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