The Children’s Early Warning Tool

Kevin McCaffery

Staff Specialist in Paediatric Intensive Care, BrisbaneSenior 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 validationICU admissions

0

1

2

3

4

5

6

7

8

9

10

11

-48 -45 -42 -39 -36 -33 -30 -27 -24 -21 -18 -15 -12 -9 -6 -3 0

time (hours)

CEW

T sc

ore

bronchiolitis n=20pneumonia n=5reactive airways n=4sepsis n=14

CEWT – BronchiolitisICU admissions: bronchiolitis

0

1

2

3

4

5

6

7

8

-48 -45 -42 -39 -36 -33 -30 -27 -24 -21 -18 -15 -12 -9 -6 -3 0

time (hours)

CEW

T sc

ore

CEWT – Bronchiolitis controlsBronchiolitis - Controls

0

1

2

3

4

5

6

7

8

9

10

3 12 21 30 39 48 57 66 75 84 93 102

111

120

129

138

147

156

165

174

183

time (hours)

Bronchiolitis - Controls

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

0

100

200

300

400

500

600

0 1 2 3 4 5 6 7 8 9 10 11 12 13CEWT score

Patie

nts

83%

n =1886

CEWT scores by centre

0

20

40

60

80

100

120

140

160

0 1 2 3 4 5 6 7 8 9 10 11 12 13

CEWT score

Patie

nts

TertiaryRegional 1Regional 2Regional 3Regional 4Regional 5Rural

Bronchiolitis: Index vs. Controls

0

1

2

3

4

5

6

7

8

9

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

time (hours)

CEW

T sc

ore

ProspectiveRetrospective controlsRetrospective index

*

Respiratory Rate: Index vs. Controls

0

10

20

30

40

50

60

70

80

1 6 11 16 21 26 31 36 41 46 51 56 61

Hours

CEW

T sc

ore

Retrospective ControlsRetrospective Index

*

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

0

5

10

15

20

25

30

35

40

45

50

0 1 2 3 4 5 6 7 8 9 10 11 12 13

n = 204

23%

51%

CEWT score by diagnostic group

0

5

10

15

20

25

0 1 to 3 4,5 6,7 ³ 8

Trauma Gen SurgeryResp infection AsthmaSepsis DKASeizure

Retrieval team composition vs. CEWT

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 10 11 12 13

CEWT score

Nurse / ICP

Doctor / nurse

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

0

5

10

15

20

25

30

35

40

45

50

Paed Nurse<3 yr

Paed Nurse>3yr

Adult / PaedNurse

Paedresident

Paedregistrar

Paedconsultant

GP

n = 115

What impact has CEWT had on your ability to care for children in hospital?

1

1.5

2

2.5

3

3.5

4

4.5

5

TertiaryHDU

TertiaryOncology

TertiaryMedical /Surgical

Regional1

Regional2

Regional3

Regional4

Regional5

Rural 1 Rural 2 Rural 3 Rural 4 Rural 5

No change

Improved

Worsened

How difficult was the CEWT chart to use?

1

1.5

2

2.5

3

3.5

4

4.5

5

Tertiar

y HDU

Tertiar

y Onc

ology

Tertiar

y Med

ical /

Surgica

lReg

ional

1Reg

ional

2Reg

ional

3Reg

ional

4Reg

ional

5

Rural 1

Rural 2

Rural 3

Rural 4

Rural 5

Very easy

Very hard

How did you rate the educational material and support?

1

1.5

2

2.5

3

3.5

4

4.5

5

TertiaryHDU

TertiaryOncology

TertiaryMedical /Surgical

Regional1

Regional2

Regional3

Regional4

Regional5

Rural 1 Rural 2 Rural 3 Rural 4 Rural 5Poor

Acceptable

Excellent

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