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Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre
Joany M Zachariasse1, Daan Nieboer2, Ian K Maconochie3
1Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands.
Insights
A new Emergency Department Paediatric Early Warning Score (ED-PEWS) effectively identifies high and low urgency children in emergency care. This score improves patient prioritisation compared to existing paediatric early warning scores (PEWSs).
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support Systems
- Health Informatics
Background:
- Paediatric Early Warning Scores (PEWSs) are crucial for identifying deteriorating children in hospitals.
- Existing PEWSs are not optimally designed for emergency department (ED) settings.
- There is a need for improved tools to prioritize pediatric patients in the ED.
Purpose of the Study:
- To develop and validate an Emergency Department Paediatric Early Warning Score (ED-PEWS).
- To enhance the accuracy of identifying children requiring urgent care in the ED.
- To improve patient flow and resource allocation within emergency departments.
Main Methods:
- Prospective observational study using electronic health record data from five European EDs (TrIAGE project).
- Inclusion of all consecutive ED visits for children under 16 years.
- Development of ED-PEWS using ordinal logistic regression and external validation in an independent cohort.
Main Results:
- The ED-PEWS incorporates age, heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing.
- The score demonstrated a cross-validated c-statistic of 0.86 for high-urgency patients.
- Specific cutoffs (≥15 for high urgency, <6 for low urgency) showed high accuracy (specificity 0.90, sensitivity 0.83).
Conclusions:
- The developed ED-PEWS is effective in identifying high and low urgency pediatric patients in the emergency department.
- This tool can significantly improve the prioritisation of care for children in emergency settings.
- The ED-PEWS offers a valuable advancement over existing paediatric early warning scores for ED use.
Background:
Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS.
Methods:
The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece).
Findings:
Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82-0·90) for high-urgency patients and 0·67 (0·61-0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87-0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81-0·85).
Interpretation:
The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs.
Funding:
Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.
