Systematic review undertaken to support the development of an Irish National Clinical Guideline - Paediatric Early Warning Systems (PEWS)

A specific priority of the Irish HSE’s National Clinical Programme for Paediatrics and Neonatology is the implementation of a National Paediatric Early Warning System (PEWS) as recommended by HIQA’s 2013 ‘investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar’. In 2014, chaired by Dr. John Fitzsimons, Consultant Paediatrician and Clinical Director for Quality Improvement HSE, the PEWS steering group developed new national age-specific paediatric observation charts that incorporate the Paediatric Early Warning Score system, as well as a comprehensive supporting educational package and other resources.

The role of the DCU research team in the development of a Paediatric Early Warning System (PEWS) to the level of a National Clinical Guideline in Ireland, funded by the Clinical Effectiveness Unit, Department of Health and overseen by the National Clinical Effectiveness Committee and the Health Service Executive PEWS Guideline Development Group, was the completion of a systematic clinical and economic literature systematic review to underpin the national clinical PEWS guideline. Led by Dr Veronica Lambert, Senior Lecturer and Deputy Head of the School of Nursing and Human Sciences and Professor Anne Matthews, Head of School Nursing and Human Sciences the aim of this review was to assess the evidence on the use, validation, education and cost-effectiveness of early warning, or track and trigger, systems used in paediatric patients in acute healthcare settings, including emergency departments, for the detection and/or timely identification of deterioration in children aged 0-16 years.

The review (of 11 clinical guideline documents, 70 research papers and various sources of grey literature) highlighted that PEWS’s were extensively used internationally in paediatric inpatient hospital settings, however there was no consensus and limited evidence on which PEW system was most useful or ‘optimal’ for paediatric contexts. While definite conclusions on the effectiveness of PEW systems could not be made, positive directional trends in improving clinical based outcomes (i.e. reduced cardio-pulmonary arrest rates and earlier intervention and transition to PICU) were identified, in addition to, enhanced multi-disciplinary team work, increased open communication, greater sense of situational awareness and increased confidence in recognising, reporting and making decisions about child clinical deterioration; all essential for organisational safety culture.

A key limitation from the review was that despite much evidence reporting on the complexity and multi-faceted nature of PEWS, no evidence examined PEW systems as a complex health-care intervention; consequently, it is unclear on what the true “active ingredients” of PEWS interventions are for improving clinical based outcomes. No economic evaluations covering the resource implications of a complete PEW system (implementation, education, detection, response) were found. This systematic review of clinical and economic literature assisted guideline developers in the rigorous development of PEWS to the level of a National Clinical Guideline in Ireland. A pilot implementation of PEWS in four paediatric inpatient healthcare settings has just been completed and it is hoped to roll out PEWS to all paediatric inpatient healthcare settings nationally by the end of 2015.