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‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems
  1. Susan M Chapman1,2,3,
  2. Jo Wray2,4,
  3. Kate Oulton2,4,
  4. Christina Pagel5,6,
  5. Samiran Ray6,7,
  6. Mark J Peters6,7
  1. 1Great Ormond Street Hospital, London, UK
  2. 2UCL Great Ormond Street Institute of Child Health, London, UK
  3. 3Department of Children's Nursing, London South Bank University, London, UK
  4. 4Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital, London, UK
  5. 5Clinical Operational Research Unit, University College London, London, UK
  6. 6Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
  7. 7Respiratory, Anaesthesia, and Critical Care Group, UCL Great Ormond Street Institute of Child Health, London, UK
  1. Correspondence to Dr Susan M Chapman, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; Sue.Chapman{at}


Objective To compare the predictive performance of 18 paediatric early warning systems (PEWS) in predicting critical deterioration.

Design Retrospective case-controlled study. PEWS values were calculated from existing clinical data, and the area under the receiver operator characteristic curve (AUROC) compared.

Setting UK tertiary referral children's hospital.

Patients Patients without a ‘do not attempt resuscitation’ order admitted between 1 January 2011 and 31 December 2012. All patients on paediatric wards who suffered a critical deterioration event were designated ‘cases’ and matched with a control closest in age who was present on the same ward at the same time.

Main outcome measures Respiratory and/or cardiac arrest, unplanned transfer to paediatric intensive care and/or unexpected death.

Results 12 ‘scoring’ and 6 ‘trigger’ systems were suitable for comparative analysis. 297 case events in 224 patients were available for analysis. 244 control patients were identified for the 311 events. Three PEWS demonstrated better overall predictive performance with an AUROC of 0.87 or greater. Comparing each system with the highest performing PEWS with Bonferroni's correction for multiple comparisons resulted in statistically significant differences for 13 systems. Trigger systems performed worse than scoring systems, occupying the six lowest places in the AUROC rankings.

Conclusions There is considerable variation in the performance of published PEWS, and as such the choice of PEWS has the potential to be clinically important. Trigger-based systems performed poorly overall, but it remains unclear what factors determine optimum performance. More complex systems did not necessarily demonstrate improved performance.

  • Resuscitation
  • Intensive Care
  • Monitoring

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  • Twitter Follow Samiran Ray @DrSamRay

  • Contributors SMC and MJP conceived the idea for the study. SMC, JW, KO and MJP contributed to the study design. SMC undertook the data collection. SMC, SR and MJP undertook the data analysis. SMC wrote the initial draft of the manuscript. All authors reviewed and revised the manuscript and approved the final draft.

  • Funding This study received no direct funding but was supported by the National Institute for Health Research, Biomedical Research Centre at Great Ormond Street Hospital for Children, NHS Foundation Trust and University College London.

  • Competing interests None declared.

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

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