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The first reported PTTS for hospitalised children, the Paediatric Early Warning Score,39 was published in 2005. The system was developed at the Royal Alexandra Hospital for Sick Children in Brighton, UK.
In February 2001 a working group was established at the Royal Alexandra Hospital to investigate the feasibility of extending the existing adult critical care outreach to children. By October 2001, a pilot was underway. Initially ward staff referred children about whom they had concerns, and the team, including staff from PICU, attended. However ward staff reported feeling deskilled, undermined and undervalued.
Focus shifted to implementing mechanisms to assist staff in the early identification of the deteriorating child. No paediatric-specific system could be identified from the literature so the working group adapted the existing adult system. Because a system based solely on vital signs would require different versions to address age- appropriate values, three main indicators were adopted: behavior, cardiovascular and respiratory status. Specific thresholds for vital signs were not provided. The system is shown in Figure 1.6.
Figure 1.6: The Royal Alexandra Children's Hospital Paediatric Early Warning Score
0 1 2 3
Behaviour Playing/ appropriate
Sleeping Irritable Lethargic/ confused Reduce response to pain Cardiovascular Pink or capillary refill 1- 2 seconds Pale or capillary refill 3 seconds Grey or capillary refill 4 seconds. Tachycardia of 20 above normal rate
Grey or mottled or capillary refill 5 seconds or above. Tachycardia of 30 above normal rate or bradycardia
Respiratory Within normal parameters, no recession or tracheal tug >10 above normal parameters, using accessory muscles, 30+% FiO2 or 4+litres/min >20 above normal parameters recessing, tracheal tug. 40+% FiO2 or 6+ litres/min 5 below normal parameters with sternal recession, tracheal tug or grunting. 50% FiO2 or 8+ litres/min Total score is derived from assessment of behaviour, cardiovascular and respiratory status. Reproduced from Monaghan 200539
Staff assessed the child against the guidance, assigning a score of zero to three for each of the three indicators. The total score was then assessed against guidance which prompted one of five actions:
Continue current care Inform the nurse in charge
Increase the frequency of the observations
Call for a medical review and inform the outreach team for a score of four Call the full medical team and outreach team for any score greater than four
Any child who scored in the ‘red’ zone (a score of three in any one indicator) would also be escalated to the medical and outreach team.
Initial feedback on the score was variable, with reports that:
“Some staff could not see why we needed a score as they felt they were quite capable of recognising patients at risk”
(Monaghan, p3539)
Concerns were also raised about the assessment being time-consuming, although when investigated, completing the early warning score only took 30 seconds over and above the time taken to record the vital signs.
During the three-month pilot 30 patients scored four, prompting the nurse to request a review by the medical team. The majority (96%) were seen within 15 minutes. All required medical intervention, after which 83% improved whilst the remaining 17% were transferred to the PICU. Children who staff felt should have scored higher prompted revision of the score to include additional weighting for prolonged post- operative vomiting.
Subsequent feedback from thirty-three staff on the acute medical and surgical wards revealed that 80% felt that the score had improved their confidence in recognising a child at risk of deterioration. Although the author reported that assessment of the sensitivity of the score was underway, with assessment of inter-rater reliability planned in the future, no subsequent publications could be identified.
Despite its limited evaluation, the study remains an important milestone, marking the first publication of PTTS.
1.2.8.2 An alternative approach
On the other side of the world another paediatric hospital was also working to improve the management of the deteriorating child. The Royal Children’s Hospital in Melbourne, Australia developed a specialist team to respond to the deteriorating child known as the Medical Emergency Team or MET.40 The MET could be activated by clinical staff if any one of nine criteria was present (Figure 1.7). Eight of the criteria represented clinical indicators and vital signs values associated with serious illness, but the MET could also be activated if the nurse or doctor was ‘worried’ about the child’s condition. Explicit age-related criteria for vital signs were specified but unlike the Paediatric Early Warning System no scoring matrix was used. This ‘trigger’ based approach was simpler and required no mathematical calculation, but unlike the Paediatric Early Warning Score, the outcome was dichotomous, with an ‘all or nothing’ response.
Figure 1.7 Criteria for activation of the medical emergency team
Fulfillment of any single category would trigger a referral to the medical emergency team. Reproduced from Tibballs et al 200540
1.2.8.3 Subsequent development of paediatric track and trigger systems Although the first publications on PTTS were in 2005, many hospitals had been developing and implementing their own local systems. A 2005 survey of 186 UK hospital trusts identified 144 who were delivering paediatric services.41 Thirty-one of these (21.5%) reported using a PTTS. Many appeared to be the same or local adaptions of the Monaghan39 Paediatric Early Warning Score or the subsequently published Bristol Paediatric Early Warning Score.42
The 31 centres were asked to report the component parameters of their PTTS. Of the 36 identified parameters (Table 1.6), respiratory and heart rate, nurse and doctor concern and respiratory effort were most prevalent.41
Table 1.6 Frequency of the component parameters reported by the 31 hospitals using an early identification system in 2005
Frequency of the component parameters in the 31 early identification systems reported by the 2005 survey respondents.
Reproduced fromDuncan41
The survey was repeated in 201343 with a response rate of 94.9% (149/157). The majority were district general hospitals (119/126) with 30 (out of 31) respondents from tertiary hospitals. Of the 149 centres who responded 99 of the 119 (83%)
district general hospitals and 27 of the 30 (90%) tertiary care hospitals reported they had a PTTS in place. Eleven district general hospitals and 15 tertiary hospitals had also introduced a rapid response team.
Respondents were asked to identify the origin of their PTTS (Table 1.7). Only a third reported that their system was based on a previously published tool, with the remainder using a mix of systems adapted from other hospitals and those purposely designed for the individual unit. The number of differing parameters had increased to 47, however respiratory and heart rate remained the most commonly cited parameters.
Table 1.7 Origin of systems
PTTS based on: Number of responses (%)
Previously published system 26 (33.8%)
Unpublished system in use at another hospital 19 (24.7%)
Purposely designed for own unit 15 (19.5%)
Unsure 8 (10.4%)
No response 9 (11.7%)
Total 77 (100%)
Respondents to a survey were asked to identify the origin of their current PTTS system. Reproduced from Roland43
The authors of the 2013 survey recommended a collaborative approach to PTTS similar to that led by the Royal College of Physicians for adult patients.43,44 They advocated that all PTTS must be simple to use and be acceptable to the end user if they are to be widely accepted and adopted into clinical practice. They proposed that respiratory rate, heart rate and oxygen saturation levels should be considered core parameters as they were the top three items in the survey results. The authors also suggested that conscious level, respiratory effort, nursing concern, blood pressure and oxygen therapy should be considered for inclusion on the basis that at least 50% of units currently included these items in their PTTS and they had also been highlighted in a systematic review of clinical features of serious illness in children.45 Finally they identified that the ideal PTTS would utilise routinely collected data. To allow expert help to be mobilised and interventions to be implemented, it
would also accurately identify patients who are deteriorating at a sufficiently early stage.
This rapid uptake in PTTS usage has been characterised as an ‘explosion’.46 Although many systems are in existence, all have adopted either the score-based approach pioneered by the Royal Alexandra Hospital or the trigger-based approach promoted by the Royal Children’s Hospital. Whilst both approaches aim to identify children at risk of clinical deterioration, there are important differences between score-based and trigger-based systems.