The-Children-s-Early-Warning-Tool

The Children’s Early Warning Tool
Kevin McCaffery
Staff Specialist in Paediatric Intensive Care, Brisbane
Senior Medical Advisor, Patient Safety Centre, Brisbane

Objective
• To design a suite of tools to meet the needs of
bedside clinicians
• Observation chart
• Reference ranges for age
• Early warning score
• Clinical escalation
• Tool to assess interventions
• Triage tool
• Customisable

Design
• Blank canvas
• What observations predict deterioration?
• Normal ranges for age?
• Single point vs. cumulative score? (both…?)
• Weighting of observations
• What observations – pragmatic
• Human factors approach to design

Validation
• Retrospective
• All patients admitted PICU from ward in 2007
• CEWT detected patients before PICU admission
• Prospective
• Twelve pilot sites (tertiary / regional / rural)
• Two month trial
• Phased roll-out
• Retrieval population
• Root Cause Analysis
• Semi-qualitative implementation study

Retrospective validation
ICU admissions
11
10
9
8
bronchiolitis n=20
pneumonia n=5
reactive airways n=4
sepsis n=14
CEWT score
7
6
5
4
3
2
1
0
-48 -45 -42 -39 -36 -33 -30 -27 -24 -21 -18 -15 -12 -9 -6 -3 0
time (hours)

CEWT – Bronchiolitis
ICU admissions: bronchiolitis
8
7
6
CEWT score
5
4
3
2
1
0
-48 -45 -42 -39 -36 -33 -30 -27 -24 -21 -18 -15 -12 -9 -6 -3 0
time (hours)

10
9
8
7
6
5
4
3
2
1
0
CEWT – Bronchiolitis controls
Bronchiolitis - Controls
Bronchiolitis - Controls
183
12
21
30
39
48
57
66
75
84
93
102
111
120
129
138
147
156
165
174
time (hours)
3

Prospective trial
• Approximately 1900 patients
• Currently analysing data
• Optimise physiological weighting
• Optimise action box (for different institutional capabilities)
• Impression is that scoring seems appropriate
• Two critical incidents
• Patients had respiratory arrests
• In both cases, CEWT had been overruled by registrar

Maximum CEWT score
600
500
400
n =1886
Patients
300
200
100
83%
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
CEWT score

CEWT scores by centre
Patients
160
140
120
100
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
CEWT score
Tertiary
Regional 1
Regional 2
Regional 3
Regional 4
Regional 5
Rural

Bronchiolitis: Index vs. Controls
CEWT score
9
8
7
6
5
4
3
2
1
0
Prospective
Retrospective controls
Retrospective index
*
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
time (hours)

Respiratory Rate: Index vs. Controls
80
CEWT score
70
60
50
40
30
20
10
0
Retrospective Controls
Retrospective Index
1 6 11 16 21 26 31 36 41 46 51 56 61
Hours
*

Retrieval CEWT
• 4 month convenience sample of retrieval referrals
• Evaluate state-wide implemetation
• Identify early and late referrers
• Improve objectivity in co-ordination

Retrieval patients - CEWT score
50
45
40
35
30
25
20
15
10
5
0
n = 204
23%
51%
0 1 2 3 4 5 6 7 8 9 10 11 12 13

CEWT score by diagnostic group
25
20
15
Trauma
Resp infection
Sepsis
Seizure
Gen Surgery
Asthma
DKA
10
5
0
0 1 to 3 4,5 6,7 ³ 8

Retrieval team composition vs. CEWT
30
25
Nurse / ICP
Doctor / nurse
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
CEWT score

Root Cause Analysis
• Currently reviewing state-wide data in last 3 years
• 20 cases filed (RCAs not total deaths)
• 1 late identification spinal injury
• 2 – haemorrhage during / post surgery
• 1 out-of-hospital arrest (discharged that day)
• 1 SUDEP

Semi-quantitative implementation study
• Questionnaire at end of prospective trial period
• Evaluation of trial-site experience
• Staff demographics
• Impact on perceived ability to care for hospitalised children
• Ease of use
• Educational material / support
• Inform design of state-wide implementation strategy

Children's Early Warning Tool - Respondents
50
45
40
35
n = 115
30
25
20
15
10
5
0
Paed Nurse
3yr
Adult / Paed
Nurse
Paed
resident
Paed
registrar
Paed
consultant
GP

What impact has CEWT had on your ability to care for children
in hospital?
5
Improved
4.5
4
3.5
3
No change
2.5
2
1.5
1
Tertiary
HDU
Tertiary
Oncology
Tertiary
Medical /
Surgical
Regional
1
Regional
2
Regional
3
Regional
4
Regional
5
Rural 1 Rural 2 Rural 3 Rural 4 Rural 5
Worsened

Very easy
Very hard
Rural 5
5
4.5
4
3.5
3
2.5
2
1.5
1
How difficult was the CEWT chart to use?
Regional 1
Regional 2
Regional 3
Regional 4
Regional 5
Rural 1
Rural 2
Rural 3
Rural 4
Tertiary Medical / Surgical
Tertiary Oncology
Tertiary HDU

How did you rate the educational material and support?
5
Excellent
4.5
4
3.5
3
Acceptable
2.5
2
1.5
1
Tertiary
HDU
Tertiary
Oncology
Tertiary
Medical /
Surgical
Regional
1
Regional
2
Regional
3
Regional
4
Regional
5
Rural 1 Rural 2 Rural 3 Rural 4 Rural 5
Poor

What next…
• Complete prospective analysis
• Optimise CEWT
• Design state-wide implementation
• Work collaboratively across borders
• Further projects
• Other charts
• Telemedicine
• Computers

Acknowledgements
• The staff of the Patient Safety Centre, Brisbane
• John Wakefield, Jillann Farmer, Rowena Richardson,
Hayden Scotter, Lynette Adams
• The other members of the CEWT team
• Jo-Anne Stephens
• Ruth McCaffery
• The staff who participated in the prospective trial