Abstract
BACKGROUND:
Late transfer of children with critical illness from community hospitals undermines the advantages of community-based care. It was hypothesized that implementation of the Bedside Paediatric Early Warning System (Bedside PEWS) would reduce late transfers.
METHODS:
A prospective before-and-after study was performed in a community hospital 22-bed inpatient paediatric ward. The primary outcome, significant clinical deterioration, was a composite measure of circulatory and respiratory support before transfer. Secondary outcomes were stat calls and resuscitation team calls, paediatrician workload and perceptions of frontline staff.
RESULTS:
Care was evaluated for 842 patient-days before and 2350 patient-days after implementation. The median inpatient census was 13. Implementation of the Bedside PEWS was associated with fewer stat calls to paediatricians (22.6 versus 5.1 per 1000 patient-days; P<0.0001), fewer significant clinical deterioration events (2.4 versus 0.43 per 1000 patient-days; P=0.013), reduced apprehension when calling the physician and no change in paediatrician workload.
DISCUSSION:
Implementation of the Bedside PEWS is feasible and safe, and may improve clinical outcomes.
Keywords: Early identification, Paediatrics, Transfer
Abstract
HISTORIQUE :
Le transfert tardif des enfants ayant une maladie grave à partir d’un hôpital général porte atteinte aux avantages des soins communautaires. Il est postulé que la mise en œuvre d’un système d’avertissement rapide au chevet des patients pédiatriques (le Bedside Paediatric Early Warning System, ou Bedside-PEWS) réduirait les transferts tardifs.
MÉTHODOLOGIE :
Les chercheurs ont mené une étude prospective avant-après dans un hôpital général comportant une aile pédiatrique de 22 lits pour les patients hospitalisés. L’issue primaire, soit la détérioration clinique importante, correspondait à une mesure composite de soutien circulatoire et respiratoire avant le transfert. Les issues secondaires étaient les appels d’urgence et les appels à l’équipe de réanimation, la charge de travail du pédiatre et les perceptions du personnel de première ligne.
RÉSULTATS :
Les chercheurs ont évalué les soins à l’égard de 842 jours-patient avant et de 2 350 jours-patient après la mise en œuvre. Le nombre de patients hospitalisés médian était de 13. La mise en œuvre du Bedside-PEWS s’associait à une diminution du nombre d’appels d’urgence aux pédiatres (22,6 par rapport à 5,1 pour 1 000 jours-patient; P<0,0001), à une diminution des événements significatifs de détérioration clinique (2,4 par rapport à 0,43 pour 1 000 jours-patient; P=0,013), à une diminution de l’appréhension au moment d’appeler le médecin et à l’absence de modification à la charge de travail du pédiatre.
EXPOSÉ :
La mise en œuvre du Bedside-PEWS est faisable et sécuritaire et améliorerait peut-être les issues cliniques.
Timely identification, treatment and referral of children who are clinically deteriorating while admitted to hospital wards are fundamental elements of inpatient care (1–3). In community hospitals, advantages including greater continuity of inpatient and outpatient care, improved geographical access for families and lower health care system costs may be undermined if children with evolving critical illness are not recognized and transferred in a timely manner (4,5).
The Bedside Paediatric Early Warning System (Bedside PEWS) is a documentation-based system of care designed to augment existing expertise and provide a safety net for children who are clinically deteriorating while admitted to hospital wards (6). The Bedside PEWS is comprised of four components: an expert-derived, validated severity of illness score; a documentation record into which the calculation of the severity of illness score is embedded; a series of score-matched care recommendations; and an educator-developed implementation program.
A demonstration project, funded by the Ontario Ministry of Health and Long-Term Care, evaluated the implementation of Bedside PEWS in the paediatric ward of a community hospital. The Bedside PEWS was implemented in addition to the existing electronic documentation system. We hypothesized that the implementation of the Bedside PEWS would be associated with lower rates of late transfer to the local paediatric referral centre, and improved or maintained staff satisfaction without a significant change in physician workload.
METHODS
A prospective before-and-after study was performed to evaluate the effect of implementation of the Bedside PEWS in a 22-bed community paediatric hospital. The primary outcome was significant clinical deterioration events. Secondary outcomes were stat and resuscitation team calls, paediatrician workload and sleep, and the perceptions of frontline nurses and respiratory therapists.
The primary outcome was the significant clinical deterioration event. This was defined as a patient transfer from the inpatient unit to a hospital with a paediatric intensive care unit, following any of invasive positive pressure ventilation, administration of greater than 60 mL/kg of resuscitation fluid in the 12 h before transfer, administration of inotropes or vasoactive medication, provision of cardiopulmonary resuscitation, or death before transfer in patients who do not have orders that limit resuscitation (Appendix A).
This composite outcome was chosen because it has high face validity as a marker of late transfer to appropriate facilities and, for the low-risk patients cared for in community hospitals, it represents one of the worst safety outcomes. Composite outcomes composed of relevant components, including death, are frequently used in clinical trials including the MERIT study (7) of the adult medical emergency team-rapid response team.
Secondary clinical outcomes were stat calls to the paediatrician, stat calls to the respiratory therapist, immediate calls to treat near or actual cardiopulmonary arrest (code-blue calls) for which the resuscitation team and resuscitation equipment were required, hospital length of stay and interhospital transfer to the regional paediatric referral centre.
Physician workload was assessed by a prospective survey completed by the paediatrician responsible for inpatient care during 24 h in-house duty periods. Workload was assessed by the number of pages, the time spent performing nonroutine patient reviews, the number of admissions and the number of pages made for patients admitted to the inpatient unit. Paediatricians also estimated the number of calls that could have been grouped or avoided, and reported the amount of sleep they obtained while on call.
Perceptions of the frontline nurses and respiratory therapist staff were evaluated by a survey administered three months before, and at two and five months after the implementation of the Bedside PEWS. The survey described interprofessional interaction, patient safety and documentation. Responses were recorded in a closed format using Likert and 100 mm visual analogue scales. All staff had an opportunity to complete surveys in each period. The survey is available from the authors by request.
Implementation
A clinical decision was made to implement the Bedside PEWS in the paediatric inpatient unit. Clinical implementation occurred in June 2008. The Bedside PEWS score was calculated with each set of vital signs documented by frontline staff (Appendix B). Staff education began one month before clinical implementation. The frontline nurses and respiratory therapists each received 4 h of didactic and interactive education about the basis and use of the Bedside PEWS. Education sessions were provided to groups of six to eight. Physicians received a 90 min interactive tutorial.
After implementation, the frequency of Bedside PEWS scoring and the reliability of score calculation were evaluated. Each week, two patients were randomly selected using a computer-generated list of bed locations. If a patient was not in the selected bed location, then the next bed location on the list was chosen. The Bedside PEWS documentation records of the selected inpatients were reviewed. The frequency of vital sign documentation was abstracted and the Bedside PEWS scores were recalculated from the documented clinical data. A maximum of eight scores were recalculated for each child.
Data and analysis
Transferred patients were identified by daily review of the administrative log of transfers that were updated by the nurses in charge of each shift in the paediatric inpatient ward, and through regular contact with the senior nurses and paediatricians responsible for organizing transfers. Data describing the intensity of resuscitation were abstracted directly from the medical record, complemented by review with the transferring physician. Data were documented using the categories of the Children’s Resuscitation Intensity Scale, and classified as either significant clinical deterioration events or urgent transfers. Other data describing stat calls and code-blue calls were in a log kept by the ward clerk and charge nurses, and were overseen by the Bedside PEWS research nurse.
Data were presented descriptively using the number of events, and the median and interquartile ranges (IQRs) for continuous data. Poisson regression was used to evaluate event rates for significant clinical deterioration events, interhospital transfer, stat calls and code-blue calls. Wilcoxon’s rank-sum test was used to evaluate continuous data describing paediatrician shifts, numbers of patients, number of pages received and the amount of sleep in 24 h. The Kruskal-Wallis test was used to compare survey responses from frontline staff in the three time periods.
The intraclass correlation coefficient was calculated for the paired measurements of the Bedside PEWS score calculated by the frontline nurse and the Bedside PEWS research nurse.
Data were collected by the Bedside PEWS research nurse on paper forms, and entered into the Oracle Database 11g (Oracle Corporation, USA). After checking, data were imported into SAS version 9.2 (SAS Institute Inc, USA) for analysis. The protocols were reviewed and approved by the research ethics board at Credit Valley Hospital (Mississauga, Ontario). The need for patient consent was waived and staff participation in the anonymous surveys was regarded as implied consent. Paediatricians provided written consent before participation.
RESULTS
Data were prospectively collected from April 14, 2008, to December 18, 2008. Over this time period, there were 1274 patient admissions, for whom care was provided by 62 frontline staff comprised of 56 registered nurses and six respiratory therapists. The respiratory therapists also cared for patients in other hospital areas. There were also 11 paediatricians who provided 24 h/day, seven days/week in-house service to the paediatric inpatient unit, the delivery suite and the emergency department. All worked before and after implementation.
Care was provided for 3192 patient-days – 842 patient-days before implementation and 2350 patient-days after implementation (Table 1). The median inpatient ward census at 07:15 was 13 (IQR 11 to 14) before and 13 (IQR 10 to 15) after implementation (P=0.87). The mean length of stay in the hospital was 2.6 days.
TABLE 1.
Clinical and process outcomes
|
Implementation |
P | ||
|---|---|---|---|
| Before | After | ||
| Patient-days, n | 842 | 2350 | |
| Median inpatient census, n (interquartile range) | 13 (11–14) | 13 (10–15) | 0.87 |
| Urgent calls to | |||
| Respiratory therapist | 8 (9.5) | 8 (3.4) | P<0.0001 |
| Paediatrician | 19 (22.6) | 12 (5.1) | P<0.0001 |
| Total patients transferred from inpatient ward to other centres* | 5 (5.9) | 19 (8.1) | P=0.041 |
| Significant clinical deterioration events | 2 (2.4) | 1 (0.43) | P=0.013 |
Data presented as n (n/1000 patient-days) unless otherwise indicated. Inpatient ward activity, urgent calls for assistance, transfers and significant clinical deterioration events before and after the implementation of the Bedside Paediatric Early Warning System in the paediatric ward of a community hospital are presented. Poisson regression was used to compare event rates, and Wilcoxon’s rank-sum test was used to compare the daily census before versus after implementation.
The total number of patient transfers includes patient transfers with significant clinical deterioration events
There were two significant clinical deterioration events before and one after implementation, with a reduction from 2.4 to 0.43 significant clinical deterioration events per 1000 patient-days (P=0.013). Implementation of the Bedside PEWS was associated with fewer stat calls to respiratory therapists per 1000 patient-days (9.5 versus 3.4; P<0.0001), fewer stat calls to paediatricians per 1000 patient-days (22.6 versus 5.1; P<0.0001) and an increase in the overall number of transfers per 1000 patient-days (5.9 versus 8.1; P=0.041) (Table 1).
Paediatrician workload and sleep
Of the 11 paediatricians, eight (73%) provided survey data describing 37 duty periods lasting 24 h, for a median of five (IQR two to 6.5) duty periods per respondent. For the 37 duty periods, paediatricians reported they admitted three (IQR two to four) patients, spent 15 min (10 min to 30 min) reviewing patients on the paediatric ward, received four (IQR three to five) pages to the paediatric ward and reported sleeping a median of 4 h (IQR 3 h to 5 h). Three (1.9%) pages from a total of 161 pages to the paediatric ward could have been grouped or avoided according to paediatricians. There were no significant differences before or after implementation of the Bedside PEWS.
Frontline staff surveys
A total of 114 completed surveys were received, for an overall response rate of 61% for the 62 frontline staff. Response rates did not vary among time periods (Table 2). Respondents’ ratings of documentation quality increased from a median of 3 (adequate) to a median of 4 (very good) for both postimplementation periods (P=0.007). Visual analogue scale ratings of documentation, interprofessional communication and apprehensiveness when calling the paediatrician to review a patient after hours improved after implementation. At month 5 of implementation, the ratings of communication quality (70 mm) were similar to preimplementation values (68 mm; P=0.32).
TABLE 2.
Survey responses by frontline staff
| Before: April |
After |
P* | ||
|---|---|---|---|---|
| August | December | |||
| Number of responses (response rate, %) | 40 (65) | 39 (63) | 35 (56) | 0.8318 (χ2 test) |
| Documentation quality | 3 (3–4) | 4 (3–4) | 4 (3–4) | 0.007 |
| How well did the charting system help you care for your patients? | 56 (47–68) | 73 (63–80) | 65 (49–76) | 0.001 |
| Communication | 68 (52–77) | 76 (67–85) | 70 (53–79) | 0.029 |
| Apprehensiveness | 66 (33–88) | 81 (65–96) | 82 (70–97) | 0.012 |
| Quality of care | 4 (4–4) | 4 (4–4) | 4 (4–5) | 0.110 |
The table represents the results of a survey administered to 62 frontline staff working in the paediatric inpatient ward of a community hospital. Data presented as question response (interquartile range) unless otherwise indicated. Question responses for the quality of documentation and quality of care were recorded using five-point Likert scales. Questions about apprehensiveness when calling the physician after hours, quality of interprofessional communication and the utility of documentation were recorded on 100 mm horizontal visual analogue scales.
The χ2 test was used to compare response rates and the Kruskal-Wallis test was used to compare the responses among the three periods
Reliability and frequency of Bedside PEWS scoring
Data from 150 randomly selected patient-days were used for the evaluation of scores and the reliability of scoring. For each of 68 days, a Bedside PEWS research nurse reviewed documentation from a median of two (IQR two to two) randomly selected patients. In all cases, the patient identification was correct (n=150; 100%) and in 146 (97%), the patient’s age group matched the age group of the Bedside PEWS documentation record.
The reliability of score calculation was evaluated using 793 vital sign documentation episodes. Frontline nursing staff calculated 786 (99%) Bedside PEWS scores a median of 5.5 (IQR four to six) times per patient-day. Bedside PEWS scores of 8 or higher occurred on nine (1.1%) occasions on four (2.7%) patient-days. The Shrout-Fleiss intraclass correlation coefficient for scoring was 0.90 (95% CI 0.87 to 0.93). There was one (0.13%) documentation episode for which the scores calculated by the frontline nurse and the Bedside PEWS research nurse differed by more than two points.
DISCUSSION
We performed a prospective observational study of the implementation of the Bedside PEWS at a community paediatric hospital. In the present nine-month single-centre study, implementation was associated with an 83% reduction in the rate of late transfers to referral centres (P=0.01), a 77% reduction in stat calls to the in-house paediatrician (P<0.0001), a 64% reduction in stat calls to respiratory therapists (P<0.0001) and a 37% increased overall interhospital transfer rate (P=0.041). Implementation was associated with persisting improvements in frontline staff ratings of documentation quality and utility, and reduced apprehension when calling the physician after hours. There was no change in paediatrician workload or sleep during duty periods, and after implementation, there was a nonsignificant increase in the number of pages that paediatricians believed could have been avoided.
Our data show that the Bedside PEWS intervention was applied as part of routine care. Scores were calculated on nearly all opportunities, the reliability of calculation compared favourably with other scores (8,9) and the opinions of frontline staff suggested that the Bedside PEWS documentation record was useful. Studies of the implementation of adult medical emergency teams with calling criteria have shown increased frequency of documentation (10,11). The success of implementation may be due, in part, to the simplicity of the Bedside PEWS score compared with our earlier 16-item score (3,6,12). Perhaps more importantly, the perceptions of improved documentation utility we found may be a mechanism explaining the observed effect of Bedside PEWS. The other potential mechanism of action we found was improved interprofessional communication (13,14).
The implementation of the Bedside PEWS required administrative commitment and additional local resources including re-allocation of 4 h to 6 h per week of paediatric nurse-educator time. The resource requirement and clinical improvement seems modest compared with other interventions to improve care processes including hospitalists, nurse practitioners, physician extenders and medical emergency teams (7,15–20).
If Bedside PEWS is implemented in community hospitals, the 2.2 additional transfers to the referral hospital per 1000 patient-days associated with implementation may have implications for transport systems and referral hospital volumes. Conversely, implementation in community hospitals may permit safer increases in capacity, and support the established practice of transfer from referral hospital emergency departments to community hospitals for inpatient care (21).
The present study has several limitations. First, a before-and-after design was used. While pragmatic, this approach is not ideal to evaluate system-level and other interventions, because temporal and seasonal effects cannot be excluded. Second, we used self-report of on-duty sleep, and subjective responses about documentation quality and utility, communication, apprehensiveness and patient safety. Third, the scope of our evaluation was limited. The number of events was small, patient-relevant outcomes such as quality of life or functional status were not evaluated and assessment was only for the duration of community hospital admission. Thus, the outcomes of hospitalization for the transferred patients – who were at risk for adverse outcomes after transfer (4,5,22) – were incompletely evaluated.
Although promising and internally consistent, the results of the present study should be interpreted with caution. The number of events is small and our results may not generalize to other hospitals, or translate into improved patient outcomes. The results of the study show that Bedside PEWS can be safely implemented; however, multicentre evaluation is required before conclusions about effectiveness can be made.
Acknowledgments
The authors thank all the staff of the paediatric inpatient unit at Credit Valley Hospital, and the paediatricians who shared their in-house experiences. In addition, they thank Simran Singh, Karen Dryden-Palmer, Kate Byrne, Matthew Van Heuse and Arial Le Huquet at the Center for Safety Research, The Hospital for Sick Children (Toronto, Ontario).
APPENDIX A. The Children’s Resuscitation Intensity Scale
| Scale category | Definition |
|---|---|
| 1. Early transfer | <60 mL/kg intravenous or intraosseous fluid resuscitation given in the 12 h before urgent transfer, no intravenous or intraosseous inotrope or vasoactive medications, and no positive pressure ventilation (bag-mask or endotracheal) in the 12 h before transfer |
| 2. Intermediate transfer: Noninvasive respiratory support | Respiratory = positive pressure ventilation in the 12 h before transfer, but not intubated at the time of urgent transfer. This category includes children receiving mask-delivered positive airway pressure at any stage in the 12 h before transfer and at the time of transfer |
| 3. Intermediate transfer: Invasive respiratory support | Respiratory = intubated and/or receiving endotracheal ventilation at the time of urgent transfer or, if intrafacility transfer, intubation within 1 h or PICU admission |
| Mechanical ventilation during anesthesia for a procedure is excluded | |
| 4. Intermediate transfer: Circulatory support | Circulatory ≥ 60 mL/kg intravenous or intraosseous fluid resuscitation given in the 12 h before urgent transfer, and administration of any intravenous or intraosseous inotrope or vasopressor administered at the time of transfer or at any stage in the 12 h preceding transfer. Patients in this category can include positive pressure ventilation (category 2) |
| 5. Late transfer | Respiratory (category 3) and circulatory (category 4) support before transfer |
| 6. Cardiopulmonary resuscitation | Chest compressions (cardiac massage) provided and/or mechanical circulatory support initiated before transfer |
| 7. Death | Death before transfer, without ‘do not resuscitate’ order written before chest compressions. No transfer |
The Children’s Resuscitation Intensity Scale was used to classify clinical deterioration events in inpatients who were admitted to the paediatric inpatient unit and had no orders to limit resuscitation. Urgent transfer is defined as transfer to a hospital with a paediatric intensive care unit (PICU) where departure from the referring hospital occurs within 6 h of the request for transfer. The transferred patient does not have to be admitted to the PICU. The Children’s Resuscitation Intensity Scale category is determined by the resuscitation interventions provided in the 12 h before departure from the referring hospital. Vasoactive and inotrope medications are medications given with the intent of producing vasoconstriction and or improving myocardial contractility to raise the patient’s blood pressure. They include dopamine, dobutamine, adrenaline (epinephrine) noradrenaline (norepinephrine), phenyladrenaline (phenylepinephrine), vasopressin, milrinone and amrinone. Intubation includes endotracheal intubation, surgical placement of airway and, in children with pre-existing tracheotomy, the provision of positive pressure ventilation. Mechanical circulatory support includes extracorporeal membrane oxygenation in arteriovenous, venovenous, and other extracorporeal circuits that include oxygenator systems such as the ‘Berlin Heart’ (Berlin Heart Inc, Germany) extracorporeal oxygenation system and other systems that provide mechanical circulatory support without oxygenation systems such as ventricular assist devices. Events in Children’s Resuscitation Intensity Scale category 3 and greater are classified as significant clinical deterioration events
APPENDIX B. The components of the Bedside Paediatric Early Warning System score
| Component | Age group |
Component subscore |
|||
|---|---|---|---|---|---|
| 0 | 1 | 2 | 4 | ||
| Heart rate, beats/min | <3 months | >110 and <150 | ≥150 or ≤110 | ≥180 or ≤90 | ≥190 or ≤80 |
| 3 to <12 months | >100 and <150 | ≥150 or ≤100 | ≥170 or ≤80 | ≥180 or ≤70 | |
| 1 to 4 years | >90 and <120 | ≥120 or ≤90 | ≥150 or ≤70 | ≥170 or ≤60 | |
| 5 to <12 years | >70 and <110 | ≥110 or ≤70 | ≥130 or ≤60 | ≥150 or ≤50 | |
| ≥12 years | >60 and <100 | ≥100 or ≤60 | ≥120 or ≤50 | ≥140 or ≤40 | |
| Systolic blood pressure, mmHg | <3 months | >60 and <80 | ≥ 80 or ≤60 | ≥100 or ≤50 | ≥130 or ≤45 |
| 3 to <12 months | >80 and <100 | ≥100 or ≤80 | ≥120 or ≤70 | ≥150 or ≤60 | |
| 1 to 4 years | >90 and <110 | ≥110 or ≤90 | ≥125 or ≤75 | ≥160 or ≤65 | |
| 5 to <12 years | >90 and <120 | ≥120 or ≤90 | ≥140 or ≤80 | ≥170 or ≤70 | |
| ≥12 years | >100 and <130 | ≥130 or ≤100 | ≥150 or ≤85 | ≥190 or ≤75 | |
| Capillary refill, s | <3 | ≥3 | |||
| Respiratory rate, breaths/min | <3 months | >29 and <61 | ≥61 or ≤29 | ≥81 or ≤19 | ≥91 or ≤15 |
| 3 to <12 months | >24 or <51 | ≥51 or ≤24 | ≥71 or ≤19 | ≥81 or ≤15 | |
| 1 to 4 years | >19 or <41 | ≥41 or ≤19 | ≥61 or ≤15 | ≥71 or ≤12 | |
| 5 to <12 years | >19 or <31 | ≥31 or ≤19 | ≥41 or ≤14 | ≥51 or ≤10 | |
| ≥12 years | >11 or <17 | ≥17 or ≤11 | ≥23 or ≤10 | ≥30 or ≤9 | |
| Respiratory effort | Normal | Mild increase | Moderate increase | Severe increase/any apnea | |
| Oxygen saturation, % | >94 | 91–94 | ≤90 | ||
| Oxygen therapy | Room air | Any: <4 L/min or <50% | ≥4 L/min or ≥50% | ||
The score is calculated by summing the subscores of each component
Footnotes
NOTE: Dr Parshuram is a Career Scientist of the Ministry of Health and Long-Term Care, and a recipient of an Early Researcher Award from the Ministry of Research and Innovation.
CONFLICTS OF INTEREST: K Middaugh and C Parshuram are the named inventors of the Bedside PEWS. A worldwide patent is owned by The Hospital for Sick Children.
REFERENCES
- 1.Parshuram CS. Risk-adjusted intensive care unit outcomes and admission from our backyard. Pediatr Crit Care Med. 2008;9:118–9. doi: 10.1097/01.PCC.0000298651.33662.2D. [DOI] [PubMed] [Google Scholar]
- 2.VandenBerg SD, Hutchison JS, Parshuram CS. A cross-sectional survey of levels of care and response mechanisms for evolving critical illness in hospitalized children. Pediatrics. 2007;119:e940–6. doi: 10.1542/peds.2006-0852. [DOI] [PubMed] [Google Scholar]
- 3.Duncan H, Hutchison J, Parshuram CS. The pediatric early warning system score: A severity of illness score to predict urgent medical need in hospitalized children. J Crit Care. 2006;21:271–8. doi: 10.1016/j.jcrc.2006.06.007. [DOI] [PubMed] [Google Scholar]
- 4.Pollack MM, Alexander SR, Clarke N, Ruttimann UE, Tesselaar HM, Bachulis AC. Improved outcomes from tertiary center pediatric intensive care: A statewide comparison of tertiary and nontertiary care facilities. Crit Care Med. 1991;19:150–9. doi: 10.1097/00003246-199102000-00007. [DOI] [PubMed] [Google Scholar]
- 5.Pearson G, Shann F, Barry P, et al. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet. 1997;349:1213–7. doi: 10.1016/S0140-6736(96)12396-5. [DOI] [PubMed] [Google Scholar]
- 6.Parshuram CS, Hutchison J, Middaugh K. Development and initial validation of the Bedside Paediatric Early Warning System score. Crit Care. 2009;13:R135. doi: 10.1186/cc7998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet. 2005;365:2091–7. doi: 10.1016/S0140-6736(05)66733-5. [DOI] [PubMed] [Google Scholar]
- 8.Birken CS, Parkin PC, MacArthur C. Asthma severity scores for preschoolers displayed weaknesses in reliability, validity, and responsiveness. J Clin Epidemiol. 2004;57:1177–81. doi: 10.1016/j.jclinepi.2004.02.016. [DOI] [PubMed] [Google Scholar]
- 9.Friedman JN, Goldman RD, Srivastava R, Parkin PC. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. J Pediatr. 2004;145:201–7. doi: 10.1016/j.jpeds.2004.05.035. [DOI] [PubMed] [Google Scholar]
- 10.McBride J, Knight D, Piper J, Smith GB. Long-term effect of introducing an early warning score on respiratory rate charting on general wards. Resuscitation. 2005;65:41–4. doi: 10.1016/j.resuscitation.2004.10.015. [DOI] [PubMed] [Google Scholar]
- 11.Chen J, Hillman K, Bellomo R, Flabouris A, Finfer S, Cretikos M. The impact of introducing medical emergency team system on the documentations of vital signs. Resuscitation. 2009;80:35–43. doi: 10.1016/j.resuscitation.2008.10.009. [DOI] [PubMed] [Google Scholar]
- 12.Fraser DD, Singh RN, Frewen T. The PEWS score: Potential calling criteria for critical care response teams in children’s hospitals. J Crit Care. 2006;21:278–9. doi: 10.1016/j.jcrc.2006.06.006. [DOI] [PubMed] [Google Scholar]
- 13.Cioffi J. Nurses’ experiences of making decisions to call emergency assistance to their patients. J Adv Nurs. 2000;32:108–14. doi: 10.1046/j.1365-2648.2000.01414.x. [DOI] [PubMed] [Google Scholar]
- 14.Dryden-Palmer K. Nursing responses to children with evolving critical illness. Victoria: University of Victoria; 2009. p. 203. [Google Scholar]
- 15.Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: A systematic review of the literature. Pediatrics. 2006;117:1736–44. doi: 10.1542/peds.2005-0609. [DOI] [PubMed] [Google Scholar]
- 16.Tieder JS, Migita DS, Cowan CA, Melzer SM. Newborn care by pediatric hospitalists in a community hospital: Effect on physician productivity and financial performance. Arch Pediatr Adolesc Med. 2008;162:74–8. doi: 10.1001/archpediatrics.2007.15. [DOI] [PubMed] [Google Scholar]
- 17.Reines HD, Robinson L, Duggan M, O’Brien BM, Aulenbach K. Integrating midlevel practitioners into a teaching service. Am J Surg. 2006;192:119–24. doi: 10.1016/j.amjsurg.2006.01.047. [DOI] [PubMed] [Google Scholar]
- 18.Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715–22. doi: 10.1056/NEJMsa012247. [DOI] [PubMed] [Google Scholar]
- 19.DeNicola L, Kleid D, Brink L, et al. Use of pediatric physician extenders in pediatric and neonatal intensive care units. Crit Care Med. 1994;22:1856–64. [PubMed] [Google Scholar]
- 20.Hunt EA, Zimmer KP, Rinke ML, et al. Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children’s center. Arch Pediatr Adolesc Med. 2008;162:117–22. doi: 10.1001/archpediatrics.2007.33. [DOI] [PubMed] [Google Scholar]
- 21.Freedman SB, Thakkar VA. Easing the strain on a pediatric tertiary care center: Use of a redistribution system. Arch Pediatr Adolesc Med. 2007;161:870–6. doi: 10.1001/archpedi.161.9.870. [DOI] [PubMed] [Google Scholar]
- 22.Odetola FO, Rosenberg AL, Davis M, Clark S, Dechert R, Shanley T. Do outcomes vary according to the source of admission to the pediatric intensive care unit. Pediatr Crit Care Med. 2008;9:20–5. doi: 10.1097/01.PCC.0000298642.11872.29. [DOI] [PubMed] [Google Scholar]