Digital Repository Doctoral Projects Fall 2021 Implementation of Pediatric Early Warning Signs Guideline in a Rural Community Hospital Angala Bryson Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Bryson, A. (2021) Implementation of Pediatric Early Warning Signs Guidline in a Rural Community Hospital. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementation of Pediatric Early Warning Signs Guideline in a Rural Community Hospital by Angala Bryson A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: IMPLMENTATION OF PEDIATRIC EARLY WARNING SIGNS 1 Implementation of Pediatric Early Warning Signs Guideline in a Rural Community Hospital Angala Bryson Annie Taylor Dee School of Nursing Weber State University November 21, 2021 IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 2 Abstract Uintah Basin Medical Center (UBMC), a rural community hospital, has infrequent pediatric admissions to the medical-surgical (MS) and intensive care units (ICU). The Pediatric early warning signs (PEWS) tool monitors, detects and responds to signs of deterioration in hospitalized children. This DNP project implemented a PEWS guideline in the MS and ICU at UBMC to provide an objective measurement tool that assists the nursing staff in identifying early signs of pediatric patient deterioration. The PEWS guideline was introduced to 28 nurses and 13 certified nursing assistants (CNAs). PEWS scoring criteria and normal pediatric vital signs were explained and distributed on a badge card for reference. PEWS usage and outcomes, and nursing confidence in detecting early pediatric clinical deterioration, were evaluated for five months through chart reviews and nursing surveys. Thirty-six pediatric patients were admitted to the MS and ICU departments during the evaluation period. 63% of the admissions had PEWS documented. Two pediatric patients were transferred to a higher acuity of care hospital. Early detection of clinical deterioration improves patient outcomes, helps prevent invasive treatments, and reduces patient transfers. PEWS assists in the early recognition and response of infrequent clinical deterioration and improves nurse confidence and competency in caring for pediatric patients, which is imperative for reducing avoidable transfers and improving pediatric patient care outcomes in rural community hospitals. Keywords: pediatric early warning signs, clinical deterioration, early interventions IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 3 Implementation of Pediatric Early Warning Signs Guideline Pediatric patients admitted to the hospital may have observable signs of clinical deterioration hours before their condition reaches the seriousness of warranting invasive treatments, transfer to a higher acuity of care facility, cardiac arrest, or death (Lambert, Matthews, MacDonell, & Fitzsimons, 2017). One in five children who die in hospitals has avoidable factors leading to death (Lambert, Matthews, MacDonell, & Fitzsimons, 2017). Signs, both physiological and behavioral, of deterioration are often present before the severity of the pediatric patient's illness worsens. Hospital staff often do not recognize or act on these signs early (Lambert, Matthews, MacDonell, & Fitzsimons, 2017). This DNP project implemented a Pediatric Early Warning Signs (PEWS) guideline in the medical-surgical (MS) and intensive care units (ICU) at Uintah Basin Medical Center (UBMC) to provide an objective measurement tool to assists the health care staff in assessing pediatric patients and identifying early signs of pediatric patient deterioration. An evaluation revealed an increase in confidence among nursing staff when providing care to pediatric patients and an improvement in response time to identifying pediatric patient clinical status changes. Purpose Statement The purpose of this DNP project was to implement PEWS in the MS and ICU departments at UBMC. UBMC is a rural hospital with infrequent pediatric patient admissions to both MS and ICU departments. Training, guidelines, and assessment tools were not available to help alert nursing staff to changes indicating an early clinical deterioration in pediatric patients. Early detection of clinical deterioration in the pediatric patient improves patient outcomes, helps prevent invasive treatment, and reduces transports to higher acuity care facilities that are hours away (Tarango, Pham, Chung, & Festekjian, 2018). Implementing a PEWS guideline has shown IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 4 high sensitivity and specificity in identifying children at risk of clinical deterioration (Tarango, Pham, Chung, & Festekjian, 2018). The implementation and utilization of a PEWS guideline at UBMC has increased awareness of pediatric inpatient clinical deterioration. With continued use of the PEWS guideline, especially during UBMCs usual peak time of year for pediatric respiratory distress-related admissions, it is anticipated the number of pediatric transfers to a higher level of care facilities will decline. Additionally, written educational material covering signs and symptoms of worsening respiratory distress to pediatric patient families encourages early outpatient interventions for pediatric patients through the respiratory outpatient clinic (ROC), decreasing the need for hospitalization. Search Method The OneSearch feature of the Stewart Library and google scholar using the keywords pediatric early warning signs, rural pediatric admissions, rural healthcare, pediatric clinical deterioration, and pediatric hospitalization transfers were used to retrieve the information presented in this literature review. The search was limited to articles published since 2008 in English. The search was not limited to peer-reviewed articles. Review of the Literature Rural Children and Hospitalizations Nearly 1 in 5 children in the United States resides in rural areas (US Department of Health and Human Services, 2011). Providing competent quality healthcare to children living in rural areas can be challenging due to the lack of children's hospitals and pediatric-specific training (Freeman et al., 2010). In addition, clinical deterioration, an unexpected, undesired experience for children admitted to the hospital, may require the pediatric patient to be transferred to a higher acuity hospital (Stotts, Lyndon, Chan, Bekmezian, & Rehm, 2019). IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 5 Rural hospitals admit pediatric patients more often than urban hospitals (Freeman et al., 2010). Children living in rural areas often experience worse health outcomes. They have higher rates of obesity, tobacco exposure, and chronic medical conditions than children living in urban areas (US Department of Health and Human Services, 2011). Hospitalized rural children accrue more costs and are readmitted more often than non-rural children (Peltz et al., 2016). Pediatric patients admitted to a general hospital (GH), such as UBMC, have nurses and physicians that care for both adult and pediatric patients (Leyenaar et al., 2016). Infrequent pediatric admissions, in addition to the lack of continuing education and clinical tools such as early warning scoring systems specific to pediatric patients, are factors that impact nurses' ability to care for the pediatric patients and recognize and respond to pediatric patient deterioration (Allen, 2020). Rural children account for one of every eight admissions to children's hospitals in the United States (Peltz et al., 2016). Pneumonia, asthma, and bronchiolitis are the most common reasons for pediatric admissions (Leyenaar et al., 2016). Children and their families living in rural areas may need to travel to access these services. Children traveling prolonged distances were observed to have more readmissions than those who do not have to travel (Peltz et al., 2016). Potentially avoidable transfers are defined as patients who were transferred to another hospital and were either discharged from the receiving emergency department or were admitted to the hospital for less than 24 hours by Mohr et al. (2016). Patients living in rural areas were transferred three times more than those living in urban areas and potentially avoidable transfers accounted for 39% of all transfers. The financial cost incurred from ambulance fees, duplicate testing, travel, lodging costs, and psychological stress can make potentially avoidable transfers burdensome for families. It also affects the confidence that families have in the care being IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 6 provided by their rural hospitals. While transfer remains a lifesaving and timely intervention for many seriously ill children, opportunities exist for improvements in early detection and care of patients hospitalized at rural facilities to improve the rates of avoidable transfers (Mohr et al., 2016). Pediatric Clinical Deterioration There are many challenges associated with caring for a hospitalized pediatric patient. Adequate assessment and collection of data, nurse experience, knowledge of the patient's health status, and available resources contribute to monitoring for clinical deterioration. Pediatric clinical deterioration can relate to the presenting condition, a new problem that arises after admission, or complication from treatment or lack thereof. A deteriorating patient is "one who moves from one clinical state to a worse clinical state which increases their individual risk of morbidity, including organ dysfunction, protracted hospital stay, disability, or death" (Jones et al., 2013). Children's clinical conditions rarely change suddenly but once they do change, they can deteriorate faster than adults (Albutt et al., 2016). Clinical deterioration signs and symptoms can include changes in respiration, circulation, mentation, agitation, pain, and unexpected trajectory (Douw et al., 2015). Clinical deterioration rates for hospitalized children in an acute care setting can be attributed to delays in recognition or escalation of clinical deterioration (Stotts, Lyndon, Chan, Bekmezian, & Rehm, 2019). In many cases there may be close to 12 hours between the first sign of deterioration and the time interventions are made (Levin, Brady, Duncan, & Davis, 2015). Nursing surveillance is a continuous process of collecting data and detecting changes in the patients' condition, anticipating decline before confirming diagnostic signs, and assessing the patient's response to treatment. Nursing bedside monitoring is essential to early detection of clinical deterioration (Jensen et al., 2019). Barriers faced by non-critical care or pediatric nurses IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 7 in the early detection of clinical deterioration include lack of experience and knowledge regarding critically ill patients, inadequate monitoring of vital signs, and infrequent direct observation of the patient. Lack of confidence in providing pediatric patient care may compromise the delivery of safe care by preventing nurses from engaging with other healthcare team members. The lack of continuing education and clinical tools such as early warning scoring systems contribute to the nurses' inability to recognize and respond to patient deterioration (Allen, 2020). Consequences of Pediatric In-Patient Clinical Deterioration An ongoing threat to hospitalized patients is delayed recognition of clinical deterioration and its association with increased morbidity and mortality and unanticipated transfer to higher levels of care (Tarango, Pham, Chung, and Festekjian, 2019). The collection of clinical data, nurse experience, patient knowledge, and resources are all confounding factors that the nurse must subjectively use when assessing a pediatric patient for clinical deterioration (Lampin et al., 2019). A cross-sectional study conducted in 2015 by Miranda et al. (2015) looked at 271 hospitalized children aged zero to 10. It showed children under two years old diagnosed with a respiratory disease had an increased likelihood of clinical deterioration. Leyenaar et al., in 2016, showed pneumonia, asthma, and bronchiolitis were the most common reasons for hospitalization in children. Consequences of worsening symptoms associated with clinical deterioration of pediatric patients diagnosed with pneumonia, asthma, and bronchiolitis could include aspiration, acute respiratory distress syndrome (ARDS), the need for transitioning from oxygen via nasal cannula to high flow oxygen or continuous positive airway pressure (CPAP) (McCance & Huether, 2019). In children, the most common causes of cardiac arrest are preceding respiratory insufficiency or hypotension/shock. There is often a prolonged period of hypoxia or IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 8 poor perfusion before cardiac arrest (Winber, Nilsson, & Aneman, 2008). All of which could lead to poor outcomes and or transfers. In addition to the physical consequences if signs of deterioration in a child are not quickly identified, the implications can be devastating to the psychological well-being of that child and their family, especially if the child is transferred to the ICU or another facility. The critical care environment can be unpleasant, intense, and stressful. Parents are overwhelmed by noises, medical equipment, the medical staff's activity, and the medical language used. Including the parents in the patients' care and keeping the parents informed helps reduce the stress associated with having a child transferred to an ICU (Dahav & Sjostrom-Strand, 2017). The financial impacts on the family and facility also need to be taken into consideration. Uhrenfeldt et al. (2013) discovered that patient transfers are associated with feelings of fear, high levels of anxiety, and distress because of the unpredictability of a transfer. Uncertainty from having a sick loved one, being separated from close relatives, and being transferred to a metropolitan hospital also added to the stress associated with hospital transfers. Barriers In Identifying Clinical Deterioration Several individual and organizational factors impact surveillance efficacy and outcomes. These factors include the availability of medical equipment, use of technology, nurse staffing, nurse skill, medical team composition, and interactions between medical personnel. Nurse staffing, and skill. The medical team composition and the interactions between medical personnel (Azzopardi, Kinney, Moulden, & Tibballs, 2011). The nurse's ability to recognize and respond to patient deterioration is vital for initiating early interventions to prevent further clinical deterioration (Allen, 2020). The nurse's ability to identify changes in the patients' vital signs and awareness of subtle behavioral and physiological IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 9 changes is crucial (Massey et al., 2017). Lack of pediatric nursing experience, knowledge, and skills increase anxieties about potentially making the wrong decision or receiving criticism from coworkers. These feelings can delay responses to patient deterioration and contribute to poor communication among the health care team (Allen, 2020). Ongoing nursing education and skills training are imperative in enabling the nurse to recognize and respond to patient deterioration (Massey et al., 2017). High nurse-to-patient ratios, heavy workloads, distractions, and interruptions can impede the nurse's ability to detect and respond to pediatric patient deterioration (Allen, 2020). The age and cognitive ability of pediatric patients determine their ability to communicate how they feel to others, which adds to the nurse's clinical assessment complexity (Bell et al., 2013). Limited ancillary resources, particularly at night, limit opportunities for interprofessional care planning. Diverse and clinically competent team members are crucial in providing bedside assistance in determining the course of treatment or the need to escalate care (Stotts et al., 2020). Pediatric Early Warning System (PEWS) The National Clinical Guideline, developed by the Irish Paediatric Early Warning System (PEWS) Guideline Development Group (GDG) (2016), was designed to improve prevention and recognition of, and respond to, children at risk for clinical deterioration in inpatient settings through the implementation of a standardized pediatric early warning system. Favorable outcomes were identified for enhanced multidisciplinary teamwork, communication, and confidence in recognizing, reporting, and planning interventions during pediatric clinical deterioration. Early warning scoring systems, such as the PEWS, are a rapid, objective, and easy-to-use tools to help increase the confidence in the nurse's ability to recognize changes in pediatric IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 10 patients. Additionally, it promotes timely and efficient communication between nurses and physicians (Bell et al., 2013). Early warning systems should enhance a heightened sense of situational awareness, open communication among providers, and support, not replace clinical judgment (Lambert et al., 2017). Pediatric-specific early warning systems have been developed to consider the unique characteristics of pediatric patients and help initiate the necessary steps to intervene (Cassidy et al., 2019). The PEWS score was the first severity of illness score for children admitted to the hospital and was developed using nursing expert opinions. PEWS aides in identifying patients at risk for clinical deterioration (Duncan, Hutchinson, & Parshuram, 2006). The PEWS provides a reproducible assessment tool based on objective physiological parameters. The PEWS is quickly performed, is not age-specific, and has five domains: behavior, cardiovascular status, respiratory status, nebulizer use, and persistent post-surgical vomiting. The domains are scored numerically, added together, and the total score is interpreted as low, intermediate, or high risk for clinical deterioration. Appropriate clinical interventions can then be initiated (Gold, Mihalov, & Cohen, 2014). Implementation and Impact of PEWS PEWS can be used to increase the nurse's awareness of signs and symptoms of pediatric clinical deterioration, decrease pediatric patient transfers to a higher level of care, improve communication and collaboration among the healthcare team, and be incorporated into yearly nursing education. The successful implementation of PEWS in a Guatemalan hospital showed 93% of patients transferred to a higher level of care had abnormal PEWS before transfer. The rate of clinical deterioration events decreased after PEWS implementation, and pediatric intensive care unit (PICU) utilization for inpatient transfers decreased by 21%. This work demonstrates that IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 11 PEWS is a feasible and effective quality improvement measure to improve hospital care for pediatric patients (Agulnik et al., 2017). PEWS is associated with fewer STAT calls to pediatricians, fewer significant clinical deterioration events, reduced apprehension when calling the physician, and no change in pediatrician workload. The implementation of the PEWS is feasible and safe, improves clinical outcomes, and increases nursing confidence in providing pediatric care. It may also improve communication between nursing staff and physicians, increasing collaboration between the bedside nurses and respiratory therapists. Enhancing nursing staff and respiratory therapists' ability to detect clinical deterioration early and intervene will improve clinical outcomes (Parshuram et al., 2011). The nurse's clinical judgment and the PEWS should be seen as essential in providing nurses with information about the patients' condition (Jensen et al., 2018). Trusting a gut feeling about an abnormal assessment also aids in identifying clinical deteriorating pediatric patients (Stotts et al., 2020). In addition, training nursing staff and physicians regarding the PEWS implementation helps alleviate any concerns regarding the roles of each healthcare provider. Pocket guides, with a quick PEWS reference, facilitate staff in using PEWS. The electronic medical record (EMR) was viewed as helping follow the trends of the PEWS. This suggests a PEWS tool, a PEWS pocket guide and an EMR compnent complement the nurses' clinical judgement (Jensen et al., 2018). Summary of Literature Review Rural children accounted for 12% of all admissions to children's hospitals and may travel long distances to get there (Peltz et al., 2016). Jensen, Kirkegaard, Aagaard, and Olesen (2019) suggest children experiencing in-hospital clinical deterioration and subsequent transfer to a higher acuity of care, either within the same facility or to a children's hospital, show symptoms IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 12 of clinical deterioration 24 hours before the critical event and in many cases can be avoidable or potentially avoidable. PEWS has been identified as a means to improve safety for hospitalized children. The bedside observation tool allows clinicians to recognize the signs of clinical deterioration and allows for early intervention. This is especially important in the rural hospital setting, where early interventions can help prevent the need for transporting a patient to a larger facility that may be hours away. Potentially avoidable transfers are burdensome and costly to families and do not always improve pediatric patient care (Mohr et al., 2016). The benefits of utilizing PEWS go beyond patient outcomes. They also empower providers to call for help and break down hierarchal cultures while giving nurses and support staff more confidence (Levin, Brady, Duncan, & Davis, 2015). Practice Change Theory Havelock's theory of change focuses on the management of change. It includes building relationships, diagnosing the need for change, getting the resources needed for change, selecting the best option to respond to the change and implementing it, establishing and accepting the change, and maintaining the change (Finkleman, 2019). Implementation of a PEWS at UBMC required building a relationship with stakeholders including Dr. Greg Staker, Chief Medical Officer (CMO), Bobby Richards, Chief Nursing Officer (CNO), managers for MS, ICU, respiratory department (RT), nursing staff, and the attending pediatricians. The identified gap in practice and the research gathered to justify both that gap and solution to the gap in practice were presented to the stakeholders who unanimously supported the implementation of PEWS. A collaboration with the nurse educator and department managers facilitated educating the medical staff on PEWS. Feedback gathered from nursing staff helped address issues that arose after the implementation of the PEWS. Addressing concerns ensures PEWS use compliance. Data IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 13 collection and analysis have tracked the impact of PEWS on pediatric inpatient hospital care and transfers. The positive impact associated with PEWS and decreased pediatric transfers will continue to validate PEWS use. Project Implementation Outcomes and Goals The overall goal of this project was to implement Pediatric Early Warning Signs (PEWS) at Uintah Basin Medical Center (UBMC), specifically in the Medical-Surgical (MS) and Intensive Care Units (ICU), to improve early identification and treatment of clinical deterioration in pediatric patients. The PEWS guideline states PEWS charting will be completed in the electronic medical record (EMR) on all inpatient pediatric patients on each shift during the nurse's assessment and anytime the patient exhibits a clinical status change. The EMR calculated PEWS score is then applied to an algorithm set by the validated tool and part of the EMR that indicates if further action is required. Further action may include more frequent assessments, consulting with team members, notifying a provider, or initiating a rapid response or code. Additionally, written educational material was provided to the pediatric and family practice clinics to alert pediatric patient's families of respiratory changes that may warrant seeking medical treatment. A respiratory outpatient clinic (ROC) information and referral guide was also distributed throughout UBMC clinics to increase ROC usage and decrease pediatric admissions for respiratory-related diagnoses. Setting and Population This project took place at Uintah Basin Medical Center (UBMC), a rural hospital in Roosevelt, Utah. UBMC has provided care to community members in Duchesne and Uintah IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 14 counties since 1944. It is the largest independent rural healthcare system in Utah (Ubh.org). UBMC has a 17-bed MS unit and a four-bed ICU. UBMC provides care to about 1,482 hospitalized patients a year (Ubh.org). Duchesne county has a pediatric population of 34.1%, which is 4% higher than the average pediatric population in Utah (Census profile, 2020). Statistical information obtained from UBMC reveals that the average yearly pediatric admissions to the medical-surgical unit were 187 and 18 pediatric admissions to the ICU from 2016 to 2019. Nine pediatric patients a year transferred from these departments to out-of-area facilities for a higher level of care. Project Considerations One barrier to this project was identifying if this quality improvement (QI) project required Weber State University Institutional Review Board (IRB) approval. IRB approval was received on December 1, 2020. Other barriers included compliance with implementation and documentation of PEWS guidelines and scoring by nursing staff at UBMC, the participation of pediatrician and family practice physicians, and ROC in distributing educational information to pediatric patients' families. Yearly nursing education and positive results after PEWS implementation will help ensure PEWS continues to be utilized in MS and ICU. Participation of facility providers in utilizing the ROC and associated educational information will be facilitated by adding those materials to the UBMC intranet for easy access. The need to implement PEWS was recognized and supported by UBMC's CMO, CNO, and department managers for the MS, ICU, and ROC. The most challenging barrier was the COVID-19 pandemic and the effects it had on pediatric admissions to UBMC. The pandemic significantly reduced the number of pediatric admissions to MS and ICU in 2020 and subsequently delayed implementing of this QI DNP IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 15 project. Despite the low pediatric inpatient census, the implementation of PEWS will benefit future pediatric patients admitted to MS and ICU at UBMC. Project Implementation The role of the DNP student was to identify a practice problem and create a QI project using an evidence-based solution for that problem. Collaborating with stakeholders, the DNP student acted as the QI project leader. The QI project leader used transformational leadership to build a culture conducive to implementing the QI project that possessed the three major themes identified by Reavy (2016) as essential for successful leadership: communication, trust, and integrity. The literature shows that through staff awareness, PEWS is an effective tool in detecting pediatric clinical deterioration and avoiding potential transfers to a higher level of care facility outside the rural area serviced by UBMC. Collaborating with the project team, the PEWS guideline, education, and ROC referral and information for outpatient pediatric patients' families and inpatient pediatric patients was developed in preparation for the implementation of the PEWS guideline. Quantitative and qualitative data regarding pediatric admissions and transfers to a higher level of care was obtained from the analytics department at UBMC to establish pre-implementation statistics on inpatient pediatric hospitalizations. PEWS charting in the electronic medical record (EMR) was available to all nursing staff on the medical-surgical and ICU team. Electronic documentation of PEWS improved the ability to detect deterioration by displaying the PEWS scoring criteria and calculating the end score and facilitated usability for the end-user by meeting workflow needs and providing data that could be analyzed to show the use and effectiveness of PEWS at UBMC (Tomasi et al., 2019). IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 16 The PEWS guideline was presented during the MS/ICU staff meeting on February 18, 2021. PEWS charting on all pediatric patients started after the meeting. Twenty-six nurses began utilizing PEWS charting on all pediatric patients. The on-call pediatrician for UBMC inpatients is notified of any changes in the patients' status or detection of clinical deterioration as indicated by the PEWS score. The training and education provided to nursing staff and reference material were added to the UBMCs intranet site as a staff resource. Staff education aims to orient and support ongoing learning to ensure that staff is competent in providing quality care and improving individual and organizational outcomes (Finkelman, 2018). Written educational information and ROC referral information were provided to the pediatric and family practice offices, the ROC, and MS/ICU departments. This information is distributed to pediatric patients' parents in outpatient settings if the pediatric patient is seen for a respiratory-related illness. The educational information is also included in the discharge teaching of inpatient pediatric patients admitted to UBMC with respiratory illnesses. The information pamphlets are available in both English and Spanish. Evaluation and Data Analysis Plan Data Collection To assess the confidence and comfort level of UBMCs MS and ICU nursing staff on providing care to pediatric patients and gauge knowledge of PEWS, a poll was conducted before implementing PEWS during the February 2021 staff meeting. Unanimously the nurses verbalized the need for education and tools to increase their knowledge of providing care to pediatric patients and recognizing early signs of clinical deterioration in pediatric patients, primarily due to the infrequency of pediatric patients. A paper survey was distributed four months after the IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 17 implementation of the project. As a google form, the same survey was emailed after the data collection period to the MS and ICU nursing staff at UBMC. Using a Likert scale, the survey included questions regarding nurses' confidence in providing care to pediatric patients before and after PEWS implementation, confidence in relaying clinical deterioration signs of pediatric patients to providers, and if PEWS was consistently being used on their pediatric patients. The effectiveness and ease of PEWS use and if pediatric patients had avoided transfer because of PEWS use were also included. Additionally, the survey asked if their pediatric patients had been referred to the ROC for outpatient care, as well as an open-ended question asking for feedback regarding the implantation and use of PEWS. Monthly from February to July, using the EMR at UBMC and Discern Analytics 2.0, data was collected for every pediatric inpatient at UBMC in the MS and ICU departments. The charts were then reviewed for the use of PEWS throughout their hospitalization. Additionally, nurses charting was reviewed for interventions on any pediatric inpatients whose PEWS increased above 3. Data Analysis Using descriptive statistics, qualitative data collected from the nursing surveys are displayed on the following bar graphs. Feedback from nursing surveys is displayed as quotes. Pediatric admissions and PEWS usage during the data collection period is shown quantitatively in a table. Quantitative results of ROC clinic patient information usage and referrals are included. Nursing feedback listed on nursing surveys is displayed as quotes. Evaluation Before implementing PEWS during the MS and ICU monthly staff meeting, only two nurses verbalized they knew what PEWS was, and only one nurse had used PEWS at a IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 18 previous place of work. Distributed nursing surveys were not mandatory, and the nursing staff was not obligated to provide their name on their completed surveys. Fifteen nurses attended the pre-implementation staff meeting, 16 surveys were conducted in June, and 13 were completed in July. The following bar graphs display the results of those surveys. Survey results indicate that PEWS has dramatically increased nurses' confidence and awareness when caring for pediatric patients and recognizing signs of pediatric patient deterioration. Despite PEWS being easy to use, the nursing staff still struggles to utilize PEWS on all pediatric patients admitted to MS and ICU. The ROC had three referrals during the evaluation period: one in May 2021 and two in June 2021. June Survey Results 14 14 10 2 1 14 14 2 2 6 14 15 2 2 THE PEWS IS QUICK AND EASY TO USE? DOES USING THE PEWS MAKE YOU FEEL MORE COMFORTABLE AND CONFIDENT TAKING CARE OF PEDIATRIC PATIENTS? HAVE ANY OF YOUR PEDIATRIC PATIENTS AVOIDED TRANSFER TO EITHER THE ICU OR A HIGHER LEVEL OF CARE FACILITY BECAUSE YOU RECOGNIZED SIGN OF DETERIORATION EARLY AND … HAVE ANY OF YOUR PEDIATRIC PATIENTS BEEN REFERRED TO THE ROC CLINIC? IF YES DID YOU PROVIDE THEM WITH THE ROC CLINIC HANDOUT? ARE YOU COMFORTABLE WITH WHAT STEPS TO TAKE TO ESCALATE CARE IF YOUR PEDIATRIC PATIENT SHOWS SIGNS OF DETERIORATION? ARE YOU CONFIDENT IN YOUR ABILITY TO COMMUNICATE YOUR CONCERNS ABOUT YOUR PEDIATRIC PATIENTS’ STATUS WITH THE MEDICAL PROVIDER? June Survey Yes No IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 19 July Results 2 4 8 2 0 1 2 3 4 5 6 7 8 9 NOT AT ALL CONFIDENT VERY COMFIDENT How confident are you in your ability to recognize signs for pediatric patient … 0 0 8 4 4 0 1 2 3 4 5 6 7 8 9 STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE Has using the PEWS increased your confidence in recognizing signs of pediatric patient deterioration? IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 20 14 14 10 2 1 14 14 2 2 6 14 15 2 2 THE PEWS IS QUICK AND EASY TO USE? DOES USING THE PEWS MAKE YOU FEEL MORE COMFORTABLE AND CONFIDENT TAKING CARE OF PEDIATRIC PATIENTS? HAVE ANY OF YOUR PEDIATRIC PATIENTS AVOIDED TRANSFER TO EITHER THE ICU OR A HIGHER LEVEL OF CARE FACILITY BECAUSE YOU RECOGNIZED SIGN OF DETERIORATION EARLY AND … HAVE ANY OF YOUR PEDIATRIC PATIENTS BEEN REFERRED TO THE ROC CLINIC? IF YES DID YOU PROVIDE THEM WITH THE ROC CLINIC HANDOUT? ARE YOU COMFORTABLE WITH WHAT STEPS TO TAKE TO ESCALATE CARE IF YOUR PEDIATRIC PATIENT SHOWS SIGNS OF DETERIORATION? ARE YOU CONFIDENT IN YOUR ABILITY TO COMMUNICATE YOUR CONCERNS ABOUT YOUR PEDIATRIC PATIENTS’ STATUS WITH THE MEDICAL PROVIDER? July Survey Yes No 2 4 8 2 0 1 2 3 4 5 6 7 8 9 NOT AT ALL CONFIDENT VERY COMFIDENT How confident are you in your ability to recognize signs for pediatric patient deterioration based on the PEWS? IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 21 A chart review was conducted on all pediatric patients admitted to MS and ICU at UBMC from February 19, 2021, through July 19, 2021. The chart review included assessing if PEWS had been charted on the patient, an increase in the PEWS score that required intervention, and any pediatric patients were transferred out of the facility because of clinical deterioration. Thirty-six pediatric patients were admitted to MS and or ICU during the project evaluation time frame. Twenty-three pediatric patient charts had at least one PEWS charted during their admission. Zero PEWS showed an increase from admission during their stay. Two pediatric patients were transferred at the request of their parents. The results are displayed in the table below. Pediatric Admission PEWS Charted on at least once during admission Increase in PEWS from admission that required intervention Patients Transferred to a higher level of care 36 23 0 2 (Twins- family requested transfer) PEWS Feedback 0 0 8 4 4 0 1 2 3 4 5 6 7 8 9 STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE Has using the PEWS increased your confidence in recognizing signs of pediatric patient deterioration? IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 22 The MS and ICU nurses were asked on the surveys conducted if the PEWS had helped their nursing practice and workflow and to provide comments, questions, or concerns regarding the PEWS. Their responses are as followed. "I haven't had any peds patients since implementing this. Sorry, I'm not much help." "It's nice to have another tool to help give you more guidance on what to do in a situation." "I don't even know what PEWS is." "Pretty easy to use, and I didn't have very many peds patients, but I can use it in the future." "Working in a rural hospital, I do not take care of many pediatric patients regularly." "Having the PEWS system helps me feel confident that I will be able to identify signs or symptoms of deterioration in a timely manner." Discussion The implementation of this quality improvement project was met with multiple obstacles. UBMCs' relatively low pediatric admission census, especially during the summer months, was even lower due to the Covid-19 pandemic. The nursing staff, already overwhelmed by the Covid-19 pandemic, were reluctant to incorporate more charting into their daily routine. Still, once they became more familiar with the PEWS score and charting, its ease of use was recognized. After implementing PEWS, the MS and ICU department had substantial staffing changes that included hiring five new nurses who required training on PEWS. As with any practice change, implementing PEWS charting in each nurse's workflow will take additional time and increase pediatric admissions before it becomes routine. IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 23 The respiratory department experienced a change in management shortly before implementing PEWS. Fortunately, the new manager was aware of the project's incorporation of the ROC, and few modifications were made to the original project objectives and goals. As with pediatric admission during the summer, the ROC historically sees very few patients in the summer. However, both inpatient and outpatient services now have educational information in English and Spanish readily available for the anticipated busy fall and winter season of respiratory infections. While being an overall success, standing order algorithms with early interventions for nursing staff were not implemented. The physicians, department managers, nursing staff, and respiratory therapists involved in that process did not have the time required to develop these due to the Covid-19 pandemic efficiently. Nonetheless, utilizing PEWS in the MS and ICU departments at UBMC will have lasting positive effects on nursing confidence and pediatric patient safety. The nursing staff's recognition that PEWS is a valuable tool in the early detection of pediatric clinical deterioration will hopefully ensure its continued use and sustainability. The addition of PEWS information in the training modules for UBMC employees can be a tool to help reinforce the importance of its use. A great lesson learned during the implementation of this quality improvement project was learning to adapt during an unpredictable and volatile time in healthcare. Recommendations PEWS is a valuable tool that aids in assessing pediatric patients and recognizing signs of clinical deterioration. Additionally, it provides more consistent communication among nursing staff and providers. In the future, the PEWS can be built upon for additional quality improvement projects. Some such future suggestions are addition of early intervention IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 24 algorithms that would give autonomy to nursing staff to initiate medical treatment while waiting for physicians to respond to the call and a pediatric rapid response team with additional training to care for urgent medical situations would benefit pediatric patients admitted to UBMC. Educating, empowering, and supporting nursing staff is essential in providing competent care and improving pediatric patient safety. Implications to Practice PEWS assists in early recognition and response of clinical deterioration and improves nurse confidence and competency in caring for pediatric patients, which is imperative for reducing avoidable transfers and improving pediatric patient care outcomes. As a future family nurse practitioner, hospitalized pediatric patients at UBMC will be cared for by nurses equipped with the education and tools to help prevent clinical deterioration and avoid unnecessary transfers. Conclusions Pediatric admissions to MS and ICU at UBMC are infrequent. As a DNP nurse leader, the increase in stress on the nursing staff when caring for pediatric patients was recognized. This QI project utilized evidence-based practice to implement a tool that helps alleviate this stress and increase nursing confidence while improve patient care. Pediatric patients rarely deteriorate rapidly, but failure to recognize and respond early to clinical deterioration can lead to invasive treatments, inter-facility transfers, and escalation of care to larger hospitals. For families living in rural areas transferring their child to another facility is often hours away and results in high medical expenses, emotional stress, anxiety, and decreased confidence in their local healthcare providers. It is essential to empower nursing staff with education and tools that enhance their ability to provide the best quality care to their pediatric patients. The PEWS implemented in this IMPLEMENTATION OF PEDIATRIC EARLY WARNING SIGNS 25 project enhances nursing confidence in recognizing and responding quickly to clinically deteriorating pediatric patients, which could be lifesaving for the pediatric patients at UBMC. The findings of this project show implementation of the PEWS increased consistency in nursing assessments and increased nursing confidence when caring for pediatric patients. Distribution of ROC referral and educational information will help pediatric patients avoid hospitalization related to respiratory illnesses. 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