection of clinical deterioration, providing opportunity for earlier intervention. What is Known: • Prompt detection of clinical deterioration is of essential importance to reduce morbidity and mortality. • Conventional Pediatric Early Warning Systems (PEWS) have limited sensitivity and a short window of detection of 1 to 2 h. What is New: • Risk stratification based on context factors allows earlier identification of patients at risk, well before deviation of vital signs. • Risk stratification combined with continuous monitoring of deteriorating trends in vital signs could lead to the development of next-generation warning systems achieving true patient safety.
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