NUR 4220 Module 6 Pediatric Deterioration Paper: Early Warning Scores and Escalation Example

A Score of 5 at Midnight: Using an Early Warning Score to Speak Up for a Child

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-4220: Nursing Care of Infants, Children, and Adolescents

Mentor Name

Month Day, Year

A Score of 5 at Midnight: Using an Early Warning Score to Speak Up for a Child

The Patient

Ethan is invented for this paper. He is 7 and had surgery two days ago for a perforated appendix. He was recovering well, eating a little and walking in the hall. At 8 p.m. his early warning score was 1. At midnight, his heart rate had risen from 110 to 138, his breathing from 22 to 32, his capillary refill had slowed to three seconds and he was quieter than usual. His temperature was 39.1. His mother said he just did not seem like himself.

Why Children Deteriorate Quietly

Children compensate for illness well, keeping their blood pressure normal until late in shock by raising their heart rate and narrowing blood vessels. A falling blood pressure is often a late, ominous sign. Earlier signs include rising heart and breathing rates, slower capillary refill, changes in behavior and parents' sense that something is wrong. Early warning scores were developed to help nurses notice these earlier signs and act on them.

The Brighton Score

Monaghan (2005) described the Brighton pediatric early warning score, developed on a children's ward in England. It scores three areas, behavior, cardiovascular status and respiratory status, each from 0 to 3, with extra points for frequent nebulizers or persistent vomiting after surgery. Higher totals trigger set actions, such as more frequent observations, review by a senior nurse or physician and, at the highest levels, an urgent response. The score is simple enough to calculate at every set of observations.

A Severity Score

Duncan et al. (2006) developed a pediatric early warning system score in a Canadian children's hospital, using vital signs and other items to predict which children on wards would need urgent medical attention, such as a call to the intensive care team. The score distinguished children who needed urgent care from those who did not with good accuracy, and it often rose hours before the event. It later formed the basis of the Bedside Pediatric Early Warning System.

Does a Warning System Save Lives

Parshuram et al. (2018) tested the Bedside PEWS in the EPOCH cluster randomized trial, involving 21 hospitals in seven countries and more than 144,000 hospital discharges. Hospitals implementing the system did not have significantly lower all-cause hospital mortality than control hospitals. The authors noted that mortality on pediatric wards is already low and that warning systems may have benefits that mortality does not capture. They emphasized that scores support, but do not replace, clinical judgment and a culture in which staff escalate concerns.

Ethan's Score

The student calculated Ethan's Brighton-style score: behavior, sleeping more than usual, 1 point; cardiovascular, heart rate 20 above normal for age and capillary refill three seconds, 2 points; respiratory, rate above normal for age with some extra effort, 2 points. The total was 5, which under the unit's policy required an immediate report to the charge nurse and a physician review within 30 minutes.

Speaking Up

The student told the assigned nurse at once and, with her, used a structured format to call the resident: situation, a 7-year-old two days after appendectomy with a warning score that had risen from 1 to 5; background, perforated appendix on antibiotics; assessment, fever, fast heart and breathing rates, slow capillary refill and a change in behavior, concern for sepsis; and recommendation, review now and consider fluids and blood tests. The resident came within ten minutes and examined Ethan with his mother at the bedside, asking her what she had noticed first.

The Response

The resident ordered a fluid bolus, blood cultures and a lactate and broadened Ethan's antibiotics. An ultrasound later showed an abscess, which was drained. After the bolus his heart rate fell to 118 and his capillary refill improved.

Listening to Parents

His mother's sense that he was not himself came before the score rose. Many hospitals now include family concern as part of their warning systems, and some allow families to call a rapid response team directly. The student told her that her observation had been important and explained what the team was doing.

Nursing Diagnoses

The student identified risk for shock related to infection and risk for ineffective tissue perfusion.

Night Shifts and Staffing

Deterioration at night is easier to miss because there are fewer staff, children are asleep and parents may hesitate to wake a nurse. The student noticed that Ethan's midnight score was taken on time only because the unit had set a fixed schedule for observations, even when children were sleeping. Keeping that schedule, and waking a child gently when needed, is part of safe care. Parents can be told in advance why a nurse will come in at midnight, which makes the check less disruptive and invites them to share any worries at the same time.

Evaluation

By morning Ethan's score was 2, he was more alert and his fever was lower. He went home five days later after a course of antibiotics.

Limits

Scores vary between hospitals, and thresholds must be adapted to local practice. The EPOCH trial measured mortality, not every possible benefit. A student calculates and reports scores but does not order treatment. Ethan is invented.

Conclusion

Ethan's deterioration showed in rising heart and breathing rates, slower capillary refill and a change in behavior, and in his mother's worry, before any fall in blood pressure. Monaghan's score and Duncan and colleagues' work gave the student a structured way to notice, and Parshuram and colleagues' trial showed that a score works best as part of judgment and a culture of speaking up. Calculating the score, reporting clearly and listening to his mother helped the team act in time.

References

Duncan, H., Hutchison, J., & Parshuram, C. S. (2006). The pediatric early warning system score: A severity of illness score to predict urgent medical need in hospitalized children. Journal of Critical Care, 21(3), 271-278. https://doi.org/10.1016/j.jcrc.2006.06.007

Monaghan, A. (2005). Detecting and managing deterioration in children. Paediatric Nursing, 17(1), 32-35. https://doi.org/10.7748/paed2005.02.17.1.32.c964

Parshuram, C. S., Dryden-Palmer, K., Farrell, C., Gottesman, R., Gray, M., Hutchison, J. S., Helfaer, M., Hunt, E. A., Joffe, A. R., Lacroix, J., Moga, M. A., Nadkarni, V., Ninis, N., Parkin, P. C., Wensley, D., Willan, A. R., Tomlinson, G. A., & Canadian Critical Care Trials Group and the EPOCH Investigators. (2018). Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients: The EPOCH randomized clinical trial. JAMA, 319(10), 1002-1012. https://doi.org/10.1001/jama.2018.0948