Context Effective triage of paediatric patients is challenging due to normal physiologically parameters varying with age. Paediatric Early Warning Score (PEWS) is an adapted tool that can be used to identify sick patients by stratifying them into four age categories and assigning a numerical score. PEWS of 3+ warrants prompt senior review (ST3+) within 30 min whilst PEWS of 2 warrants prompt review (but not necessarily senior) within 30 min. PEWS of 0 or 1 are less unwell and therefore able to wait.
Problem Due to service reconfiguration a new Paediatric Assessment Unit (PAU) was opened in Autumn 2014 but concerns were raised that a PEWS based initial triage was not being implemented correctly.
Assessment of problem and analysis of its causes Dual approach using both quantitative and qualitative data was used to assess the issue. 43 of 55 patients’ notes were reviewed over one week in October 2014. All patients had triage observations documented but 18 (42%) did not have PEWS calculated. Of the 25 (58%) which had PEWS documented only 18 (72%) were correct. Overall only 41% of patients had the correct PEWS assigned at triage.
Regarding escalation only 62% of patients with higher PEWS followed the protocol for prompt medical review of appropriate seniority.
Discussions with members of staff working in PAU highlighted many contributing factors including time pressure and unfamiliarity with PEWS escalation policy.
Intervention An interactive departmental MDT teaching session held in early January 2015. Attendees were presented with a series of patients of different ages and asked to triage based on their initial observations. The correct PEWS were given and the appropriate escalation discussed. This acted as a platform for open discussion across the MDT around potential solutions.
One point identified was the high level of accurate PEWS documentation when using the inpatient observation charts. These are stratified for age and colour coded so that abnormal values are visually highlighted as recorded. As a direct result of this meeting inpatient PEWS charts were incorporated into the triage process.
Study design Retrospective study that reviewed patient notes after attending PAU.
Strategy for change Our strategy throughout the process has been focused on empowering PAU staff and engaging with them in order to maximise the effectiveness of the triage process.
Measurement of improvement All PAU patients over one week in April 2015 were included and their notes reviewed for triage observations, PEWS and time of medical review. These values were compared to the baseline data collected in October 2014 to measure improvement.
Effects of changes Repeat cycle of 51 patients showed 39 (76%) had PEWS documented of which 34 (87%) were correct.
This meant that now 66% of all patients were assigned the correct PEWS on triage compared to 41% originally.
83% of high PEWS patients were escalation appropriately up from 62% at baseline.
Lessons learnt Key learning points included the effectiveness of an interactive teaching scenario to break the ice in an MDT audience in order to maximise constructive discussion from all parties.
Another was that change does not necessary require new resources to be designed specifically but to reconsider the use of available tools. This not only minimises cost but also enables quick implementation, as staff are already familiar with the resource.
Message for others Paediatric triage is a challenging process due to multiple contributing factors. An MDT approach to education and brainstorming solutions can be pivotal in shifting culture and improving effectiveness of such a dynamic process.
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