Early warning scores in the ED

One of our current paediatric SpRs, Dr Anil Krishnaiah, has been looking at some papers on the various paediatric warning scores that are in existence.  Here is his summary of a paper from Sunderland in 2008:

Emerg Med J 2008;25:745-749 doi:10.1136/emj.2007.054965

The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department

P Egdell, L Finlay, D K Pedley

 Existing UK paediatric early warning scoring systems (PEWS) were developed mainly for hospitalised patients and may be less useful for initial assessment in the ED. Until recently these are mainly used to look at admission to the HDU and PICU and trying to produce a system which would recognize those children at risk of admission.

 Assessment of paediatric patients is complicated by the range of normal parameters in different age groups. Inexperienced staff may find it difficult to interpret the significance of physiological readings over a wide range of ages.

 This pilot study was conducted in Sunderland to validate the scoring system by performing a retrospective analysis of 50 consecutive children attending the ED who required admission directly to the paediatric intensive care unit (PICU).  A control group of 50 consecutive children who were admitted from the ED to the general paediatric ward within the same time period was also identified from the ward admission book. They compared the Paediatric Advanced Warning Scores (PAWS) scores between the two groups in order to see whether the PAWS chart would be able to identify those children in need of admission to a critical care area. Primarily the aim of this study was to design and validate a scoring system to identify children attending the ED in need of urgent medical assessment and appropriate intervention. At a trigger score of 3, the PAWS score was able to identify those children requiring admission to the PICU with a sensitivity of 70% and a specificity of 90%.

This pilot evaluation demonstrates that the PAWS chart shows promise as a ‘‘rule-in’’ tool for PICU admission.

Since the introduction of the 4 hour target in the ED, departments have been under increasing strain to assess, treat and admit patients (if required) as quickly as possible. Few studies have been designed to identify if the PEWS score could be used as a triage tool, to detect those patients who will need admission and therefore speed up the process of admitting children to the ward. 

Dr Anil Krishnaiah, Paediatric SpR

My problem with this paper, Anil, is that I want a tool that will “rule-out” predictably ie. one that will tell me reliably which ones I am safe to send home – without overloading the system with too low a threshold for admission.  Anyone got one of those?

3 thoughts on “Early warning scores in the ED

  1. The problem with all the warning scores is that they use basic physiological parameters as a mark of significant illness. The diversity of patients that present to a paediatric ED make these parameters unreliable as an indication of significant illness when used alone.

    Heart rate (HR) is one of the physiological markers measures and it is well documented that this is raised in all children presenting with fever whether due to a simple virus or a significant bacterial infection. HR can also be significantly elevated in pain and anxiety.

    The use of a warning score is useful for monitoring deterioration of the clinical condition but to date has not been shown to be reliably useful as a rule-out admission tool.

    Dr K Bradman
    Emergency Paediatric Consultant
    Princess Margaret Hospital

    1. My daughter had Toxic Shock Syndrome. I would like to “rule-out” being sent home from Emergency dept. after stats are 128 heart rate, 24 respiratory rate, blood pressure 83/55, temp 37.6, sp02 96%. or at least redo stats after 3 hours before being sent home. I plead you to get some tool in place!

      1. Your daughter’s case proves the point well. She was brewing a serious problem but the PEWS (or PAWS) did not flag her up as one who needed an eye keeping on her. We had a child with a new diagnosis of leukaemia the other day with a low PEWS as well. It does not stand on its own as a “rule out” test. Hence the need to adequately “safety net” the 90% of children we send home from the ED.

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