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A preimplementation survey for a standardised approach to paediatric early warning systems
  1. Jayne Wheway1,
  2. Philippa Anna Stilwell2,
  3. Adam Cook3,
  4. Damian Roland4,5
  1. 1 Patient Safety Team, NHS England and NHS Improvement, London, UK
  2. 2 Children and Young People's Transformation Team, NHS England and NHS Improvement, London, UK
  3. 3 Patient Safety Measurement Unit, NHS England and NHS Improvement, London, UK
  4. 4 SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
  5. 5 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University of Leicester, Leicester, UK
  1. Correspondence to Dr Damian Roland, Health Sciences, University of Leicester, Leicester LE1 7RH, UK; dr98{at}

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The term paediatric early warning systems (PEWS) has emerged to describe an array of interventions needed to improve recognition of children who require review/escalation of care. In 2005, 21.5% of National Health Service (NHS) trusts in the UK that care for children used a PEWS1; by 2013, 85% of units were using a PEWS and 18% had an RRT (Rapid Response Teams) in place.2 The PEWS in use were extremely variable: 36 different parameters were used in various combinations in 2005, growing to 47 in 2013.

In 2018, NHS England and NHS Improvement (NHSE/I), the Royal College of Paediatrics and Child Health and the Royal College of Nursing brought together a national PEWS Programme Board with the aim of producing a national PEWS for England. This letter describes the outcome of a workstream to repeat the national PEWS survey to determine current practice and enable a consensus exercise on the components of a national PEWS.

A SurveyMonkey survey, based on questions used in the 2013 PEWS survey, was sent to all clinical leads/clinical directors of paediatric departments (with inpatient beds). Non-responders were further contacted and in December 2019, 33 organisations with children’s inpatient services which had not yet responded were contacted and completed a shorter telephone survey.

In total, 135 separate organisations (133 NHS and 2 private) that provide paediatric inpatient care were contacted and responded to (at minimum) a mandatory question on PEWS use. All 135 organisations (100%) reported using a PEW Score, described as patients being given values based on objective or subjective criteria.

94% (127/135) reported which criteria form part of their PEWS (table 1). Table 2 describes the range of formats currently used.

Table 1

Criteria used in PEWS in 2013 and 2018–2019 surveys

Table 2

Responses to various domains relevant to PEWS use

These data are being used to support the derivation of a standard inpatient PEW Score as part of the national programme, aimed at improving the response to the deteriorating child. Parental concern was only reported to be used in one trust in the last national PEWS survey but is now being used in approximately 50%. The increase may reflect increasing research and media attention on serious illness recognition and the importance of parental insight in that. Our survey highlights this progression in moving from a solitary score to a whole system over time. Critically there is further learning from understanding what happens in organisations without these wider elements and how outcomes for children may differ where they are in place and where they are not. The Paediatric early warning system—Utilisation and Mortality Avoidance (PUMA) study,3 which examined a range of interventions to improve the recognition of deterioration in four hospitals over several years will report on some of these findings later this year.

Almost half of the organisations are using an e-PEWS now, or soon, which suggests the importance of developing an electronic format alongside a paper-based system.

In conclusion, PEWS are being universally used with common elements across nearly all systems, but some areas of variance. These data will be used to support the derivation of a common PEWS chart as part of the national System-wide Paediatric Observation Tracking programme (SPOT).

Ethics statements

Ethics approval

The authors reviewed the National Institute for Health Research advice on defining research (available from: and determined that this project was not classified as research.


We thank all the survey contributors, Dr Taofikat Agbabiaka for support with the survey design and the Patient Safety Collaboratives for distributing the survey.



  • Twitter @damian_roland

  • Contributors The original idea was conceived by DR and JW. JW and PAS wrote initial drafts and completed data collection. AC provided data analysis support.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JW, AS and DR are members of the National PEWS steering committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.