Background/ Why Is This Important?
Deterioration in pediatric patients can have serious adverse consequences including morbidity and death. Evidence indicates prevention is possible with early detection, mitigation, and escalation. Internationally, Pediatric Early Warning Systems (PEWS) have been implemented to improve safety for hospitalized children; these are particularly common throughout the USA, England, Australia, Ireland, Canada and Wales. Health Authority leaders and clinicians report that the PEWS is a high priority for them, and that critical incidents in their sites have escalated this priority.
Child Health BC, in partnership with Health Authorities, are implementing and evaluating a pediatric early warning system in hospital inpatient units that provide care to children across BC and undertaking a pilot in the Emergency Department at Richmond General Hospital. A survey of nurses across these care settings was done in the summer of 2014 and revealed that 40% of nurses responding to the survey reported caring for children once a week or less, and 21% of nurses reported caring for children only occasionally. Most nurses reported themselves as needing support in distinguishing normal and abnormal vital signs in infants and children, and being able to anticipate and respond to pediatric clinical deterioration or acute urgent situations.
The Provincial Pediatric Early Warning System includes:
- a risk score based on physiological findings incorporated into pediatric flow sheet,
- an escalation protocol,
- a situational awareness bundle (evidence based risk factors), and
- a communication framework .
Together these system parts are designed to provide a standardized framework and language to identify potential deterioration in a child; mitigate that risk; and escalate care as needed — all as early as possible. This is a unique initiative and the first of its kind in North America where an entire state or province adapts a standardized early warning system for pediatrics.
The PEWS project Includes:
- A comprehensive literature and practice review, including connections with worldwide experts and researchers in pediatric early warning system.
- A Provincial education strategy including tools and resources to support the education and implementation; online module development to ensure standardized approach to education across the Province; regional workshops for hospital clinical pediatric leaders, support for site specific staff training and physician education, and development of quality improvement strategies to assist with sustainment of the PEWS implementation.
- A robust evaluation strategy and plan for spread.
In the fall of 2015, inpatient units of 14 BC hospitals and 1 emergency department implemented and will evaluate the PEWS system (Phase One). The hospitals include BC Children's Hospital, larger urban regional hospitals and small more rural hospitals across 4 health authorities. The experience and outcomes of these first BC sites will be used to inform the implementation of the rest of the Province (Phase Two).
What Actions Have Already Been Taken?
Following a Child Health BC Steering Committee endorsement to implement PEWS in BC hospitals, a workshop was held by Child Health BC in Vancouver. In December 2014 over 40 people, including pediatricians, nurses and leaders from all over BC worked to develop a foundation for the PEWS framework which includes the tools and strategy to implement PEWS. As of September 2016, the PEWS framework and system has been implemented in 29 hospitals inpatient units and 1 emergency department. Preliminary feedback suggests that hospitals are seeing significant improvements in the knowledge and confidence levels in managing pediatric patients and feel supported through the development of a network of hospitals, staff and physicians across the province.
A number of tools have been created to support the implementation of the PEWS system, see documents below including:
Provincial Flow Sheet
- Pediatric Foundational Competencies e-Learning Course will help develop frontline pediatric care providers' core pediatric knowledge
- Child and Youth at Risk of Clinical Deterioration (PEWS) e-Learning Course will provide the necessary knowledge and tools to assist in the development of pediatric competencies required to care for at risk pediatric patients
- What Physicians need to know about PEWS presentation
- Support Tools
Where Are We Now?
The next few months will be focused on the evaluation strategy which will determine:
- Can PEWS increase identification of pediatric deterioration within a year of implementation?
- Can PEWS provide earlier identification of pediatric deterioration within a year of implementation?
- Can PEWS decrease time to mitigation of pediatric deterioration within a year of implementation?
- Can PEWS increase usage of appropriate responses for mitigation including the appropriate usage of escalation protocols (improved timing, following of escalation protocols) within and between facilities at all tiers of service within a year of implementation?
- Can we identify the 'active ingredients' (most helpful, usable elements) of PEWS in identifying, mitigating and escalating children at risk?
- Can PEWS enhance communication (clarity & thoroughness of verbal & written communication) related to identification, mitigation, escalation within a year of implementation?