The document discusses the Pediatric Early Warning Score (PEWS) system, which is a standardized tool used to assess early clinical deterioration in pediatric patients. PEWS uses parameters like behavior, cardiovascular status, and respiratory status to assign a score that determines the appropriate level of monitoring and care. Higher scores indicate greater risk and require more frequent reassessment and escalation of care, including notification of providers and calling rapid responses. The goal of PEWS is to help clinicians recognize subtle changes in pediatric patients and intervene earlier to prevent cardiac or respiratory arrest.
2. How do we measure clinical deterioration in
pediatric patients?
• The Pediatric Early Warning Score (PEWS) is a systematic
standardized approach to patient assessment.
• Reliable validated objective tool.
• Used to assess early clinical deterioration and provide subsequent
intervention for pediatric patients.
• Uses set parameters to provide the bedside RN with an action plan
to care for a declining patient.
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4. Rationale for PEWS
• Studies have shown that in hours prior to a cardiopulmonary
arrest 51-80% of patients had a critical physiological change in
condition.
• Clinical changes may occur slowly and over a relatively long
time frame.
• Inexperienced front line clinicians may not be able to
accurately identify patients who have subtle clinical changes.
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5. Rationale for PEWS
• It can be difficult
for the bedside
nurse to look
beyond the
patient’s current
status to notice
trends in vital
signs and other
parameters.
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6. PEWS scoring
• PEWS is utilized in Peds, PACU, and Pediatric ER
• The following areas/populations are exempt from utilizing the
PEWS tool:
– Newborn and Neonatal Intensive Care Nurseries
– Pediatric Intensive Care Unit
– Pediatric patients in outpatient Test and Treatment areas
– End of life patients
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7. PEWS scoring
• Based on 3 criteria
– Behavior
– Cardiovascular status
– Respiratory status
• Each criteria can be scored from 0-3
• Total score determines the color zone for the patient
• The color zone determines the action plan for care
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8. PEWS scoring
• A PEWS score will be assessed on admission and a minimum
of every 4 hours during hospitalization.
• Continued assessment and documentation is based on
patient’s score and patient care activity.
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10. PEWS Decision Tree
• All patients are to be assessed / reassessed per guidelines
established in the PEWS policy.
• This decision tree is to be used as a guideline. If at anytime, clinical
judgment indicates that a patient’s status warrants a higher level of
surveillance, the covering MD/Mid Level Practitioner should be
notified and /or a Pediatric Rapid Response or Code Blue should be
called.
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11. • Green
– Score 0-2
– Assess
every 4
hours
• Yellow
– Score 3
– Assess
every 2
hours
• Orange
– Score 4
– Assess
every 1
hour
• Red
– Score 5 or
greater
– Assess
every 30
minutes
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Score Color Action
0-2 Green Reassess per PEWS policy.
3 Yellow RN assigned to patient notifies Charge Nurse of patient score and status.
RN assigned to patient performs full reassessment within 2 hours of
previous assessment.
Covering MD is notified if PEWS score remains at a 3 or if score increases.
4 RN assigned to patient notifies Charge Nurse of patient score and status.
Charge Nurse performs assessment, huddles with RN assigned to patient to
communicate findings and develop plan, and documents assessment in EHR.
RN assigned to patient notifies covering MD of patient score and status.
RN assigned to patient reassesses and rescores patient every hour. If the
patient’s PEWS score is 4 or greater on two consecutive assessments the
covering MD will perform an assessment within 15 minutes. If covering
MD is unable to arrive or provide plan of care, RN will call a Pediatric
Rapid Response.
5 OR
a “3” in
any one
categor
y
Red RN assigned to patient calls a Pediatric Rapid Response or Code Blue.
PICU Charge Nurse performs assessment, takes interventions necessary to
meet immediate needs of patient, huddles with RN assigned to patient to
communicate findings and develop plan.
RN assigned to patient will reassess every 30 minutes.
Pediatric Charge Nurse organizes actions of team members to facilitate safe
care of the patient and other patients on unit.
13. Zone Actions
• Green Zone
– Continue to reassess every 4 hours
and PRN
• Yellow Zone
– RN notifies the Charge Nurse
– The Charge Nurse will
• Assist with implementation of
interventions to meet immediate
patient needs.
• Huddles with the patient’s assigned
RN to communicate findings and
develop a plan.
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14. Zone Actions
• Orange Zone
– Total score of 4
• Continue to reassess q 1 hour
– RN
• Notify the charge nurse of the patient’s score and status
• Documents in the EHR
• Remain with patient until a plan is formulated a plan of care with the
health care provider
• Consider calling a rapid response
– Charge Nurse
• Assists with implementation to meet immediate patient needs
• Huddles with patient’s assigned RN to communicate findings and develop
a plan
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15. Zone Actions
• Red Zone
– Total score of 5 or greater
– RN assigned to patient
• Remain with the patient and notify the provider immediately
• Consider calling a rapid response
• Reassess and document patient status in the EHR until assistance arrives
– Charge nurse
• Organize and facilitate safe care of this patient and others on the unit
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17. Documentation and Communication
• Where to chart PEWS
– Simple and Complex Vitals in EPIC
– Viewable on the Vitals report (last 24 hours) and the Vitals Accordian
• PEWS should be documented each time it is assessed.
• PEWS handoff communication
– RN’s should obtain, document and report a PEWS score
• Within 30 minutes prior to a transfer to another area ie: PACU
• During shift handoff
• With any deterioration in status
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18. Documentation and Communication
• Communicated to credentialed health care provider utilizing
standard communication tools such as SBAR or CUS words
– CUS- I am Concerned. I am Uncomfortable. This is a patient Safety
issue.
• If a parent or caregiver voices concern that the patient is
clinically deteriorating, notify:
– The charge nurse and the health care provider
– Per nursing judgement, initiate a Pediatric Rapid Response following
the facility policy/procedure
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19. Nursing Judgement Trumps ALL.
If you are not comfortable with
your patient’s condition.
CALL A RAPID RESPONSE
21. Rapid Response
• Call 16911
This is saying “We need to have a conversation about this
patient.”
• Responders have 15 minutes to arrive at bedside
• Who responds
– Pediatric charge nurse
– PICU charge nurse
– Hospitalist
– RT
– Bedside nurse
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22. Rapid Response
• Chart rapid responses in the Rapid Response Navigator in EPIC.
• The PICU charge nurse also needs to chart a head to toe
assessment.
• This does not guarantee a transfer to the PICU. It only guarantees
a conversation.
• Educate parents and families that they may also call a rapid
response
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23. IF YOU HAVE AN EMERGENT &
IMMEDIATE NEED
CALL A CODE BLUE
