New inpatient tool for spotting deterioration in children launched by NHS England

3rd November 2023

A single, national standardised early warning system for paediatric teams in hospital settings is being rolled out by the NHS in England as a way of ensuring deterioration in a child’s condition is detected and escalated quickly.

Available from today (3 November), the new inpatient Paediatric Early Warning System (PEWS) chart allows paediatricians to measure things like blood pressure, heart rate, oxygen levels and levels of consciousness. The system tracks any changes and has different scores representing the level of concern.

If a parent or carer raises a concern that their child is getting ill or sicker than the score shows, this will immediately escalate the child’s care regardless of other clinical observations.

Unlike the similar universal system currently in place for adults, there are four separate charts for different age ranges, including 0-11 months, one to four years, five to 12 years, and those aged 13 and over.

The ultimate aim of the PEWS is to improve working methods and safety to support better health outcomes.

It is part of the System-wide Paediatric Observations Tracking (SPOT) programme, led by NHS England in collaboration and endorsement from the Royal College of Paediatrics and Child Health (RCPCH) and the Royal College of Nursing (RCN).

The partnership has been developing PEWS for three years, with pilots running across 15 sites demonstrating clear benefits for both patients and staff.

Updates to the system – such as those based on any guidance from Martha’s Rule, which gives families and patients the right to a second medical assessment – will continue to be implemented as required.

Professor Sir Stephen Powis, NHS national medical director, said: ‘We know that nobody can spot the signs of a child getting sicker better than their parents, which is why we have ensured that the concerns of families and carers are right at the heart of this new system with immediate escalation in a child’s care if they raise concerns and plans to incorporate the right to a second opinion as the system develops further.’

The NHS will develop and circulate a leaflet and video content for parents to explain how to communicate concerns to healthcare staff and encourage them to escalate if needed.

Dr Mike Mckean, vice president for policy, at the RCPCH, said: ‘The National PEWS chart is an extremely important new tool that will support all paediatricians and wider child health teams to spot deterioration in children in hospital. Alongside training and resources, it will help teams across the country improve patient safety, efficacy and quality of care.

‘The SPOT programme builds on systems already in place in many trusts and has the many advantages of becoming a national system. I’d strongly encourage all paediatricians to look at the chart and consider what they need to do to smoothly transition towards integration and embedding the National PEWS into their trusts.’

Standardised tools and e-learning for using national PEWS charts in a range of health settings are in development.

In 2023/24 trusts are expected to appoint an education/implementation lead who will begin to support their trust to roll out the national PEWS.

Plans are in place to expand the system to emergency departments as well as mental health, ambulance and community services in due course. It is also hoped that the national PEWS chart will become the standard of care in England, meaning all medical and nursing students will receive instruction on its use during their training.

Pharmacist sepsis notification system improves patient outcomes

13th September 2021

A sepsis notification system contained within electronic health records monitored by pharmacists significantly improved patient outcomes.

Sepsis is a life-threatening organ dysfunction response to infection which, according to the World Health Organization, in 2017, affected 48.9 million people and caused 11 million sepsis-related deaths. The early administration of broad-spectrum antibiotics is associated with a reduced progression to severe sepsis and septic shock and a lower mortality. These findings have prompted the development of several automated rule-based sepsis notification systems which have been combined with alerting systems. In a review of studies, it was concluded that digital sepsis alerting systems, reduce both hospital and intensive care unit stays for patients with sepsis. The incorporation of sepsis notification systems within electronic health records (EHRs), providing a real-time alert, could therefore lead to improvements in patient outcomes although recent trial concluded that this was not the case.

Whether sepsis notification systems incorporated into EHRs and monitored by an emergency department pharmacist could improve patient outcomes was the subject of a study by a team from the Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Centre, Cleveland, Ohio, US.

The team incorporated a sepsis alert within with the EHR and randomised patients admitted to hospital with suspected sepsis to either standard care or augmented care (intervention group) in which the sepsis early-warning system (EWS) was visible and monitored by an emergency department pharmacist. Once the sepsis EWS score crossed over the established threshold, an alert occurred, triggering a flag that was displayed on the patient emergency department tracking tool and a message to the EHR system which was monitored by an emergency department pharmacist. Once an alert was raised, the pharmacist ordered appropriate blood tests, antibiotics and fluid boluses for the patient. The primary outcome measure was time to antibiotics from arrival and the primary clinical outcome score was a composite of days alive and out of hospital, 28 days after arrival.

Findings
A total of 598 patients were included over a 5-month period and randomised to standard care (313) or intervention. The median age of participants ranged from 62.3 (standard care) to 61.5 (intervention group) years with the proportion of females ranging from 46% to 51.2%, standard care and intervention group respectively. Among those assigned to the intervention arm, the time to antibiotic administration from emergency department arrival was 2.3 hours compared with 3 hours in the standard care group (p = 0.039). In addition, the clinical primary outcome score was also higher for the intervention, reflecting better outcomes (median 24.1 vs 22.5 days, p = 0.011). However, the length of stay between groups was not significantly different (p = 0.124) and neither was hospital mortality (p = 0.086).

In their discussion, the authors noted how their results showed only a slightly modest improvement from the intervention. The study was designed as a quality improvement initiative to compare whether visibility of the sepsis notification systems by both clinicians and pharmacists improved outcomes. They concluded that further studies are needed to determine if their approach is generalisable to other healthcare settings.

Citation
Tarabichi Y et al. Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A randomised Controlled Quality Improvement Initiative. Crit Care Med 2021.