The Modified Pediatric Early Warning Score Innovation Project (mPEWS-InPro) Mobile-Based Application Development

Another Way of Monitoring A Child's Clinical Deterioration

Lia Kartika, Ns, MKep., Sp.Kep.An; Dessie Wanda, PhD, MN, S.Kp; Nani Nurhaeni, Dr., MN, S.Kp


Pediatr Nurs. 2021;47(1):38-44. 

In This Article

Abstract and Introduction


Children who are hospitalized have the potential for experiencing clinical deterioration during the treatment period. Nurses who recognize abnormal physiological parameters and implement appropriate, integrated, multidisciplinary interventions can prevent a child's condition from worsening. However, communication problems may delay the required decision-making. The present study assessed the effectiveness of monitoring physiological changes in children via the modified Pediatric Early Warning System (mPEWS)-InPro mobile-based application in determining the risk of clinical deterioration and in providing appropriate intervention. This initial validation study consisted of three stages: literature search, instrument development, and instrument application. The study involved 108 pediatric patients from March to April 2018. Data were collected via a mobile-based demographic field. Eight physiological parameters were observed, inputted, and automatically computed. The writing of this manuscript follows TRIPOD Checklist for Prediction Model Validation. The mPEWS-InPro mobile-based application obtained an AUC value of 0.942 (95%, CI: 0.865 to 1.000; p = 0.001), indicating very strong degrees of accuracy and significance in predicting a child's clinical deterioration. With a cut value of 4, the mPEWS-InPro has a sensitivity of 92.3% and a specificity of 80%. The mPEWS-InPro mobile-based application is effective for predicting and monitoring a child's clinical deterioration. Its application can be integrated with any hospital's electronic health record system. This form of nursing informatics can be considered a strategy for detecting the clinical deterioration of pediatric patients. Its user-friendly application and automatic parameter scoring allow nurses to take care the patients while maintaining the human touch, which is essential in nursing care.


The clinical deterioration of inpatients is usually characterized by physiological disorders. Some key issues related to deteriorating conditions of children in hospitals include the failure of nursing staff to monitor changes, recognize deteriorative conditions, communicate regarding recognized deteriorative conditions, and respond appropriately (Ennis, 2014). Further more, when children's health conditions suddenly decline, parents often say they already know and feel their child's symptoms are more serious than what health professionals understand (Ray et al., 2009).

The prompt detection of clinical deterioration can reduce the risk of unexpected clinical conditions. Moreover, the early recognition of a patient's deterioration and the implementation of an appropriate nursing care plan are critical in providing acute care that is safe and effective (Capan et al., 2015). The majority of sudden cardiac and pulmonary arrest incidents in hospital settings are preceded by significant clinical impairments in the patient's physiological parameters. Although these changes have been documented, no actions have been taken in response to the findings, thereby increasing the number of associated deaths because of nonconformities or delays in medical management (Skaletzky et al., 2012). Therefore, interventions based on changes in a patient's physiological parameters can reduce the incidence of code blue emergencies in hospitals (Fuijkschot et al., 2015).

To distinguish between those at high risk of sudden cardiac arrest from those with low risk and those whose condition is good, the use of a system that aims to minimize the incidence of unnecessary calls to critical care teams is recommended. Such a system will be used to identify those at risk for deterioration to prevent late rescue. Several such identification systems have undergone evaluation and appropriate methodology development (Parshuram et al., 2011). The Pediatric Early Warning Score (PEWS) system enables nurses to communicate the current health conditions of the patient to other health care providers in a terminology that is clear, intuitive, and easily accessible. PEWS also creates a standardized method of evaluation of which the quantitative data can be easily interpreted and give both the nurse and the provider a shared mental regarding the patient's condition (Brown et al., 2019). The prevalence of sudden cardiac and pulmonary arrest in the child population is a rare phenomenon, but the instances that occur have poor prognoses. In the inpatient setting, a child needs at least an hour (Breznak, 2013) to exhibit early clinical signs of deterioration prior to respiratory arrest; however, these clinical taken. Early recognition of deterioration can improve survival from arrest from 27% to 80% (Levin et al., 2015).

The description of the patient's condition as stated by all health care providers, such as nurses and doctors, needs to be clearly defined. However, a hierarchical health care system, when the identification of deterioration of a patient's condition starts with nurses then is referred to doctors, ineffective communication often results, which in turn leads to a lack of appropriate follow up (Azzopardi et al., 2011; Ennis, 2014). Therefore, an early warning system improves communication between nursing staff and doctors, and both professions can help identify those in the high-risk patient population (Skaletzky et al., 2012).

Several attempts have been made to improve the safety of acutely ill patients, but injuries to patients, unexpected deaths, and admissions to intensive care units (ICUs) persist because of the failure of nurses to recognize the clinical deterioration of their patients. Nurses have direct patient contact and spend more time with patients than other health workers, so nurses in all settings must recognize deterioration and respond appropriately by improving nurses' decision-making skills in the situation (Ruata, 2016). Accordingly, PEWS is one approach that supports nurses in monitoring a patient's condition.

The use of an early warning tool can reduce unplanned ICU admissions, the occurrence of respiratory arrest, and ICU care (Tume et al. , 2014). However, the final score of PEWS determines the rapid response team (RRT) activation. A meta-analysis about an RRT by Chan and colleagues (2010) that involved hundreds of thousands of pediatric patients showed the significance of 38% reduction of cardiopulmonary arrest and 21% reduction in hospital mortality rates. In spite of reduced respiratory arrests, RRT implementation in the first 12 hours also reduced the predicted need for ICU care (Bonafide et al., 2014). RRT implementation also decreased the period between clinical impairment and treatment from 9 hours 55 minutes to 4 hours 15 minutes (Muliasari et al., 2010). This implementation becomes less consistent with a large number of scale variations of PEWS used, response activation criteria, the availability of RRTs, and membership of an RRT. National coordination is necessary for the evaluation of PEWS implementation, its impact, and the effectiveness of standardized PEWS programs in various environments where sick children are treated. Each health care provider needs to evaluate the available tools and choose the one that best suits local needs (Dewi, 2016).

Most hospitals in developed countries that have applied the PEWS system use paper-based PEWS. Muliasari (2017) also implemented a paper-based PEWS system in the infectious infant care unit at the top referral hospital in the capital city of Indonesia. The evaluation has been conducted in regard to the implementation of Muliasari's (2017) project, and which resulted in heavy nurse workloads and more specific items to be considered in determining scores, requiring time, manual dexterity, and precision for nurses to conduct the screening in monitoring the children's clinical deterioration. Based on these findings, the researchers in the present study considered the need for a device that facilitates the implementation of this scoring system without increasing the burden to nurses. The expected result is the application of mPEWS-InPro mobile app to assess the clinical deterioration of children and to provide an effective and efficient intervention flow.