Background

Objectives

Methods

Conclusion

Early warning scores are used to predict clinical deterioration, in order to optimize prevention strategies to reduce potentially occurring adverse events. They are widely used, because of national recommendations, governance and accreditation agencies requirements. Pediatric frameworks explicitly recognize the role of early warning scores in support of healthcare provider’s process of observing and recognizing the severity of deteriorating patients.

In pediatrics there are more than 33 Pediatric Track and Trigger Tools (PTTT) published which have undergone formal validation. Tool composition and characteristics are variable as well as their performance. Also PTTT impact on health outcomes, such as unplanned PICU admissions or cardiac arrests, or resource utilization is still uncertain, while there is some moderate evidence of impact on mortality when associated to a team of PICU experts available to respond.

Beyond looking at PTTT screening power and impact on clinical outcomes, attention is been lately given to how those systems are used and at the exploration of contextual, social or organizational factors that may contribute to their uptake. Human factors need to be carefully analyzed as ward cultures, hierarchies and the availability of competency based education have been found to negatively affect the implementation of complex multi-faced interventions such as Pediatric Early Warning Systems, designed to improve the recognition and response to deteriorating patients. Additional weighing of scores and response algorithms, particularly for patient populations with complex conditions and comorbidities and different clinical settings also deserves future investigation.

Background

Children with cognitive impairment generally express their pain through idiosyncratic, subjective behavior. The Comfort Behavior Scale (CBS) is validated for the assessment of distress, pain and sedation in mechanically ventilated children in PICU. However it has not been validated yet in children with cognitive impairment.

Objectives

To explore the criterion validity of CBS comparing it with the Individualized Numeric Rating Scale(INRS) and revised FLACC scale (R-FLACC) for pain.

Methods

Observational validation pilot study from March to September 2018 in 3 PICU’s in a tertiary care pediatric hospital. Pain and sedation was assessed in 16 patients before and after tracheal suctioning by two independent clinicians, using the CBS, INRS and R-FLACC. Interrater reliability using linearly weighted kappa was evaluated at the beginning of the study. To evaluate the correlation between scales the Spearman rho correlation coefficient was applied.

Results

Results: 38 tracheal suctioning events were assessed on 16 cognitively impaired patients. Interrater reliability between nurses was evaluated on 11 events: interrater reliability was maximum for the R-FlACC (Cohen’s kappa = 1), and moderate for the CBS (Cohen’s kappa = 0.42): The correlation between R-FLACC and CBS was was 0.75 before and 0.80 after the procedure.

Conclusion

This is the first study to validate a standardized pain and sedation scale on a population of mechanically ventilated patients with cognitive impairment. Results seem promising for the use of CBS on this patient population.

Background

Objectives

Methods

Conclusion

Early warning scores are used to predict clinical deterioration, in order to optimize prevention strategies to reduce potentially occurring adverse events. They are widely used, because of national recommendations, governance and accreditation agencies requirements. Pediatric frameworks explicitly recognize the role of early warning scores in support of healthcare provider’s process of observing and recognizing the severity of deteriorating patients.

In pediatrics there are more than 33 Pediatric Track and Trigger Tools (PTTT) published which have undergone formal validation. Tool composition and characteristics are variable as well as their performance. Also PTTT impact on health outcomes, such as unplanned PICU admissions or cardiac arrests, or resource utilization is still uncertain, while there is some moderate evidence of impact on mortality when associated to a team of PICU experts available to respond.

Beyond looking at PTTT screening power and impact on clinical outcomes, attention is been lately given to how those systems are used and at the exploration of contextual, social or organizational factors that may contribute to their uptake. Human factors need to be carefully analyzed as ward cultures, hierarchies and the availability of competency based education have been found to negatively affect the implementation of complex multi-faced interventions such as Pediatric Early Warning Systems, designed to improve the recognition and response to deteriorating patients. Additional weighing of scores and response algorithms, particularly for patient populations with complex conditions and comorbidities and different clinical settings also deserves future investigation.