The Cardiac Children's Hospital Early Warning Score (C-CHEWS)1,2

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Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other hospitalized children. Pediatric early warning scoring tools have helped to provide early identification and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring. However, the tools have rarely been used and have not been validated in the pediatric cardiac population. This paper describes the modification of a pediatric early warning scoring system for cardiovascular patients, the implementation of the tool, and its companion Escalation of Care Algorithm on an inpatient pediatric cardiovascular unit.

Section snippets

Arrest Prevention

PEDIATRIC CARDIOPULMONARY ARRESTS have been reported in 0.7–2% of all pediatric inpatient admissions (Reis et al., 2002, Slonim et al., 1997, Suominen et al., 2000) and 5.5–14% of intensive care unit (ICU) admissions (Reis et al., 2002, Rhodes et al., 1999, Suominen et al., 2000) despite diligent monitoring (Akre et al., 2010, Nadkarni et al., 2006, Reis et al., 2002, Suominen et al., 2000) and advances in medicine and technology. Survival to discharge outcomes are poor (11–37%) for children

Sample and Setting

Pediatric cardiovascular patients have the highest incidence of cardiopulmonary arrests as compared to other hospitalized children (Berg et al., 2008, Hunt et al., 2008, Parra et al., 2000, Rhodes et al., 1999; Samson, Nadkarni, et al., 2006). They are unlike other pediatric populations whose arrest etiology is typically respiratory failure and/or circulatory shock (Berg et al., 2008, Lopez-Herce et al., 2004, Nadkarni et al., 2006, Reis et al., 2002, Samson et al., 2006a, Samson et al., 2006b,

Purpose

The purpose of this manuscript is to describe the implementation and subsequent modifications of the CHEWS tool and its companion Escalation of Care Algorithm for pediatric cardiovascular patients and early detection of deterioration and prevention of cardiopulmonary arrests or unplanned transfers to a cardiac ICU (CICU).

Tool Modification

A pilot study consisting of current electronic health record documentation and clinician interview was implemented on the cardiac unit. A single staff nurse, qualified in the use of the CHEWS tool, scored all the patients (n = 27; observations = 157) on the unit during two consecutive 12-hour shifts. Scores were based on documentation in patients' electronic health records. The pilot study nurse concurrently interviewed the charge nurse and the patients' nurses, nurse practitioners or fellows and

Discussion

Nurses often verbalize that they “feel or sense something is not right” with their patient however the subtle differences in the patient's presentation causing their unease may not be evident to the physicians as quantifiable changes are minimal and there is nothing obvious to treat (Andrews & Waterman, 2005). An early warning score can be an effective tool for nurses to use when communicating concern about subtle changes in the patient as the score provides a common language between nurses and

Limitations

This is a single center experience of an acute pediatric cardiovascular care unit and may not be generalized to all pediatric cardiovascular units. Formal validation of the C-CHEWS tool, including sensitivity and specificity are needed. At the time of this writing, formal validity testing is proceeding within the institution for the C-CHEWS tool in both the inpatient cardiac and non-cardiac units with favorable preliminary data. The institution is also tracking whether there is a sustainable

Conclusions

The C-CHEWS is a tool that was specifically created for identifying pediatric cardiovascular patients at risk for deterioration, the tool previously used at our hospital was not effective for this patient population. The C-CHEWS tool and companion Escalation of Care Algorithm provides a standardized assessment and approach to deteriorating patients, ensuring that there is the appropriate dispersal of resources allocated to the acuity of the patients. Early activation of resources to at-risk

Acknowledgments

We would like to thank Roger E. Breitbart MD, Jane C. Romano MS, RN, Monica Kleinman, MD and Suzanne Reidy MS, RN, NE-BC for participating in the expert multi-disciplinary panel.

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    1

    This paper did not receive any extramural or commercial support.

    2

    This paper was presented at the Cardiology 2010 conference in Orlando, FL, in February 2010 as an oral abstract.

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