Assessing children who are acutely ill in general practice using the National PEWS and LqSOFA clinical scores: a retrospective cohort study
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Published on: February 5, 2019
Amy Clark1, Rebecca Cannings-John2, Enitan D Carrol3
1Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge.
Insights
Neither the Liverpool quick Sequential Organ Failure Assessment (LqSOFA) nor the National Paediatric Early Warning System (PEWS) accurately identified hospital admissions in children under five presenting to general practice. Their low predictive accuracy suggests caution is needed to avoid unsustainable referrals.
Area of Science:
- Pediatric Emergency Medicine
- General Practice Research
- Clinical Tool Validation
Background:
- Clinical tools are essential for identifying seriously ill children in general practice.
- The Liverpool quick Sequential Organ Failure Assessment (LqSOFA) showed good performance in emergency departments.
- The National Paediatric Early Warning System (PEWS) is being considered for general practice implementation.
Purpose of the Study:
- To validate the LqSOFA and National PEWS in a general practice setting.
- To assess the accuracy of these tools in identifying children requiring hospital admission.
Main Methods:
- Secondary analysis of 6703 children under 5 years old presenting to 225 general practices.
- Data linked with hospital admission records within 2 days of consultation.
- Calculated sensitivity, specificity, PPV, NPV, and AUC for LqSOFA and National PEWS.
Main Results:
- Neither LqSOFA (AUC=0.58) nor National PEWS (AUC=0.66) demonstrated strong discriminative ability for hospital admission.
- Both tools had high Negative Predictive Values (NPVs) but low Positive Predictive Values (PPVs).
- Low pre-test probability (1.6%) influenced the observed NPVs, not inherent accuracy.
Conclusions:
- The LqSOFA and National PEWS did not accurately identify children needing hospital admission from general practice.
- Relying on these tools without considering low pre-test probabilities may lead to inappropriate referrals.
- Further research is needed to develop effective tools for pediatric illness assessment in primary care.
Background:
Clinical tools are needed in general practice to help identify children who are seriously ill. The Liverpool quick Sequential Organ Failure Assessment (LqSOFA) was validated in an emergency department and performed well. The National Paediatric Early Warning System (PEWS) has been introduced in hospitals throughout England with hopes for implementation in general practice.
Aim:
To validate the LqSOFA and National PEWS in general practice.
Design And Setting:
Secondary analysis of 6703 children aged <5 years presenting to 225 general practices in England and Wales with acute illnesses, linked to hospital data.
Method:
Variables from the LqSOFA and National PEWS were mapped onto study data to calculate score totals. A primary outcome of admission within 2 days of GP consultation was used to calculate sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUC).
Results:
A total of 104/6703 children were admitted to hospital within 2 days (pre-test probability 1.6%) of GP consultation. The sensitivity of the LqSOFA was 30.6% (95% confidence interval [CI] = 21.8% to 41.0%), with a specificity of 84.7% (95% CI = 83.7% to 85.6%), PPV of 3.0% (95% CI = 2.1% to 4.4%), NPV of 98.7% (95% CI = 98.4% to 99.0%), and AUC of 0.58 (95% CI = 0.53 to 0.63). The sensitivity of the National PEWS was 81.0% (95% CI = 71.0% to 88.1%), with a specificity of 32.5% (95% CI = 31.2% to 33.8%), PPV of 1.9% (95% CI = 1.5% to 2.5%), NPV of 99.1% (95% CI = 98.4% to 99.4%), and AUC of 0.66 (95% CI = 0.59 to 0.72).
Conclusion:
Although the NPVs appear useful, owing to low pre-test probabilities rather than discriminative ability, neither tool accurately identified admissions to hospital. Unconsidered use by GPs could result in unsustainable referrals.
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