Missed opportunities: incomplete and inaccurate recording of paediatric early warning scores.

BACKGROUND: Paediatric early warning scores (PEWS) are widely used as an adjunct to support staff in recognising deterioration in hospitalised children. Relatively little is known about how staff use these systems. OBJECTIVE: To examine the completeness and accuracy of PEWS recording in hospitalised children in a tertiary specialist children's hospital. DESIGN: This is a secondary analysis of retrospective, case-controlled study data. Case patients suffering from a critical deterioration event were matched with controls present on the same ward at the same time and matched for age. Data were extracted from the PEWS chart for the 48 hours before the critical deterioration event for case patients and the corresponding 48 hours period for the control. Observation sets were assessed for completeness and accuracy of PEWS scoring. RESULTS: In total 297 case events in 224 patients were available for analysis. Overall 13 816 observations sets were performed, 8543 on cases and 5273 on controls. Only 4958 (35.9%) of observation sets contained a complete set of vital sign parameters and a concurrent PEWS. Errors were more prevalent in the observation sets of case patients versus controls (19.5% vs 14.1%). More errors resulted in the PEWS value being underscored rather than overscored for all observation sets (p<0.0001). 9.1% of inaccuracies for case patients were clinically significant, as the accurately calculated PEWS would have prompted a different escalation from the documented value. CONCLUSION: Failure to record complete and accurate PEWS may jeopardise recognition of children who are deteriorating. Technology may offer an effective solution.

Parents' prioritised outcomes for trials investigating treatments for paediatric severe infection: a qualitative synthesis.

OBJECTIVE: To identify parents' prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection. DESIGN: Qualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection. PARTICIPANTS: n=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved. RESULTS: In addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that parents' prioritisation of outcomes was influenced by their experience of their child's illness, survival and the point at which they are asked about outcomes of importance in the course of their child's illness. CONCLUSIONS: Findings provide insight into parent prioritised outcomes to inform the design of future trials investigating treatments for paediatric suspected or proven severe infection as well as core outcome set development work.

Randomised crossover trial of rate feedback and force during chest compressions for paediatric cardiopulmonary resuscitation.

OBJECTIVE: To determine the effect of visual feedback on rate of chest compressions, secondarily relating the forces used. DESIGN: Randomised crossover trial. SETTING: Tertiary teaching hospital. SUBJECTS: Fifty trained hospital staff. INTERVENTIONS: A thin sensor-mat placed over the manikin's chest measured rate and force. Rescuers applied compressions to the same paediatric manikin for two sessions. During one session they received visual feedback comparing their real-time rate with published guidelines. OUTCOME MEASURES: Primary: compression rate. Secondary: compression and residual forces. RESULTS: Rate of chest compressions (compressions per minute (compressions per minute; cpm)) varied widely (mean (SD) 111 (13), range 89-168), with a fourfold difference in variation during session 1 between those receiving and not receiving feedback (108 (5) vs 120 (20)). The interaction of session by feedback order was highly significant, indicating that this difference in mean rate between sessions was 14 cpm less (95% CI -22 to -5, p=0.002) in those given feedback first compared with those given it second. Compression force (N) varied widely (mean (SD) 306 (94); range 142-769). Those receiving feedback second (as opposed to first) used significantly lower force (adjusted mean difference -80 (95% CI -128 to -32), p=0.002). Mean residual force (18 N, SD 12, range 0-49) was unaffected by the intervention. CONCLUSIONS: While visual feedback restricted excessive compression rates to within the prescribed range, applied force remained widely variable. The forces required may differ with growth, but such variation treating one manikin is alarming. Feedback technologies additionally measuring force (effort) could help to standardise and define effective treatments throughout childhood.