Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper

Lillitos et al are to be congratulated on a most helpful paper clarifying whether disease severity and the need for hospital admission can be predicted using two similar PEWS systems (Brighton PEWS and COAST - the Children's Observation And Severity Tool).

There has been a proliferation in the uptake and usage of Paediatric Early Warning Scores (PEWS) in recent years, as part of the patient safety agenda. Their original (dare I say, intended) purpose was to detect early deterioration in hospitalised children, prompting timely interventions and predicting the need for possible Paediatric Intensive Care admission whereas increasingly, PEWS are being employed generically in paediatric practice in the UK. Like Cinderella's slipper (following the spirit of this season), Early Warning systems are attractive, colourful and everybody wants to claim them for their own, with Ambulance Call Response/Prioritisations, Hospital Admissions, ED Triage Systems, Telephone Triage and Decision Making algorithms, Minor Injury/Walk-in centres (to name but a few potential suitors) all seeking to shoe-horn their patient's demographics into one of the currently available scoring systems, in some situations avoiding the need for proper face-to-face clinical assessment.

Of particular importance was the author's subdivision of presenting complaints into both minor and significant "Medical" and "Surgical" conditions which highlights some of the limitations of Early Warning Scores.

It is reassuring to find that both the Brighton and COAST scores were good at detecting significant respiratory illnesses, (Brighton and COAST ROC scores yielding AUCs of 0.9 and 0.87, respectively). Whilst intended to be universally applicable, both these scores have an inherent respiratory design-bias, measuring multiple respiratory parameters (respiratory rate, moderate-severe respiratory distress, supplemental oxygen (Brighton), hypoxia (saturations ?92% in air (COAST))), both expected and desirable qualities given the prevalence of respiratory illness encountered in acute "paediatric practice" (asthma/wheeze, bronchiolitis, croup, URTI, LRTI etc.)

Importantly, both local and regional experience and reviews of adverse incidents, morbidity and mortality have anecdotally found PEWS scores to be less reliable in the early detection of neurological conditions, surgical conditions and blunt and penetrating trauma (where compensatory mechanisms delay physiological abnormalities until disease progression has advanced) and again the authors should be thanked for quantifying these reported observations (they describe AUC's of i) 0.48AVERAGED for significant neurology, 0.56 for general surgical conditions, 0.65 for significant trauma and 0.7 for head injury; Table 3). (I suspect that in major trauma, simple descriptors such as "fall from height", "ejected through windscreen" might well outperform medical COAST/PEWS systems).

The study also validates what has been termed the "currency of COAST" - that a high COAST score (a score ?3) must be taken seriously. (Due to the score's poor specificity, the converse is not true - a low score does not exclude significant illness/the need for admission). By choosing to use the PEWS/COAST score at Triage, the authors were reliant solely on abnormal physiological findings at one isolated point in time (influenced by external factors such as crying and fever etc.) whereas tracking scores over a period of observation or on an admissions/inpatient wards may have revealed the trends of deterioration described in the early papers that supported the introduction of PEWS systems (1). Even so, like other clinical descriptors (e.g. haemorrhagic rash, shock, unresponsive, fitting) the chosen individual trigger parameters would be expected to prompt an appropriate nursing/medical response e.g. this child's heart rate is abnormally high, their respiratory rate is depressed, their conscious level diminished etc. (Previous authors have discussed the possible merits of using aggregate weighted scores rather than single clinical parameters but neither approach has been found to be superior to the other (2); aggregate scores are certainly more complex, less user- friendly and suggest a knowledge and appreciation of disease processes that - if universal- is at best, currently poorly understood i.e. what happens to "normal" heart rates in an unwell/injured 5-year old as their condition progresses).

One of the study's shortcomings was to "wrongly" assign each child with a universal score of "1" for parental concern, "on the basis that parents/carers, by bringing their child to the ED, were by default concerned". Parents do sometimes make uninformed choices when presenting to ED; 60% of parents whose children had ATS (Australasian Triage System) category 4 and 5 scores described the severity of their child's illness as the primary (or secondary) reason for ED attendance (3). The intension behind the "Doctor/Nurse/Family concern" trigger was to appreciate the importance of gut feelings - something subjective, often unquantifiable and unmeasurable - to prompt an appropriate clinical response. (Van den Bruel, A et al's paper helpfully supports this approach (4)). [Within the confines of a retrospective study, the authors can legitimately claim that they unfortunately had no alternative]. As an advocate of PEWS scores (I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010), I do question how often these scoring systems have identified a child that would not otherwise have been identified and am concerned that, in the headlong rush to employ a PEWS system in any and every clinical setting, their value has been overstated at the expense of comprehensive nursing observations and medical assessments. They do most certainly i) have an important role to play in ensuring deteriorating trends are appreciated, communicated and acted upon by nursing and medical teams and ii) can be useful when used as a safety netting tool but, paraphrasing social media, might I suggest that we.... "Don't confuse my early warning score for years of clinical training and experience!"

Dr Julian Sandell, Consultant in Paediatric Emergency Medicine, Poole Hospital NHS Foundation Trust, and author of the Children's Observation And Severity Tool (COAST), 2010

www.institute.nhs.uk/safer_care/paediatric_safer_care/pews_charts.html

REFERENCES: (1) Detecting and managing deterioration in children. Monaghan A. Paediatric Nursing. 2005 Feb;17(1):32-35 (2) "Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration". Chapman SM et al. Intensive Care Med. 2010 Apr;36(4):600-11. Epub 2009 Nov 26. (3)Why parents present to ED for non-urgent care. Williams A et al. ADC 2009;94:817-820 (4)Clinicians' gut feeling about serious infections in children: observational study. Van den Bruel, A et al. BMJ 2012;345:e6144

Conflict of Interest:

I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010

Dear Editor,

We read with interest the article by Seligman and colleagues (1) which evaluated a novel first responder scheme for medical students as a collaborative venture between a medical school and the local ambulance service. Previous authors have advocated the early introduction of Emergency Medical Technician teaching in an undergraduate medical curriculum in the United States.(2) We would like to report our experiences in delivering an innovative special study module (SSM) in pre- hospital emergency care (PHEC), which has consistently been one of the most popular elective modules offered to the preclinical medical students at our institution.

The PHEC SSM was designed by senior medical educators in partnership with paramedics and advanced paramedics at our local hospital. Our university has conferred honorary clinical fellowships on the paramedic supervisors involved. Second year students complete the SSM over a 10-week period in small groups of 12 students as part of their core medical professionalism module. Participants actively shadow ambulance crews on emergency calls and assist in patient assessment, monitoring and hand-over in the emergency department, under the supervision of experienced paramedics. Students have the opportunity to consolidate their theoretical knowledge and practise procedural skills such as blood pressure measurement, capillary blood glucometry, electrocardiography and oxygen administration in an authentic clinical environment. They also become familiar with standardised emergency management, first aid, and patient safety protocols. Students maintain a reflective log of their emergency calls and are debriefed in the case of traumatic incidents. Assessment involves a combination of supervisor-led student evaluation, and submission of a written assignment based on a contemporary emergency medicine topic. Students also deliver a group presentation in which they are required to critically analyse the efficiency of the ambulance service and compare it to international best practice.

The PHEC SSM provides a formative early introduction to immediate care and emergency medicine and it focuses students' attention on the realities of clinical practice outside of a hospital setting. SSMs such as this are a useful vehicle for fostering greater inter-professional learning opportunities and improving communication between members of a multidisciplinary clinical team, as well as promoting a deeper appreciation for team-working and the ethical dilemmas of patient care. Some medical students will also benefit from being motivated towards a future career in emergency medicine. This educational intervention has greatly facilitated collaboration between the ambulance service, emergency department and the medical school, and we propose that it may serve as a model of good practice for other higher educational institutions. Consideration should be given to ultimately integrating this clinical placement into the core undergraduate medical curriculum.

Ben Murphy, Craig Joyce, Barry Hannagen, Michael Smith, Gerard Flaherty

School of Medicine, National University of Ireland, Galway, Ireland

Correspondence to Dr. Gerard Flaherty, School of Medicine, National University of Ireland, Galway, Ireland; gerard.flaherty@nuigalway.ie

REFERENCES

1 Seligman WH, Ganatra S, England D, et al. Initial experience in setting up a medical student first responder scheme in South Central England. Emerg Med J 2015;0:1-4. Doi:10.1136/emermed-2015-204638.

2 Kwiatkowski T, Rennie W, Fornari A, et al. Medical students as EMTs: skill building, confidence and professional formation. Med Educ Online 2014;19:24829. Doi: 10.3402/meo.v19.24829.

Conflict of Interest:

None declared

We read this article with interest, given the high prevalence of penetrating chest trauma in South Africa and the fact that we and others (1,2) have published on the challenges faced in high-volume systems with errant tube placement. While we also advocate the "safe-triangle" approach, we aim to place the tube rather in the 4th ICS to avoid the risk of trans-diaphragmatic injury. We are also adamant that the "finger-sweep" be performed to gently displace any organ (lung or herniated viscus) away from the chest tube during placement and to ensure placement within the thoracic cavity. Directing all tubes apico-posteriorly is also advocated strongly.

What has been clearly shown in previous studies is that senior clinicians have much lower complication rates and that technical "errors of execution", especially the continued use of trochars (3), are to blame for many complications. The range of complication rates are listed between 10 and 30% across most of the studies. Indeed, it may be time for a "check -list approach" for trauma chest tubes! (4)

Better training, under the watchful supervision of senior experienced clinicians, could probably reduce the complication and misplacement rates where often junior staff place these tubes initially1,2,3. In addition, a return to the counting of the intercostal spaces and the use of the 4th ICS rather than the 5th ICS may further reduce these misplacements.

Regards, Dr TC Hardcastle, MMed(Chir), PhD, FCS(SA), Trauma Surgeon Deputy Director: Trauma Services, and Trauma ICU, IALCH, and Head: Trauma Training Unit, UKZN, Durban ZA Dr MS Morris, MBBS, FCEM(UK), Emergency Medicine Specialist (ret) Honorary Senior Lecturer, Emergency Medicine, Groote Schuur, UCT, Cape Town, ZA

References 1) Maritz D, Wallis L, Hardcastle T. Complications of tube thoracostomy for chest trauma. S Afr Med J, 2009;99:114-117. 2) Kong V, Oosthuizen GV, Sartorius B, Keene C, Clarke DL. An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa. Ann R Coll Surg Engl, 2014;96:609-613 3) Kong V, Clarke DL. The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South Africa. Injury, 2014;45:1435-1439 4) Civil IDS. Tube thoracostomy in trauma: Is it time for a checklist for chest tubes? Injury, 2013; 44:1143-1144

Conflict of Interest:

None declared

Just to clarify, they can be cut off using the same tool for cutting off precious metal rings found in most high street jewellers. Probably the only stipulation is that the blade is in new/really good condition and lubrication is used e.g. Aquagel,(although a lubrication oil on the blade such as WD40 would be better for prolonging the blade life)

It can heat up quite rapidly as well so keeping it cool with irrigation is advisable. Ampoules or tap water dripped on whilst cutting can aid here.

For ease, it is advisable to cut the ring twice from both sides so that the ring falls off making it a 'one man job'. Failing that, if the ring is cut only once, a method will be needed to force the ring open enough to be removed from the finger which could involve more staff, tools and brute force.

As shown in the article, a method of forcing the ring open when it has only been cut once would be to feed a couple of straightened paperclips through each side of the cut and grip with pliers. It may be only necessary to spring the ring open a short distance to remove it.

A single unused blade will cut off one or two titanium rings with ease. New blades are available from specialist jewellery tool companies.

Conflict of Interest:

None declared