Tawam Hospital implements Pediatric Early Warning Scoring Tool in combination with a Critical Care Pediatric Rapid Response Team


By Alexander A. Jankuloski, Dr Zuhair Shihab, Amanda Jane O’Neil, Aiman Rahmanu, Marian Van Taak, Said Abuhasna

Critical Care Medicine, Pediatric Department and Nursing Services at Tawam Hospital, Al Ain, UAE, jointly developed an evidence-based identification, escalation and response pathway allowing effective communication and coordination of healthcare professionals caring for acutely deteriorating hospitalised children. Children admitted to Tawam Hospital have benefited from the initiative due to early detection of deterioration and timely clinical interventions and follow-up.


There is a considerable amount of literature that highlights the fact that patients experience avoidable adverse clinical events during hospitalisation (Shein et al 1990, Franklin et al 1994, Buist et al 1999). 15% - 20% of all hospitalised patients develop serious adverse events. They are rarely sudden and unpredictable and are frequently preceded by one or more signs of physiological and biochemical deterioration (Buist 1999.

The traditional model of response to subtle signs of deterioration has been associated with a substantial delay in treatment initiation (DeVita et al 2006). DeVita et al (2006) explains that in order for the traditional model to be successful the following steps need to occur:

1. Timely response of all staff in a wellcoordinated sequence
2. Correct diagnosis
3. Appropriately communicating the correct assessment of the severity of the patient’s condition
4. Taking appropriate action
5. The actions taken are documented
6. Response is documented

A pilot study by Buist et al (1999) showed that the median duration for the coordination of the above-mentioned processes in a traditional model is 6.5 hours prior to cardiac arrest and/or ICU admission. In some cases the entire process takes up to 432 hours. Causative factors for such delays are lack of organisation and communication, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.

Pediatric Rapid Response Team

Pioneered in Australia, rapid response teams have been introduced in many hospitals in the United States participating in the 100,000 Lives Campaign, according to the Institute for Healthcare Improvement (IHI; 2009). The IHI advocates the use of multidisciplinary teams to assist with early identification and intervention in patients who are at high risk for deterioration. These teams are designed to rescue patients early in their decline, before respiratory or cardiac arrest occurs.

Pediatric Early Warning Scoring

The concept of utilising a scoring tool for early detection of deterioration in children is relatively new. Monaghan implemented the first reliable model in 2005. Subsequently, additional models were introduced by Duncan et al (2006), Tucker et al (2008) and Parshuram et al (2009). The model of Parshuram et al (2009) has been identified as the most reliable and used as basis for Tawam’s Pediatric Early Warning Scoring (PEWS) tool. Our PEWS tool has a twotiered structure. The first tier provides a score based on objective and subjective nursing physical assessment data. A physical assessment and a set of vital signs are completed directly after admission and at the beginning of each 12- hour shift. The total score is based on 20 specific clinical parameters representing five end-organ systems assigned as follows:

1. A score of ‘0’ indicates assessment findings congruent with normal physiological parameters

2. A score of ‘1’ indicates a mild to moderate deviation from normal physiological parameters

3. A score of ‘2’ indicates a moderate to severe deviation from normal physiological parameters

Subsequent additional points can be added to the score for specific clinical situations (e.g. persistent vomiting postsurgery; adjuvant to maintain an airway: mechanical ventilation, CiPAP, BiPAP or tracheostomy on admission and subsequently first 24 hours only).

The resulting total PEWS of:

1. 0 - 10 indicate to continue with the current clinical observation frequency and treatment plan

2. 11 - 21 indicate to increase the clinical observation frequency and adjustment of treatment plan.

3. 22 - 32 indicate to increase the clinical observation frequency, changes in nurse patient ratio, adjustment in treatment plans and possible consultation of further specialties such as paediatric critical care physicians. The primary physician has to be notified within 60 minutes.

The second tier is based on a single calling criteria structure which can be activated at any given time. Our tool has six objective single calling criteria such as heart rate, respiratory rate, respiratory quality, oxygen saturation, level of consciousness and capillary refill time. Sudden changes in any of these parameters have to be reported immediately to the primary physician and subsequently to a paediatric critical care physician. A seventh single calling criterion has been added. It is based on the intuition of the nurse and is described as ‘patient just does not look right’. Based on this criterion the nurse or any other clinician can initiate the Pediatric Rapid Response Team at any time. Success through collaboration The planning phase from November 2009 to March 2010 was a show model for successful multidisciplinary teamwork. All efforts were geared towards our principle goal of a safer environment for our sick children. Members of different medical and nursing divisions met in order to remodel and align long-established structures and processes. All aspects of the project were based on best available evidence and anchored on the development of hospital policies and education. The outcomes of the multidisciplinary planning phase were increased trust and respect between the involved stakeholders, a strong foundation for the challenges anticipated during the clinical implementation and a ‘script’ on how to enhance clinical practice as a multidisciplinary team for future endeavours. The multidisciplinary team continues to meet regularly in order to review results and further develop our Pediatric Rapid Response Team system.


The Pediatric Rapid Response Team (PRRT) and the Pediatric Early Warning Scoring (PEWS) tool were implemented in April and May 2010. The implementation of the Pediatric Rapid Response Team (PRRT) and the Pediatric Early Warning Scoring tool was two-tiered.

The PRRT was rolled out to all pediatric areas in April 2010. All areas were made aware of the related policy. The PRRT is led by a pediatric intensivist consultant and has a dual function. The primary role is to respond to deteriorating patients after being activated based on the calling criteria. Secondly, the PRRT follows-up on children for the first 24 hours after being transferred from PICU to a lower level of care.

The Pediatric Early Warning Scoring tool (PEWS) was initially implemented in the Pediatric Medical Ward in May 2010. The reasons for the staged implementation were the relative complexity of the tool and the anticipated need for reviewing some aspects of the tools. All nurses and physicians received education prior to implementation. Since implementation, all children on the Pediatric Medical Ward had their potential risk for clinical deterioration assessed once per shift through utilising the PEWS tool. Patients identified to be at higher risk have been quickly reassessed by the Pediatric Medical Team and the PRRT has been activated when needed. 90% of the patients have been identified early enough to initiate early goal directed therapy allowing patients to remain on the ward avoiding PICU admission. The tool is now well established and has been implemented across all pediatric impatient areas.


Our preliminary data shows that since implementation there was a 50% reduction in cardiopulmonary arrests in our hospitalised children in comparison to the same months in 2009. Between April and November 2010, the PRRT had 111 call activations. 44 of those children (39.6%) required admission to the Pediatric Intensive Care Unit.

A review of the data may allow the cautious supposition that there is a relative reduction for patients in need for a higher level of care. However, a longer time period is required for our evidence to support reliable conclusions. The PEWS has been well accepted by the nursing team in the pilot unit. This is reflected by the 100% compliance rate in completing the tool at the beginning of each shift.

Discussion and Recommendations

The implementation of the Pediatric Early Warning Scoring tool and the Pediatric Rapid Response Team has markedly changed our daily practice. It has become routine that the nursing team members score their patients after the physical assessment and prioritise their nursing interventions based on the results. The systematic scoring approach complements critical thinking and supports clinical decisionmaking processes. Furthermore, it supports succinct communication through the use of the SBAR tool. (SBAR stands for Situation, Background, Assessment and Recommendation and is widely used in healthcare and other industries to communicate effectively during critical situations.) Communicating PEWS findings through the SBAR tool has the potential to reduce the risk of misunderstanding among healthcare professionals (Haig et al 2006).

The additional use of a single calling criteria structure allows healthcare professionals to further accelerate clinical interventions for children at risk of deterioration.

Readers are encouraged to initially engage their multidisciplinary pediatric team, conduct a literature review on this topic and adopt or develop a scoring tool. Subsequently, focus and energy needs to be invested to gain wide understanding of the principles of early warning signs and appropriate response structures on all levels of the organisations through structured education. The clinical implementation phase requires active and ‘hands-on’ change management and leadership in addition to close clinical supervision, support and review.

Early Warning Scoring tools (Gao et al 2007) and Rapid Response Teams in general require further rigorous clinical research in order to analyse patient outcomes reliably (Chan et al 2010). The tool discussed in this article is based on best available evidence; however, the tool’s specificity, sensitivity and impact on patient outcome require further research. Several single-center research studies have been conducted with promising results. In order to increase the validity of research conducted in this field readers are encouraged to seek out opportunities to conduct multi-center research.

The Authors

Alexander Jankuloski, RN (A) Associate Director of Nursing,Surgery, Women and Children Services Tawam Hospital Corresponding author:

Dr. Zuhair Shihab Chief PICU Division Critical Care Medicine Department Tawam Hospital

Amanda Jane O’Neil, RN Clinical Resource Nurse Pediatric Division Tawam Hospital

Aiman Rahmanu, MD, FAAP Chairman, Department of Pediatrics Consultant, Division of Neonatology, Tawam Hospital Clinical Associate Professor of Pediatrics, FMHS-UAE University

Marian Van Taak, RN, RM Nurse Manager Pediatric Medical Ward Tawam Hospital

Said Abuhasna, MD, FACP, FCCP, FCCM Chairman, Department of Critical Care Medicine, Tawam Hospital Associate Clinical Professor, FMHS – UAE University


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 Date of upload: 10th Jul 2011


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