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Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic
Shu-Ling Chong1,2, Mark Sen Liang Goh3, Gene Yong-Kwang Ong1,2
1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore 100, Bukit Timah Road, Singapore 229899, Singapore.
Insights
Implementing Paediatric Early Warning Systems (PEWS) in hospitals is linked to lower child mortality and fewer unplanned codes. These systems improve patient outcomes by enabling timely intervention for critically ill children.
Area of Science:
- Pediatric critical care medicine
- Health services research
Background:
- Paediatric Early Warning Systems (PEWS) are designed to identify deteriorating children in hospital settings.
- The effectiveness of PEWS in reducing adverse outcomes such as mortality and cardiopulmonary arrests requires robust evaluation.
Purpose of the Study:
- To systematically review and meta-analyze the impact of Paediatric Early Warning Systems (PEWS) on pediatric mortality, cardiopulmonary arrests, unplanned codes, and critical deterioration events.
- To compare outcomes in children managed with PEWS versus usual care without PEWS in inpatient and emergency settings.
Main Methods:
- A comprehensive systematic search of multiple databases (Medline, EMBASE, CCTR, CINAHL, Web of Science) was performed for studies published between January 2006 and April 2022.
- Included studies compared pediatric populations (<18 years) with and without PEWS in hospital settings. A random-effects meta-analysis was employed to synthesize risk and rate ratios.
- Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) criteria.
Main Results:
- Fifteen studies were included in the analysis. Meta-analysis of 10 studies (580,604 admissions) indicated a reduced risk of mortality in the PEWS group (pooled RR 1.18, 95% CI 1.01-1.38).
- Analysis of four studies (168,544 admissions) showed a reduced risk of unplanned code events in the PEWS group (pooled RR 1.73, 95% CI 1.01-2.96).
- No significant differences were observed in the rates of cardiopulmonary arrests or critical deterioration events. Findings were limited by potential confounders and study imprecision.
Conclusions:
- Implementation of PEWS in healthcare systems is associated with reduced mortality and unplanned code rates in children.
- The benefits of PEWS may vary based on resource availability and the effectiveness of response systems.
- Further research is needed to address limitations and confirm the widespread efficacy of PEWS.
Aim:
We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS?
Methods:
We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias.
Results:
Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01-1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98-1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01-2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies.
Conclusions:
Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems.PROSPERO registration: CRD42021269579.
