Evaluation of a Paediatric Early Warning System (PEWS) score on admission to a paediatric intensive care unit to predict mortality risk in a low resource setting, Guinea-Bissau

CONTEXT: The Paediatric Early Warning System (PEWS) is a clinical monitoring tool used routinely in emergency and observation rooms to detect rapid deterioration in paediatric patients, allowing timely action. MSF has been using an adapted version of PEWS in all paediatric projects since 2013 and started using it in the Simao Mendes National Hospital (HNSM) in 2017. The PEWS has not been previously considered as a predictive tool for mortality risk. In this study, we evaluate whether the PEWS could be validated as a paediatric mortality risk score in our Paediatric Intensive Care Unit (PICU) setting. 

METHODS: This is an observational study with prospective data collection among children admitted to the HNSM PICU, assessing an adapted version of PEWS on admission, 24 hours after admission, and notification of the outcome of the hospitalization. Data analysis, using State 15.0, was conducted in three stages: description of participants, univariate analysis, and multivariate analysis. 

RESULTS: The main analysis showed that the greater the PEWS score, the higher the risk of death. However, only a PEWS score >7 was significantly associated with an increased risk of death, OR =5.9; 95% CI: 2.3 - 12.9, p < 0.001. In addition, having an underlying pathology increased the risk of death, OR=4.2; 95% CI: 1.3 - 13.2, p=0.015. Age was not significantly associated with increased risk of death, which may be due to the small sample size of patients less than one year old. A PEWS score greater than five, 24 hours after admission, indicated a significantly higher risk of death, OR=6.2; 95% CI: 2.8 - 13.6, p < 0.001. 

CONCLUSION: Our evaluation of PEWS among children on admission to the PICU found that it could be a simple and useful predictive tool of mortality risk in low resource settings. It may allow better organization of the human resources, and improve the analysis of the mortality ratio, in a PICU. However, adequate follow-up and management of those classified as orange, yellow, or even green by the PEWS should be maintained as the PEWS would fail to identify a significant proportion of patients at risk of death.