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


Of 135 patients, blood pressure measurements could not be obtained from 27 patients. Accordingly, only 108 patients were involved in the study; of these, 13 patients experienced clinical deterioration. The proportion of boys and girls were equal, and most respondents' age ranged from 1 to 4 years (34%). Most of the children suffered from pneumonia.

Figure 2 describes the result of sensitivity and specificity analysis. The area under the ROC curve between the mPEWS-InPro and the reference standard was 0.942 (95%, CI: 0.865 to 1.000, p < 0.001) – that is, 94.2% of the times the mPEWS-InPro will be able to discriminate the true positives and the true negatives and will give false results 5.8% of the time. In comparison, the result of prognostic analysis obtained an AUC score of a Duncan PEWS score of 0.938 (95%, CI 0.852 to 1.000; p = 0.001). In conclusion, both scores are equal, which signifies a very strong ability to predict a patient's clinical deterioration (AUC > 90%). Table 3 provides the comparison of sensitivity and specificity of Duncan mPEWS-InPro PEWS scores.

Figure 2.

The Receiver Operating Characteristic (ROC) Curve Analysis of mPEWS-InPro and PEWS Duncan Scores

An essential consideration is that the more the cut-off point is decreased, the more prominent the sensitivity and the lower the specificity of the score. In this way, healthy patients can be distinguished as sick by the test (false positive). Balancing between sensitivity and specificity scores is the ideal process (Miranda, 2017). In this study, as described in Table 3, the mPEWS-InPro score of 4 was the cut-off point that maximized sensitivity (92.3%) and specificity (80%), and obtained the best accuracy (94.2%). The mPEWS-InPro score of 4 was the most accurate cut-off point. It means that in 92.3% of cases, the mPEWS-InPro score of 4 will be able to detect patients with the sign of clinical deterioration (true positives); even so, 20% of patients are included without these signs (false positive). Therefore, mPEWS-InPro demonstrated to be a valid instrument, with good execution within the indication of warning signs for clinical deterioration in patients studied, expanding the likelihood of this event occurring once the score was ≥ 4. This result came out through the obtained validity indicators based on the reference standard.

Furthermore, through a Google survey, 15 nurses commented on the advantages and disadvantages, as well as suggestions for improvement, in mPEWS-InPro implementation. All comments from nurses were divided into three topics: 1) mPEWS-InPro application strengths, 2) mPEWS-InPro application weaknesses, and 3) improvement for the application.

mPEWS-InPro Application Strengths

Nurses stated the mPEWS-InPro application had advantages and was easy to score and apply, fast, and efficient because the scores could be known directly after data were entered. In addition, this application was suitable for use in this technologically advanced era, when a majority of individuals cannot be separated from their mobile phones. It helped nurses know the condition of the patient being treated, such as noting vital signs remotely, and determining appropriate interventions for a pa tient. In other words, nurses reported mPEWS-InPro made their documentation process more convenient and their time working with patients more efficient. In addition, they viewed the application as a paper-saving, applicative, and innovative tool. Primary nurses also revealed the mPEWS-InPro application made it easy for them to monitor a patient's condition from a distance and determine the needs of nursing staff. Head nurse (who may not be on duty) determine the PEWS scoring from patient physiological parameters by entering the application. Nurses can log in using their respective usernames to monitor the patient's PEWS scoring in the ward on their mobile phone monitor. The nurse in charge in every shift and head nurse expressed positive comments about this app because they can monitor the worsening of the patient's condition in one ward anytime and anywhere.

mPEWS-InPro Application Weaknesses

During the implementation process, nurses reported difficulties in operating the application due to problematic Internet access, insufficient Internet quota, and different network speeds from each service provider, which prompted the suggestion that the application be offered in an offline version. Most nurses expressed difficulty in filling out the blood pressure parameters column because the application required the patient's blood pressure data to be inputted. Nurses said the blood pressure measurement was rarely done because of the limited tools, which are not suitable for use with children under the age of 3 years.

Improvements for the Application

Nurses suggested the app add a menu and describe its applicability, not only in infectious care units, but also in noninfectious care units, such as chemotherapy rooms. Nurses also said the screen display needed shortcuts and other added features to facilitate nursing care documentation.