Continuing Nursing Education

Objectives and instructions for completing the evaluation and statements of disclosure can be found on page 174.

An Integrative Review of Pediatric Early

Warning System Scores
John S. Murray, Lee Ann Williams, Shelly Pignataro, and Diana Volpe

Case Study
Increasingly, early warning system scores are being introduced into pediatric

K.
S. was an expert night clinical practice to support the early recognition of and intervention for clinical
charge nurse at the top of deterioration in hospitalized children at risk. This integrative review explored
the clinical ladder. She what is known about early warning system scores with pediatric patients. Twenty-
received clinical hand off at eight publications, including research, clinical practice articles, and conference
12:00 midnight in a pediatric emer- abstracts, were identified. Five major concepts emerged from analysis of
gency department (ED). R.M. was a retrieved documents: overview of pediatric early warning system scores, supple-
four-year-old boy with a three-day mentary benefits, facilitators to successful implementation, barriers to successful
history of rash and fever. Upon exam- implementation, and needed research. Greater psychometric testing of tools is
ination, K.S. was alarmed by the needed before any recommendations can be made regarding extensive imple-
severity of R.M.’s rash. His skin was mentation with the pediatric population.
sloughing, with areas of serous
drainage and edema. A review of his
due to his skin breakdown and was and coronary aneurysms were discov-
vital signs revealed he was febrile,
given triple antibiotics. A disposition ered. R.M. was immediately trans-
tachycardic, and hypotensive. K.S.
for inpatient hospital admission was ferred to the ICU where more frequent
immediately consulted the attending
made at 2:00 a.m. assessments and attention from the
physician and established a plan of
K.S. noted that the ED attending health care team could be provided.
care. R.M. was placed on a monitor,
arranged for bed placement on a
intravenous access was obtained, and
short-stay unit. This concerned her Early Warning System
antipyretics and a normal saline bolus
greatly because she believed R.M.’s
were administered. Vital signs were
vital signs, lack of improvement, and
Scores
closely monitored yet showed no
improvement. Another fluid bolus need for focused nursing interven- When the Institute of Medicine
was repeated. R.M. remained persist- tions required a higher level of care. (IOM) (1999) report, To Err is Human:
ently tachycardic, febrile, and Recognizing this, K.S. advocated for Building a Safer Health System, was re-
hypotensive. Laboratory results indi- the patient to be admitted to the in- leased, many were surprised by the
cated dehydration and infection. R.M. tensive care unit (ICU). Although the findings. The report revealed that the
was at high risk for a suprainfection attending valued K.S.’s expert opin- U.S. health care system was not as safe
ion, he held firm and disagreed. as consumers thought or hoped
Collaboration became strained. R.M.’s (Demmel, Williams, & Flesch, 2010).
John S. Murray, PhD, RN, CPNP-PC, CS, vital signs continued to deteriorate, To reduce the occurrence of subopti-
FAAN, is an Independent Consultant, Boston, and K.S. realized she had a short mal care in adults, systems to identify
MA; and a Graduate Student, Master of Sci- amount of time to impact this pa- patients at risk for clinical deteriora-
ence in Global Health Online Program, North- tient’s outcome. She was familiar with tion were developed. These early
western University, Feinberg School of Medi- the Pediatric Early Warning System warning systems heightened attention
cine and Professional Studies, Chicago, IL.
(PEWS) score that was implemented on declining clinical parameters and
Lee Ann Williams, PhD(c), RN-BC, is a on the inpatient units and saw this as encouraged emergent intervention by
Program Manager, Clinical Informatics, an objective tool that could help all health care professionals.
Clinical Education and Informatics, Boston disciplines speak the same language in The use of PEWS scores in clinical
Children’s Hospital, Boston, MA. determining care for R.M. practice is a new concept. Some of the
As suspected, the PEWS score earliest work conducted on pediatric
Shelly Pignataro, BSN, RN, is an Education
Coordinator, Surgical Programs, Boston
placed R.M. at increased risk for rapid early warning system scores was based
Children’s Hospital, Boston, MA. deterioration. Using the tool, K.S. was on available adult assessment tools
able to convince her physician col- (Akre et al., 2010; Monaghan, 2005;
Diana Volpe, BSN, RN, is a Patient Safety league that R.M. met the heightened Skaletzky, Raszynski, & Totapally,
and Quality Nurse, Emergency Department, physiological parameters for advanced 2012). Pediatric clinicians and re-
Boston Children’s Hospital, Boston, MA. care. This resulted in an ICU consult searchers learned from the experiences
Acknowledgment: The authors recognize where a newly developed heart mur- of adult health care professionals with
Stephanie Harrison, BSN, RN, CPEN, Child- mur was auscultated. Kawasaki’s dis- early warning tools. They have taken
ren’s Hospital Colorado, for sharing her clini- ease was now in the differential. A bed- into consideration and incorporated
cal exemplar for the case study. side echocardiogram was performed, into tools the necessary elements

PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4 165

An Integrative Review of Pediatric Early Warning System Scores

unique to the pediatric population rating is essential to patients’ lives. es), data evaluation (assessing the
(infants to adolescents) because Pediatric early warning system tools quality or hierarchy of evidence, by
anatomy and physiology of children are used by many pediatric hospitals, more than one individual, for stud-
differs widely from adults, and predis- nationally and internationally, to aid ies/publications found), data analysis
position for sudden deterioration is in evaluating key vital signs, but there and interpretation (interpreting infor-
greater (Demmel et al., 2010; Duncan, are only a small number of research mation such as findings, themes or
2007; Haines, Perrott, & Weir, 2006; studies on the development, reliabili- concepts from collected publications),
Monaghan, 2005). ty, and validity of the these instru- and report preparation (developing
Increasingly, the focus for identi- ments (Akre et al., 2010; Duncan et tables, graphs, or narratives of findings
fying children at risk for deterioration al., 2006; Edgell et al., 2008; Edwards, for publication and presentation).
in clinical status is the early recogni- Powell, Mason, & Oliver, 2009; Haines
tion of changes in physiologic condi- et al., 2006; Parshuram et al., 2009, Search Method
tion by utilizing objective clinical in- 2011; Tucker et al., 2009). The pur- Several key words were used to
dicators and risk assessment tools pose of this integrative review was to search for research and clinical prac-
(Akre et al., 2010; Duncan, Hutchison explore the literature about the use of tice publications and conference ab-
& Parshuram, 2006; Edgell, Finlay, & early warning system scores with stracts on pediatric early warning sys-
Pedley, 2008; Haines et al., 2006; pediatric patients. The clinical ques- tem scores. The following words were
Parshuram, Hutchison, & Middaugh, tions being addressed in this integra- searched individually and in combi-
2009; Skaletzky et al., 2012; Tucker, tive review of evidence are 1) Among nation with each other: pediatrics,
Brewer, Baker, Demeritt, & Vossmeyer, infants, children, and adolescents re- infants, children, pediatric early warning
2009). The challenge lies in the ability quiring hospital care, what is known system scores, early warning scores, early
of pediatric health care professionals about the use of pediatric early warn- detection, and PEWS. Inclusion criteria
to identify what early signs of clinical ing system scores related to care deliv- were a) nursing journals, interdiscipli-
deterioration might require prompt ered? and 2) Among infants, children, nary journals, and dissertations; b)
intervention and referral to a higher and adolescents requiring hospital focus on the pediatric population
level of care (Tucker et al., 2009). care, what research is needed to expli- (infants to 18 years old); and c) publi-
Establishing a practice that supports cate the phenomena of early warning cations written in English. Search
early identification of children at risk systems related to outcomes? engines used included Cumulative
using reliable and valid early warning Index of Nursing and Allied Health
system tools, and delivery of timely Methods Literature (CINAHL), PsychInfo, Nurs-
and helpful interventions, is critical ing and Allied Health, and MEDLINE.
to prevent progression to deteriora- The integrative review method is The search included all publications
tion in health status (Chapman, a systematic approach using a detail- from 1980 through August 2012.
Grocott, & Franck, 2010; Hogan, ed search procedure to locate relevant
2006; Skaletzky et al., 2012). evidence of varying levels and per- Search Results
The purpose of early warning sys- spectives to answer a specific clinical An initial search conducted by the
tem tools is to alert staff to decline in question. Evidence may be obtained first author on pediatrics, infants, chil-
clinical status of patients using prede- from quantitative and qualitative re- dren, pediatric early warning system
termined criteria so that needed inter- search methods and observational scores, early warning scores, early detec-
ventions and resources (e.g., staff, studies, as well as clinical practice tion, and PEWS yielded 30 publications
equipment, medications) are made publications and expert opinion (e.g., and conference abstracts. Two articles
available to care for children before letters to editors, conference abstracts). were subsequently omitted from
their health status deteriorates further The integrative review approach dif- review because they excluded pediatric
(Akre et al., 2010). Although pediatric fers from other appraisal methods (e.g., patients from data collection or did
early warning system tools have the meta-analyses, systematic reviews) that not discuss pediatric early warning sys-
potential to avert further deteriora- involve rigorous research evaluations tem scores. The remaining 28 publica-
tion in a child’s status, concerns about to compare and contrast findings tions and conference abstracts were
the tools exist. One of the greatest from various studies (Whittemore & obtained and evaluated. Additionally,
concerns is the number of published Knafl, 2005). The authors applied the the remaining authors, who had
tools available to pediatric health care integrative review approach to pres- reviewed PEWS literature in the past,
professionals. It is estimated that as ent a diverse number of sources to inspected their personal files of publi-
many as 10 exist, each with signifi- increase the understanding of pedi- cations on PEWS scores to determine if
cantly divergent numbers and cate- atric early warning system scores hop- additional information was available
gories of parameters to be assessed. ing to inform nursing practice. but not located during the first
Further, some published tools have Cooper’s (1982) guidelines for author’s literature search.
not undergone rigorous testing to ex- completing an integrative review were Critical appraisal of the evidence
amine reliability and validity, as well used: problem formulation (identify- when conducting an integrative re-
as clinical effectiveness and utility ing the topic to be examined, clarify- view is important to ensure validity
(Chapman et al., 2010). ing the question to be answered, and (Cooper, 1982; Fineout-Overholt,
determining inclusion and exclusion Melnyk, Stillwell, & Williamson, 2010).
criteria for the search method), data The literature reviewed was ranked
Purpose of the Integrative according to level of evidence using
collection (identifying all publications
Review on the identified problem/topic and the Melnyk and Fineout-Overholt
Early identification of pediatric pa- gathering information from the publi- (2005) hierarchy of evidence rating
tients whose conditions are deterio- cation search using keywords or phras- system (see Table 1). Each author

166 PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4

reviewed the literature and assigned a Table 1.
level of evidence. When inconsisten- Hierarchy of Evidence
cies occurred, the authors discussed
and came to consensus on a rating. Level I Evidence from a meta-analysis or systematic review of relevant ran-
Because of the evolving understand- domized controlled trials (RCTs).
ing of PEWS scores, the authors felt it
important to include in the review Level II Evidence gathered from a minimum of one well-designed RCT.
published conference abstracts, com- Level III Evidence from non-randomized controlled trials.
mentaries, and letters to editors.
Level IV Evidence from well-designed cohort and case-control studies.
Although these sources represent the
lowest level of evidence, this informa- Level V Evidence from reviews of qualitative studies.
tion has the potential to inform clini- Level VI Evidence from a single qualitative study.
cal practice and future research.
Level VII Evidence from expert opinion.

Findings Source: Melnyk & Fineout-Overholt, 2005.

Twenty-eight publications were
included in the review; 13 were data- a 12-month period. This tool was dif- op and test the Bedside PEWS score.
based, 10 were clinical practice litera- ferent in that the authors changed a Using focus groups with expert pediatric
ture, and 5 were conference abstracts. couple of criteria in some compo- nurses (N = 10), participants generated
Levels of evidence ranged from IV to nents (e.g., O2 liters/minute) as well as 16 tool items and a severity of illness
VII. A summary of search results is terminology (e.g., retractions vs. tra- score for use with hospitalized children.
presented in Table 2. cheal tug/recessions). This study not Initial statistical measures on perform-
Three PEWS tools that explored only explored sensitivity and speci- ance of the tool demonstrated sensitivi-
psychometric properties (Akre et al., ficity, but examined inter-rater relia- ty of 78% and specificity of 95% at a
2010; Skaletzky et al., 2012; Tucker et bility as well. Findings included that score of 5 (Duncan et al., 2006). At this
al., 2009) were adaptions of the Royal PEWS was effective in differentiating time, the tool was named the PEWS
Alexandra Hospital for Sick Children, children who required transfer to a score. Next investigators used a case-
Brighton – PEWS developed by higher level of care and those not control design (60 case and 120 case-
Monaghan (2005). This tool is based needing advanced treatment. The control patients) to create a more user-
on five domains: behavior, cardiovas- sensitivity and specificity for a score friendly severity of illness score that
cular status, respiratory condition, of 3.0 were 90% and 74%, respective- could discriminate between various
nebulizer use, and persistent postop- ly. Inter-rater reliability was high degrees of illness acuity in children. The
erative vomiting (see Figure 1). Akre et (intra-class correlation coefficient = resulting Bedside PEWS tool is a simple,
al. (2010) conducted a retrospective 0.92, p < 0.001). The authors recom- seven-item (heart rate, systolic blood
chart review (N = 186) and found mended that additional research be pressure, capillary refill, respiratory rate,
PEWS to be highly sensitive (85.5%) conducted to accurately depict the respiratory effort, transcutaneous oxy-
in identifying patients at risk for dete- comprehensive impact of the early gen saturation, and oxygen therapy)
rioration in clinical status. The warning system scores on clinical out- severity of illness score. The tool is also
authors highlighted the importance comes in children. inclusive of age groups (0 to 3 months, 3
of additional research to confirm their Another study explored adapting to 12 months, 1 to 4 years, 4 to 12 years
findings and describe the impact of Monaghan’s (2005) tool specifically and older than 12 years). Scores range
PEWS on clinical outcomes. for the pediatric cardiac population from 0 to 26, increasing with severity of
Skaletzky and colleagues (2012) but did not look at psychometric illness. The sensitivity and specificity
conducted a retrospective case-control properties. A pilot study was conduct- were 82% and 93%, respectively, at a
study including 100 cases and 250 ed that involved reviewing electronic score of 8 (Parshuram et al., 2009).
controls to begin to explore a Modified health records (N = 100) and conduct- Finally, a case-control study was per-
PEWS, which does not include adding ing interviews with nurses (N = 27). formed to validate the Bedside PEWS
points for nebulizer use or persistent The authors reported that the Cardiac score using a larger population of chil-
post-operative vomiting. Scores range Children’s Hospital Early Warning dren (N = 2,074) across multiple medical
from 0 to a maximum potential total Score (C-CHEWS) might assist pedi- centers (N = 4). The authors noted the
of 9. The researchers found that the atric critical care nurses with early importance of conducting prospective
Modified PEWS helps to recognize recognition and treatment of patients studies as well as exploring the impact of
children on medical-surgical wards at risk for deterioration. The need for the Bedside PEWS on clinical outcomes
who were at increased risk for clinical psychometric testing of the tool was (Parshuram et al., 2011).
deterioration. The sensitivity and acknowledged by the authors Edwards et al. (2009) also devel-
specificity for a score of 2.5 were 62% (McLellan & Connor, 2013). oped an original tool. The Cardiff and
and 89%, respectively. The researchers Six other tools were described as Vale Paediatric Early Warning System
were not able to completely validate original and developed based on param- (C&VPEWS) was developed using
the tool in view of its low sensitivity. eters the authors believed most appro- physiological parameters according to
Tucker et al. (2009) used a pros- priate for the pediatric patient popula- pediatric advanced life support rec-
pective descriptive design to evaluate tion in their clinical setting. For exam- ommendations (e.g., airway threat,
the use of the PEWS to detect worsen- ple, over a 5-year period, Duncan et al. such as stridor; oxygen therapy re-
ing of the clinical status of 2,979 chil- (2006), Parshuram et al. (2009), and quired to keep saturations greater
dren admitted to a medical unit over Parshuram et al. (2011) worked to devel- than 90%, respiratory rate; respiratory

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An Integrative Review of Pediatric Early Warning System Scores

Table 2.
Summary of Articles Included in the Integrative Review

Level of
Author/Year Tool Used/Design/Sample Evidence Conclusion
Summary of Data-Based Publications
Duncan, Hutchison, & Pediatric Early Warning Score (PEWS) developed IV Use of PEWS helped to identify
Parshuram (2006) by authors/focus groups/10 nurses greater than 75% of code blue
calls within one hour of warning.
Hogan (2006) No specific tool identified; explored early warning VI It is critical for nurses to focus
systems in general/focus groups/nurses, health on all physiological parameters
care assistants and nursing students from a variety for the early identification of
of specialties, sample size not provided patients at risk for deterioration.
Haines, Perrott, & Weir Paediatric Early Warning Tool developed by IV The use of a validated pediatric
(2006) authors/prospective observational/360 children early warning tool is critical for
admitted to all types of specialties including PICU; the early recognition and
infants to adolescents treatment of acutely ill children.
Edgell, Finlay, & Pedley Paediatric Advanced Warning Score developed by IV Use of a Pediatric Advanced
(2008) authors/retrospective pilot evaluation/46 children Warning Score can help identify
admitted from emergency department (ED) to PICU children in the ED who require
and 49 children admitted from ED to general admission to the PICU.
pediatric ward; infants to 16 years
Tucker et al. (2009) Adapted Brighton – Pediatric Early Warning VI The PEWS tool was found to
Score/prospective descriptive/2,979 children reliable and valid with
admitted to a 24-bed inpatient general medicine identifying hospitalized children
unit; newborns to 22 years at risk for decline in clinical
status.
Edwards, Powell, Mason, Cardiff and Vale Paediatric Early Warning IV Further research is needed to
& Oliver (2009) System/prospective cohort study/1,000 pediatric determine optimum criteria
patients admitted to inpatient units; infants to 16 needed for widespread
years implementation of an early
warning system.
Parshuram, Hutchison, & Bedside PEWS Score Developed by authors/case- IV Initial validation of the bedside
Middaugh (2009) control/ 60 case and 120 case control patients; pediatric early warning system
infants to adolescents score demonstrated the
instrument can identify critically
ill children.
Akre et al. (2010) Adapted Brighton – PEWS/retrospective chart VI PEWS has the potential of
review/186 medical-surgical unit patients excluding being able to assess in
ICU and ICU step-down units; infants to 21 years advance (more than 11 hours)
the need to adapt a patient’s
plan of care to avoid the need
for rapid response.
Oliver, Powell, Hutchison, Cardiff and Vale Paediatric Early Warning IV Successful use of early warning
& Middaugh (2010) System/observational study/1,000 patients admitted scores requires adherence to
to all inpatient units; infants to 16 years recording observations.
Edwards, Mason, Oliver, Melbourne Activation Criteria/cohort study/1,000 IV The Melbourne Activation
& Powell (2011) pediatric patients admitted to all pediatric wards Criteria demonstrated low
predictive value for activating
early response to emergencies.
Parshuram et al. (2011) Bedside PEWS Score developed by IV Bedside PEWS can potentially
authors/multicenter, case-control study/2,074 help clinicians identify children
patients from four hospitals admitted to inpatient who are deteriorating clinically.
units other than ICU; infants to 18 years

continued on next page

168 PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4

 Table 2. (continued)
Summary of Articles Included in the Integrative Review

Level of
Author/Year Tool Used/Design/Sample Evidence Conclusion
Summary of Data-Based Publications (continued)
Skaletzky, Raszynski, & Adapted Brighton – Pediatric Early Warning Score IV Use of a modified PEWS was
Totapally (2012) to Modified Pediatric Early Warning System Score/ helpful in identifying patients at
retrospective case-control/100 cases and 250 risk for deterioration who
controls admitted to medical-surgical wards; infants required further evaluation.
to 14 years
McLellan & Connor Adapted Brighton – Pediatric Early Warning Score VI C-CHEWS is helpful in
(2013) to Cardiac Children’s Hospital Early Warning Score identifying pediatric
(C-CHEWS)/pilot study/27 nurses cardiovascular patients at risk
for deterioration; validation
including sensitivity and
specificity are needed.
Summary of Clinical Practice Literature
Tume & Bullock (2004) Focus of Paper/Tool Discussed VII Early warning tools for children
Clinical discussion/no specific tool identified; must be derived from sound
explored early warning systems in general data.
Monaghan (2005) Summary of process of setting up a pediatric critical VII Implementation of a response
care response team/Brighton Paediatric Early team has resulted in children
Warning Tool showing sign of clinical
deterioration receiving optimal
care during the acute phase of
illness.
Fraser, Singh, & Frewen Commentary/Bedside PEWS Score VII PEWS scores offer a possible
(2006) method for identifying children
requiring a higher level of care.
Tibballs & Kinney (2006) Letter to editor/Paediatric Early Warning Tool VII Determining the sensitivity and
specificity of criteria to identify
children potentially requiring a
higher level of care is needed.
Author Unknown (2006) Commentary/no specific tool identified; explored VII Nurses report that early warning
early warning systems in general systems support clinical
decision making and
assessment.
Duncan (2007) Letter to editor/no specific tool identified VII There is no consistent
approach to use of early
warning systems for children.
Waller (2008) Abstract/no specific tool identified; explored early VII PEWS has the potential to
warning systems in general empower nurses to obtain
appropriate care for patients.
Adshead & Thomson Implementation of an early warning system in the VII Application of an early warning
(2009) Emergency Department/Brighton Paediatric Early system in the ED can assist
Warning Tool nurses with accurate
assessment of children’s needs
including interventions.
McCabe, Duncan, & Clinical article highlighting early identification VII A multidisciplinary, collaborative
Heward (2009) systems for children at risk for critical illness or approach to the development,
deterioration/no specific tool identified; explored implementation and evaluation
early warning systems in general of PEWS is needed.
Demmell, Williams, & Implementation of PEWS on Pediatric VII Implementing PEWS helped
Flesch (2010) Hematology/Oncology Unit/Pediatric Early Warning eliminate obstacles, which
Scoring System prevented early referral for
children who were clinically
deteriorating.
continued on next page

PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4 169

An Integrative Review of Pediatric Early Warning System Scores

Table 2. (continued)
Summary of Articles Included in the Integrative Review

Level of
Author/Year Tool Used/Design/Sample Evidence Conclusion
Summary of Clinical Practice Literature (continued)
The Joint Commission Case example of use of PEWS in clinical VII PEWS improves staff
(2011) practice/Pediatric Early Warning Score communication and patient
safety.
Ryan (2011) Abstract – No results/Pediatric Early Warning VII PEWS empowers nurses to
Scoring System share information with health
care team that is complete.
Breslin, Marx, McBeth, & Abstract – Relationship between PEWS and ED VII PEWS alone does not provide
Pavulurl (2012) disposition/no specific tool identified adequate discriminant ability to
predict ED disposition.
Keyes, Goreleck, Yen, & Abstract – Evaluation of PEWS for pediatric VII The PEWS score, measured at
Myer (2012) placement after inter-facility transfer/ two points in time, is associated
Bedside PEWS Score with patient placement upon
transfer.
Eggen, Solevag, Abstract – validation of PEWS in a Norwegian VII The modified PEWS is helpful
Schroder, & Nakstad clinical for children and adolescents/Pediatric Early in identifying patients at risk for
(2012) Warning Scoring System deterioration in the pediatric
clinic setting.

Figure 1.
Royal Alexandra Hospital for Sick Children, Brighton – Paediatric Early Warning

0 1 2 3 Score
Behavior/Neuro Playing/appropriate. Sleeping. Irritable. Lethargic/confused.
Reduced response to pain.
Cardiovascular Pink or capillary Pale or capillary Grey or capillary refill Grey and mottled or
refill 1 to 2 seconds. refill 3 seconds. 4 seconds. capillary refill 5 seconds or
Tachycardia of 20 above. Tachycardia of 30
above normal rate. above normal rate or
bradycardia.
Respiratory Within normal Greater than 10 Greater than 20 5 below normal
parameters, no above normal above normal parameters with sternal
recession or parameters, using parameters recession, tracheal tug or
tracheal tug. accessory muscles, recessing, tracheal grunting. 50% FiO2 or 8+
30+% FiO2 or 4+ tug. 40+% FiO2 or liters/minute.
liters/minute. 6+ liters/minute.
Total:
Score 2 extra for quarter-hourly nebulizers or persistent vomiting following surgery

Source: Monaghan, 2005.

observations, such as use of accessory While testing the C&VPEWS, plete set of observations required for
muscles; heart rate; blood pressure; Oliver, Powell, Edwards, and Mason the C&VPEWS to activate successfully
level of consciousness; and nurse or (2010) noted a lack of consistency by were only documented in 52.7% of
physician worried about child’s clini- nurses in recording vital signs, which patients. The authors emphasized that
cal state). Using a prospective cohort is essential for successful completion for C&VPEWS implementation to be
design, the researchers collected data and application of early warning sys- effective, improved adherence to doc-
on 1,000 children to explore the accu- tem tools. Following modifications to, umenting observations was critical.
racy of C&VPEWS in identifying chil- and educational sessions on the Earlier in 2006, Hogan noted similar
dren at risk for critical deterioration. C&VPEWS, an observational study findings. Conducting three focus
The C&VPEWS had a sensitivity of was conducted to determine if nursing groups with expert nurses, health care
89% and specificity of 64% for a score staff were recording a complete set of assistants, and nursing students (n not
of 1. The C&VPEWS was not fully val- vital signs as required. Data collected reported), the author found that the
idated due to the low specificity. on 1,000 children revealed that a com- lack of completing and recording vital

170 PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4

signs a barrier to successful use of In 2008, researchers (Edgell et al., explicit variability in naming of tools
early warning system scores. For exam- 2008) began to explore development (e.g., if a tool is modified from another,
ple, one finding noted that the respira- and validation of an early warning why are new names being assigned?),
tory rate of children was only complet- scoring system that could be used to physiological parameters and scores
ed 50% of the time. assess pediatric patients in the emer- used, the wide ranging methods of
Finally, reflecting on the low speci- gency department (ED) setting. Con- development, and the absence of rigor-
ficity in the Edwards et al. (2009) in- ducting a retrospective pilot evalua- ous psychometric testing with many of
vestigation, Edwards, Mason, Oliver, tion, Edgell and colleagues (2008) de- the tools available (Chapman et al.,
and Powell (2011) conducted a cohort veloped the Paediatric Advanced 2010). For example, the Adapted
study to determine if other criteria Warning Score (PAWS) based on age- Brighton – PEWS used by Tucker et al.
(Melbourne Activation Criteria [MAC]) dependent physiological parameters (2009) has 5 parameters whereas the
resulting in the activation of a med- (cardiovascular, respiratory, and neu- Paediatric Early Warning Score
ical emergency team would improve rological). To explore psychometric Developed by Duncan et al. (2006) has
identifying children at risk for deteri- properties of PAWS, the researchers 16. Although it is estimated that as
oration. Physiological parameters retrospectively calculated scores on 46 many as 36 parameters are used in var-
were similar to those used in the consecutive children admitted from ious PEWS tools, the one uniformity is
study by Edwards et al. (2009). How- the ED to the pediatric intensive care that three domains (e.g., cardiovascu-
ever, some parameters were defined unit (PICU) and 49 children admitted lar, respiratory, and behavior) are used
differently. For example, in the cur- from the ED to the general pediatric with all tools (Duncan, 2007; Edwards
rent study, the investigators exam- ward. Initial psychometric properties et al., 2011). Scores using the
ined oxygen saturation less than 90%; were adequate (sensitivity of 70% and Monaghan (2005) assessment tool are
abnormal respiratory observations specificity of 90% for a score of assigned in three domains: behavior
included apnea and cyanosis, and greater than 3). The authors recom- (e.g., playing/age appropriate behavior,
level of consciousness was defined as mended that future research use a sleeping, irritable, lethargic), respirato-
acute changes in neurological status prospective design. ry, and cardiovascular. Scores in each
to include seizure activity. Data were domain can range from 0 to 3 points.
collected on 1,000 pediatric patients. Additionally, two points are added for
Results of this exploration were not The Use of PEWS Scores respiratory nebulizer treatments that
favorable. The MAC had a sensitivity And Relationship to Care are continuous or provided every 15
of 68.3% (95% CI = 57.7 to 77.3), Delivered minutes and two points for persistent
specificity 83.2% (95% CI = 83.1 to vomiting following surgery (see Figure
83.2), positive predictive value (PPV) Five major concepts emerged 1). The total score can range from 0 to
3.6% (95% CI = 3.0 to 4.0), and nega- from analysis of retrieved documents 13, with the higher number reflecting
tive predictive value 99.7% (95% CI = regarding the phenomena of early a sicker child at higher risk for clinical
99.5 to 99.8). The low PPV would lead warning system scores in the pediatric deterioration and potentially requiring
to a significant number of triggers population: overview of pediatric an advanced level of care. A total score
activating the emergency medical early warning system scores, supple- equal to or greater than 4, or a score
team when, in fact, such intervention mentary benefits, facilitators to suc- of 3 in any of the three domains, is
was not required. cessful implementation, barriers to reflective of a critical value in need of
Haines et al. (2006) developed their successful implementation, and need- consultation to assess the child and
own tool (Bristol Paediatric Early ed research. All concepts relate to what provide intervention as needed
Warning Tool) because there were no is known about PEWS scores and (Monaghan, 2005). Some researchers
published PEWS scores available at what research is needed to further have adapted tools previously devel-
the time their study was conducted. advance this practice in the care of oped (Akre et al., 2010; McLellan &
Using a retrospective case control the hospitalized pediatric population. Connor, 2013; Skaletzky et al., 2012;
design (N = 360), the authors devel- Tucker et al., 2009), while others have
Overview of PEWS Scores
oped and evaluated a physiologically created their own (Duncan et al.; 2006;
based tool for the identification of It is important for pediatric nurses Edgell et al., 2008; Edwards et al., 2009;
acutely ill children at risk for further to be aware of all the early warning sys- Haines et al., 2006; Parshuram et al.,
clinical deterioration. The tool con- tem scores available for children and 2009, 2011). Most importantly, very
sists of 5 parameters, including acute what should be considered in selecting few studies have provided strong evi-
airway obstruction, breathing, circu- a tool for implementation in clinical dence to support the reliability and
lation, disability (neurological), and practice. A PEWS score has the poten- validity of pediatric early warning tools
other (hyper or hypokalemia, suspect- tial to offer a reasonable and testable (Akre et al., 2010; Duncan et al., 2006;
ed meningococcus). The researchers method for recognizing children at risk Edgell et al., 2008; Edwards et al., 2009;
reported the tool to have 99% sensi- for decline in clinical status (Fraser, 2011; Haines et al., 2006; Parshuram et
tivity and 66% specificity. However, Singh, & Frewen, 2006). The ideal tool al., 2009; Skaletzky et al., 2012; Tucker
other researchers (Edwards et al., would be one that uses routinely mon- et al., 2009).
2009; Tibballs & Kinney, 2006) report- itored clinical parameters, is easy to What is clearly understood with
ed that the methodology and analysis use, and is psychometrically sound all early warning system scores in the
used were inappropriate; therefore, (Chapman et al., 2010). However, it is pediatric population is that the uni-
the tool was not accurately evaluated, recognized that early warning system que needs of children of all age
and it is impossible to accurately scores are not without challenge in the groups, from infants to adolescents,
report either the sensitivity or speci- pediatric population. What is most need to be considered when develop-
ficity of the tool. confusing to pediatric nurses is the ing and implementing a tool (Haines

PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4 171

An Integrative Review of Pediatric Early Warning System Scores

et al., 2006). Clinical parameters for ing system score is critical if health PEWS scoring tool is ensuring staff
the pediatric population vary widely care professionals are to prevent need- take immediate action should the
across age groups; therefore, one set of less clinical deterioration and improve score indicate. To address this, re-
physiological parameters would not outcomes in the pediatric population searchers have demonstrated that hav-
be feasible. Additionally, the health (Hogan, 2006). It is critical that pedi- ing an interdisciplinary algorithm that
status of children with cardiac and res- atric nurses be engaged in the devel- defines specific steps to be taken
piratory disease can worsen rapidly, opment and implementation of tools according to a child’s early warning
further compounding this problem as part of a multidisciplinary team score facilitates collaborative clinical
(Haines et al., 2006). early on in the process (Tucker et al., decision-making among team mem-
The primary aim of all PEWS 2009). Adshead and Thomson (2009) bers (Demmel et al., 2010). The events
scores is to identify children early who found during implementation of delineated in the algorithm encour-
are at risk of rapid deterioration so PEWS in the ED setting that the reac- ages and supports nurses to consult
that immediate referral for prompt tions of nurses were mixed. Concerns with other members of the health care
treatment can begin to halt further raised were the perception that intro- team at the earliest possible time a
decline (Hogan, 2006; Skaletzky et al., ducing another assessment tool would change in patient status is observed
2012). Early intervention and treat- increase already busy workloads, while (Akre et al., 2010).
ment might include closer monitor- others looked forward to experiencing
ing, 1:1 nurse patient ratio, more fre- the same successes reported with adult Barriers to Successful
quent assessment by the attending patient populations. A lesson learned Implementation
physician, response team alert, and was the importance of having nurses As noted earlier, an unsystematic
potentially transfer to a higher level of participate early on in discussions as a manner of completing and document-
care, such as the PICU (Demmel et al., standard for selecting a pediatric early ing a full set of vital signs is as an
2010; Duncan et al., 2006; Skaletzky et warning system tool that best meets impediment to successful implemen-
al., 2012). Equally important is having local needs as well the requirements of tation of PEWS scores. Oliver et al.
a standardized assessment tool so that a specialized patient population (2010) found that while the successful
a more thorough and consistent (Adshead & Thomson, 2009). use of early warning scores requires
approach is used by all members of Key to implementing a pediatric adherence to recording observations
the health care team to identify the early warning system score in any set- (e.g., vital signs), the frequency and
needs of children at risk within hospi- ting is ensuring all staff receive timely documentation of assessments varied
tals. Such a tool would provide a com- multidisciplinary education to not widely. The authors recommended
mon language and approach to pro- only recognize patients who may be that in order for early warning systems
viding care among all members of the deteriorating clinically but to also to be effective, the lack of consistency
health care team. know how to appropriately use the in observing and recording vital signs
assessment tool chosen by the institu- must be addressed because current
Supplementary Benefits tion for implementation (Adshead & scores for children require that a thor-
In addition to identifying patients Thomson, 2009; Haines et al., 2006; ough set of observations be recorded
at risk for clinical deterioration, use of Monaghan, 2005). Demmel et al. (Oliver et al., 2010). However, it is
pediatric early warning system scores (2010) and Tucker et al. (2009) found important to recognize that in some
can have value-added advantages as that providing staff education at the clinical settings and under some cir-
well. In the adult patient population, early stages of implementation that cumstances, it may not always be pos-
use of early warning scores have been covered the history and development sible to observe, and therefore docu-
correlated with greater confidence, of the pediatric early warning scoring ment data points (e.g., parental con-
authority, and empowerment among tool, as well as the rationale for the use cern) required for scoring some tools
nursing staff and enhanced communi- of early warning systems, to be of (Demmel et al., 2010; McLellan &
cation among health care teams over- great value with obtaining buy-in dur- Connor, 2013). For example, in the ED
all (Andrews & Waterman, 2005; ing the application process. Particular setting, nurses may not be able to
Skaletzky et al., 2012; The Joint Com- emphasis should be on the procedure assess level of parental concern
mission, 2011). Tucker et al. (2009) for scoring the assessment tool as well because the child is being brought in
found similar results with pediatric as how to best integrate the instru- via helicopter transport or resides in
nurses in the inpatient setting. Using ment into other aspects of clinical an extended care facility and parents
PEWS, nurses found there was a de- practice already in place. This would are not readily available because they
crease in miscommunication among help address the concern related to are en route to the hospital.
members of the team regarding the increased workload. To fully engage
patient’s actual status and improved staff in pre-implementation educa- Needed Research
collaboration. Further, use of the tion, nursing experts recommend that While the use of early warning
PEWS algorithm removed barriers and staff practice using a PEWS tool apply- system scores in the adult patient pop-
empowered nurses to make independ- ing interactive case scenarios based on ulation has been effective, establishing
ent clinical decisions based on the pre- patients previously cared for by the benefit in pediatric health care has not
determined multidisciplinary plan respective clinical area (Demmel et al., been well studied, and there is limited
(Tucker et al., 2009). 2010). A multimodal approach (e.g., research on reliability and validity
in-services, web-based learning, visual of assessment tools (Adshead &
Facilitators to Successful aids, simulation) to multidisciplinary Thomson, 2009; Chapman et al.,
Implementation education encourages participation 2010; Tibballs & Kinney, 2006; Tucker
Introducing a culture that sup- from staff who work a variety of shifts. et al., 2009; Tume & Bullock, 2004).
ports the use of a pediatric early warn- Critical to the proper use of the Pediatric researchers and clinicians

172 PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4

have reported that few early warning Education in the clinical setting greater psychometric testing of tools
system scores have undergone meth- regarding early warning system scores is needed before any recommenda-
odologically rigorous development should emphasize that these tools aid tions can be made regarding extensive
and evaluation to date recommend- nurses with all levels of expertise. Ap- implementation with the pediatric
ing that further validation studies be plication of the pediatric early warn- population.
completed (Chapman et al., 2010; ing tool should be introduced in an
Edwards et al., 2009; Parshuram et al., inter-professional forum to engage all
2011; Tume & Bullock, 2004). Critical users (e.g., nurses, nursing assistants, References
to future research is adequately pow- physicians, respiratory therapists) of Akre, M., Finkelstein, M., Erickson, M., Liu,
M., Vanderbilt, L., & Billman, G. (2010).
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to determine whether early warning any assessment instrument, it is score to identify patient deterioration.
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alizability (Chapman et al., 2010; gency systems does not have to be a paediatric early warning system in
emergency departments. Emergency
Parshuram et al., 2011). Further, psy- delayed due to a low score. It is also Nurse, 17(1), 22-25.
chometric testing of assessment tools critically important that all pediatric Andrews, T., & Waterman, H. (2005). Pack-
should occur in all pediatric popula- health care professionals pay close aging: A grounded theory of how to
tions before widespread application attention to the lessons learned from report physiological deterioration effec-
takes place within individual health clinicians and researchers who have tively. Journal of Advanced Nursing, 52(5),
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a health care utilization and cost per- ence to date for adults is that by using children. Nursing Standard, 2(3), 10.
spective, clinical utility, resource uti- invalidated tools, very little benefit Breslin, K., Marx, J., McBeth, R., & Pavulurl,
lization, and cost-benefit analyses has been achieved. For hospitals just P. (2012). Relationship between pedi-
need to be described and compared beginning to consider implementing atric early warning score and emer-
gency department disposition. Proceed-
across the various tools available an early warning system score for ings from Pediatric Academic Societies
(Chapman et al., 2010). Despite these children, it is important to select a Annual Meeting, April 28-May 1, 2012,
important recommendations for tool that best meets the needs of the Boston, MA.
future research, experts believe that patient and is reliable and valid Chapman, S.M., Grocott, M.P.W., & Franck,
PEWS scores have the potential to (Chapman et al., 2010). There still L.S. (2010). Systematic review of paedi-
identify children at risk for clinical remains an open window of opportu- atric alert criteria for identifying hospi-
talised children at risk of critical deterio-
deterioration, and with proactive nity for pediatric health care profes- ration. Intensive Care Medicine, 36,
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health care and outcomes (Parshuram ate how we can approach this critical- Cooper, H.M. (1982). Scientific guidelines for
et al., 2011). ly needed aspect of care from a clini- conducting integrative research re-
cally appropriate and scientifically views. Review of Educational Re-
sound perspective (McCabe, Duncan, search, 52(2), 291–302. doi:10.3102/
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& Heward, 2009). Demmell, K., Williams, L., & Flesch, L. (2010).
Pediatric nurses should be involv- Implementation of the pediatric early-
ed in deciding which psychometrical- Limitations warning scoring system on a pediatric
ly sound (evidence-based) PEWS tool As characteristic with many inte- hematology/oncology unit. Journal of
they believe most meets the needs of grative reviews, references may have Pediatric Oncology Nursing, 27(4), 229-
their patient population within their been unnoticed due to exclusion of 240. doi:10.1177/1043454209358410
Duncan, H., Hutchison, J., & Parshuram, C.
respective health care institution. In other databases or search methods.
(2006). The pediatric early warning sys-
health care organizations where an PEWS scores are a new, evolving phe- tem score: A severity of illness score to
assessment tool has been adopted, nomena, and key terms may not predict urgent medical need in hospital-
continuous monitoring needs to be allow full capture of all available liter- ized children. Journal of Critical Care,
conducted to ensure the procedure is ature. Additionally, as a result of lan- 21, 271-279. doi:10.1016/j.jcrc.2006.06.
working properly to identify children guage restrictions, selection bias may 007
Duncan, H.P. (2007). Survey of early identifi-
requiring a higher level of care versus have occurred.
cation systems to identify inpatient chil-
children who may not need this level dren at risk for physiological deteriora-
of intervention (Chapman et al., Conclusion tion. Archives of Diseases in Childhood,
2010). Ongoing monitoring, evalua- 92, 828. doi:10.1136/adc.2006.112094
tion and education are critical to suc- Although still in its infancy, ini- Edgell, P., Finlay, L., & Pedley, D.K. (2008).
cessful implementation of early warn- tial data on the use of PEWS scores The PAWS score: Validation of an early
suggest that this assessment tool has warning scoring system for the initial
ing systems. Weekly assessment of
assessment of children in the emer-
scoring procedures to ensure inter- the potential to quantify severity of gency department. Emergency Medi-
rater reliability by having two nurses illness in children, In turn, it is hoped cine Journal, 25, 745-749. doi:10.
independently score patients and dis- this results in facilitating early identi- 1136/emj.2007.054965
cuss findings has also been found to fication of patients at risk for clinical Edwards, E., Mason, B., Oliver, A., & Powell,
support effective application of the deterioration and prompt interven- C. (2011). Cohort study to test the pre-
tion to avoid the need for transfer to dictability of the Melbourne criteria for
tool in practice (Chapman et al.,
activation of the medical emergency
2010; Demmel et al., 2010). a higher level of care. However, team. Archives of Diseases in Child-

PEDIATRIC NURSING/July-August 2015/Vol. 41/No. 4 173

 Instructions For
An Integrative Review of Pediatric Early Warning System Scores
Continuing Nursing Education
hood, 96, 174-179. doi:10.1136/174 Parshuram, C., Hutchison, J., & Middaugh, K. Contact Hours
adc.2010.187617 (2009). Development and initial valida- An Integrative Review of
Edwards, E., Powell, C., Mason, B., & Oliver, tion of the bedside paediatric early warn-
A. (2009). Prospective cohort study to ing system score. Critical Care, 13, Pediatric Early Warning
test the predictability of the Cardiff and R135. doi:10.1186/cc7998. System Scores
Vale paediatric early warning system. Ryan, N. (2011). The psychometric proper-
Archives of Diseases in Childhood, 94, ties of the pediatric early warning score
602-606. doi:10.1136/adc.2008.142026 system in the pediatric medical surgical
Deadline for Submission:
Eggen, E., Solevag, A., Schroder, J., & units. Retrieved from http://linkinghub. August 31, 2017
Nakstad, B. (2012). The pediatric early elsevier.com/retrieve/pii/S08825963110
warning score (PEWS): Validation in a 04593 PED 1504
Norwegian clinic for children and adoles- Skaletzky, S., Raszynski, A., & Totapally, B. To Obtain CNE Contact Hours
cents. Proceedings from the Pediatric (2012). Validation of a modified pedi-
Academic Societies Annual Meeting, atric early warning system score: A ret- 1. To obtain CNE contact hours, you must
April 28-May 1, 2012, Boston, MA. rospective case-control study. Clinical read the article and complete the evalua-
Fraser, D., Singh, R., & Frewen, T. (2006). The Pediatrics, 51(5) 431-435. doi:10. tion through the Pediatric Nursing web-
PEWS score: Potential calling criteria for 1177/0009922811430342 site at www.pediatricnursing.net/ce
critical care response teams in children’s The Joint Commission. (2011). Keeping 2. Evaluations must be completed online
hospitals. Journal of Critical Care, 21, watch: Cincinnati children’s hospital by the above deadline. Upon completion
278. doi:10.1016/j.jcrc.2006.06.007 develops PEWS monitoring system for of the evaluation, your CNE certificate
Haines, C., Perrott, M., & Weir, P. (2006). Pro- high-risk patients. Perspectives on for 1.4 contact hour(s) will be mailed to
moting care for acutely ill children: Patient Safety, 11(9), 1, 3-5.
Development and evaluation of a paedi- Tibballs, J., & Kinney, S. (2006). Evaluation
you.
atric early warning tool. Intensive and of a paediatric early warning tool – Fees – Subscriber: Free Regular: $20
Critical Care Nursing, 22, 73-81. Claims unsubstantiated. Intensive and
doi:10.1016/j.iccn.2005.09.003 Critical Care Nursing, 22, 315-316.
Hogan, J. (2006). Why don’t nurses monitor doi:10.1016/j.iccn.2006.10.003
the respiratory rates of patients? British Tucker, K., Brewer, T., Baker, R., Demeritt, Goal
Journal of Nursing, 15(9), 489-492. B., & Vossmeyer, M. (2009). Pros- The purpose of this learning activity is to
Institute of Medicine (IOM). (1999). To err is pective evaluation of a pediatric inpa- provide an overview of early warning system
human: Building a safer health system. tient early warning scoring system. scores in the pediatric patient population.
Retrieved from http://www.iom.edu/ Journal for Specialists in Pediatric
Reports/1999/to-err-is-human-building- Nursing, 14(2), 79-85. doi:10.1111/
a-safer-health-system.aspx j.1744-6155.2008.00178.x Objectives
Keyes, J., Goreleck, M., Yen, K., & Myer, M. Tume, L., & Bullock, I. (2004). Early warning 1. Identify the various types of early warning
(2012). Evaluation of the bedside pedi- tools to identify children at risk of deteri- system tools.
atric early warning system score for pedi- oration: A discussion. Paediatric Nurs- 2. Explain the importance of establishing an
atric placement after inter-facility trans- ing, 16(8), 20-23. early warning system for pediatric patients.
ports. Proceedings from the Pediatric Waller, D. (2008). Could pediatric early warn-
Academic Societies Annual Meeting, ing scores (PEWS) help nurses’ as-
Statement of Disclosure: The author(s) report-
April 28-May 1, 2012, Boston, MA. sessment acuity? An evaluation of as-
ed no actual or potential conflict of interest in
McCabe, A., Duncan, H., & Heward, Y. (2009). sessment practice for children who
relation to this continuing nursing education act-
Paediatric early warning systems: Where become critically ill. Dynamics: The
ivity.
do we go from here? Paediatric Nursing, Journal of the Canadian Association of
21(1), 14-17. Critical Care Nurses, 19(2), 32-33. The Pediatric Nursing Editorial Board members
McLellan, M.C., & Connor, J.A. (2013). The Whittemore, R., & Knafl, K. (2005). The inte- reported no actual or potential conflict of interest
Cardiac Children’s Hospital Early grative review: Updated methodology. in relation to this continuing nursing education
Warning Score (C-CHEWS). Journal of Journal of Advanced Nursing, 52(5), activity.
Pediatric Nursing, 28(2), 171-178. 546-553. doi:10.1111/j.1365-2648.2005.
doi:10.1016/j.pedn.2012.07.009 03621.x
Melnyk, B.M., & Fineout-Overholt, E. (2005).
Evidence-based practice in nursing and Additional Readings This independent study activity is provided
healthcare: A guide to best practice. Heitz, C., Gaillard, J., Blumstein, H., Case, D. by Anthony J. Jannetti, Inc. (AJJ).
Philadelphia: Lippincott, Williams & Messick, C., & Miller, C. (2010). Perfor- Anthony J. Jannetti, Inc. is accredited as a
Wilkins. mance of the maximum modified early provider of continuing nursing education by the
Melnyk, B.M., Fineout-Overholt, E., Stillwell, warning score to predict the need for American Nurses Credentialing Center's Com-
S.B., & Williamson, K.M. (2010). Evi- higher care utilization among admitted mission on Accreditation.
dence-based practice: Step by step: The emergency department patients. Jour- Anthony J. Jannetti, Inc. is a provider
seven steps of evidence-based practice. nal of Hospital Medicine, 5(1), E46-E52. approved by the California Board of Registered
American Journal of Nursing, 110(1), 51- doi:10.1002/jhm.552 Nursing, Provider Number, CEP 5387.
53. doi: 10.1097/01.NAJ.0000366056. Lerret, S. (2009). Discharge readiness: An
06605.d2. integrative review focusing on dis- Licenses in the state of California must
Monaghan, A. (2005). Detecting and manag- charge following pediatric hospitaliza- retain this certificate for four years after the CNE
ing deterioration in children. Paediatric tion. Journal for Specialists in Pediatric activity is completed.
Nursing, 17(1), 32-35. Nursing, 14(4), 245-255. doi:10.1111/j. This article was reviewed and formatted for
Oliver, A., Powell, C., Edwards, D., & Mason, 1744-6155.2009.00205.x contact hour credit by Rosemarie Marmion,
B. (2010). Observations and monitoring: Murray, J.S., & Mahoney, J.M. (2012). An MSN, RN-BC, NE-BC, Anthony J. Jannetti, Inc.,
Routine practices on the ward. integrative review of the literature about Education Director; and Judy A. Rollins, PhD,
Paediatric Nursing, 22(4), 28-32. the transition of pediatric patients with RN, Pediatric Nursing Editor.
Parshuram, C., Duncan, H., Joffe, A., Farrell, intestinal failure from hospital to home.
C., Lacroix, J., Middaugh, K., … Parkin, Journal for Specialists in Pediatric
P. (2011). Multicentre validation of the Nursing, 17(4), 264-274. doi:10.1111/
bedside paediatric early warning sys- j.1744-6155.2012.00325.x
tem score: A severity of illness score to
detect evolving critical illness in hospi-
talised children. Critical Care, 15, 1-10.

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