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


According to the aim of this study, the researchers developed the score system using mobile app and identified the effectiveness of the new application (mPEWS-InPro). The mPEWS-InPro sensitivity score is 94.2%, indicating high accuracy in predicting a patient's clinical deterioration. According to Sefton and colleagues (2014), the implementation of PEWS in the tertiary areas of hospitals decreases the possibility of a condition in which death is imminent during pediatric intensive care unit (PICU) admission, the need for PICU interventions, and the length of stay in PICU. PEWS implementation identifies not only sick children in earlier phases, but can also prevent further clinical deterioration (Fuijkschot et al. 2015).

Scoring results and the direct notification function of the application tools also facilitate nurses' delivery of information about the status of a patient's deterioration. The result is in line with the study by Tume and colleagues (2014), which is related to communication problems in reporting a patient's condition, where the nurse is reluctant to use medical language. Hence, this subjective communication pattern is very dependent on the team's ability to understand the nurse's description of the patient's condition. Communication via notification using a mobile-based mPEWS-InPro application shortens delivery times by passing existing hierarchical paths and provides clear written instructions for nurses to provide interventions. Some nurses said the mPEWS-InPro application was effective because senior nurses and doctors could obtain immediate knowledge about the condition of a patient's deterioration through mPEWS scoring.

Technology has grown rapidly during the last four decades and has become an integral part of health care. Nurses participate in buying, designing, and implementing information technology in health services. Nursing informatics includes science and systems that feature processes and data (Maryniak, 2013); it combines nursing, information, and computer science to manage and to process data into knowledge to be used in nursing practice (Murphy, 2010). The American Nurses Association defines nursing informatics as "a specialty that integrates nursing science, computer science, and information science to manage and to communicate data, information, knowledge, and policies in nursing practice" (Staggers & Thompson, 2002, p. 260).

mPEWS-InPro is an application of nursing informatics. As stated by Topaz (2013), nursing informatics consists of data, information, knowledge, and wisdom. Results of observations conducted by nurses serve as preliminary data and are organized into information. Nurses who interpret and understand this information proceed to a form of knowledge. Ethics-related decisions and compassion for knowledge in existing nursing practice lead to wisdom, which prompts a nurse to decide to intervene. It is important to note that even when nurses use the software in their nursing practice, the essence of the human touch in their interventions remains. Finally, PEWS should be viewed as more than a score; rather, it is a part of a diverse system based on implementation to improve child safety and clinical outcomes (Lambert et al., 2017).

In their statements, some nurses revealed another advantage of the mPEWS-InPro application, not only for the patient, but also for the nurses themselves. Through this application, primary nurses and nursing managers, including those in advanced nursing divisions, can monitor the patient's condition in one ward from a distance, without time or place limits. This facilitates the determination of daily nurse-to-patient ratios and can automatically document, on a daily basis, the number of patients whose care is managed by nurses.


The researcher found that data collected from 27 patients could not be used because there were no blood pressure data. Some nurses' statements featured complaints about the urgency of blood pressure measurement in the mPEWS-InPro application. Furthermore, challenges relating to blood pressure measurement in this hospital included finding an appropriate cuff that suited the anatomy of a child's extremities, which is limited in number. Further, Bird and Michie (2008) wrote that measuring children's blood pressure is more difficult than measuring adults (e.g., blood pressure results tend to be very high in babies who cry, the absence of a displayed normal blood pressure range from each child's stage of age, and the unavailability of proper cuff in the ward).

Although automatic blood pressure devices are currently recommended and are widely used for children at home, the published evidence about the accuracy of these devices in the pediatric population is still limited. Blood pressure results are uncertain because most of the studies are analyzed together with older subjects. The recommendation is to have common protocols that meet specific problems of children, have more automatic blood pressure devices tested on children, and have a review process (Stergiou et al., 2017). On the other hand, measuring a child's blood pressure is an important skill that a nurse must have (Howlin & Brenner, 2010). Measurement of blood pressure can be conducted on children beginning at age 3 years. However, blood pressure measurements can also be performed on children younger than 3 years under the following conditions: 1) a history of prematurity, 2) low infant weight, 3) congenital heart disease, 4) recurrent urinary tract infections, 5) hematuria or proteinuria, 6) family history of heart disease, or 7) a transplantation process (Pittard, 2016; Puchalski, 2018).

Another challenging circumstance found during the implementation of mPEWS-InPro application was a longer adaptation process for senior nurse staff. Some senior staff nurses needed more intensive assistance on how to use the application. At the end, all nurses involved were successful in using the application.