Leading change

The Chief Nurse and Nursing Team at Great Ormond Street Hospital for Children NHS Foundation Trust led on the introduction and embedding of the Paediatric Early Warning System (PEWS) across the Trust. The PEWS system has led to improved outcomes and experience through early identification of triggers to deterioration in children and young people at the Trust.

Where to look

Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) is an acute specialist paediatric hospital providing care to children and young people with rare, complex and difficult-to-treat conditions. The early identification of patients at risk of clinical deterioration and matching the severity of illness to the appropriate level of care are key elements of high-quality medical care (Gold et al 2014).

Central to GOSH’s paediatric assessment functions when caring for unwell children and young people was the Trust’s Children’s Early Warning System (CEWS) which assisted staff to identify deterioration within a child or young person within their care. The CEWS system monitored key vital signs such as a patient’s heart rate, systolic blood pressure, capillary refill time and respiratory rate.

However, the nurse leaders, with other clinicians in the multidisciplinary team (MDT) at GOSH identified unwarranted variation in the signs of deterioration that were being captured and measured. They observed that it would be optimal to enhance the system to also include clinical items such as oxygen delivery, breathing work and hypertension. The nursing leads, in collaboration with the MDT identified an opportunity to use the early warning score evidence base to improve practice at the Trust, to improve deterioration rates and outcomes for children and young people in their care.

What to change

The clinical leads at the Trust worked in partnership to develop the Paediatric Early Warning Score (PEWS) system, to provide a replicable assessment of a child’s clinical status while hospitalised. The Chief Nurse and nursing team, as a part of the MDT conducted a review of the evidence to compare the predictive performance of 18 paediatric ‘track and trigger’ early warning score systems that were routinely used across the health and care sectors. Analysis of over 1.7 million clinical observations were collated and the data demonstrated clinical sensitivity in the PEWS, suggesting it could be utilised as a tool to identify deterioration in children and young people.

Chapman et al (2017) highlight that the PEWS system is a comprehensive step towards reducing the unwarranted variation in the recognition and response to a seriously unwell child and with this evidence, the MDT recommended it was implemented at GOSH.

How to change

Between March and May 2018, the move to the PEWS system began, following a period of piloting. This period gave nursing staff an opportunity to use the new PEWS system and provide feedback to the project group leading the change. These suggestions were then incorporated into the model and the improved version was rolled-out across the Trust.

An e-learning module and a bespoke PEWS training session were developed to support understanding and use of the new system and a Train-the-Trainer approach adopted to help cascade this efficiently.

Adding value

Better outcomes – The use of the PEWS to produce an Early Warning Score is now above 98% since March 2018. This increase in PEWS scores improves the likelihood of identifying children and young people at risk of deterioration. It also enhances the availability of clinical information to support decision-making processes.

Better experience – Feedback regarding the PEWS has been positive. Nursing staff have reported that they trust the scoring system as a tool to support their clinical judgement. GOSH are currently working with a Young People Forum to ensure patients and parents understand what PEWS is and how it fits in clinically with their care.

Better use of resources – Although no formal assessment has been conducted to identify how the introduction of the PEWS has impacted use of resources, the nurse leaders observe that by harnessing a digitally-intelligent tool to support clinical decision making, this has complemented and freed up nursing time which can be used to provide care. The digital nature of the system has also supported senior oversight across the Trust so that areas of good practice can be celebrated and shared.

Challenges and lessons learnt for implementation

The success of implementing a tool such as the PEWS is largely dependent on the engagement, involvement and leadership of nursing staff at all levels.

It essential to have strong nursing representation and leadership within your project groups, e.g. Chief Nurse as Executive Sponsor.

When implementing an electronic system such as the PEWS, it is important to develop an electronic test environment to simulate the changes you want to make prior implementing them into practice. This reduces the potential for harm, but also allows you to understand how staff may interact with the system before it goes live.

Find out more

For more information contact:

• Maria Banaghan, Quality and Safety Team, Great Ormond Street Hospital for Children NHS Foundation Trust, Maria.Banaghan@gosh.nhs.uk
• Sarah Newcombe, CNIO, Great Ormond Street Hospital for Children NHS Foundation Trust, Sarah.Newcombe@gosh.nhs.uk