Paediatrics Publications

Title

Effect of a pediatric early warning system on all-cause mortality in Hospitalized pediatric patients: The epoch randomized clinical trial

Authors

Christopher S. Parshuram, Hospital for Sick Children University of Toronto
Karen Dryden-Palmer, Hospital for Sick Children University of Toronto
Catherine Farrell, Centre Hospitalier de L'Universite de Montreal
Ronald Gottesman, Centre Universitaire de Santé McGill, Hôpital de Montreal Pour Enfants
Martin Gray, Hospital for Sick Children University of Toronto
James S. Hutchison, Hospital for Sick Children University of Toronto
Mark Helfaer, The Children's Hospital of Philadelphia
Elizabeth A. Hunt, University of Toronto
Ari R. Joffe, University of Alberta
Jacques Lacroix, Centre Hospitalier de L'Universite de Montreal
Michael Alice Moga, Hospital for Sick Children University of Toronto
Vinay Nadkarni, The Children's Hospital of Philadelphia
Nelly Ninis, Imperial College Healthcare NHS Trust
Patricia C. Parkin, SickKids Research Institute
David Wensley, BC​ Children​'​​s Hospital
Andrew R. Willan, SickKids Research Institute
George A. Tomlinson, Institute of Health Policy, Management and Evaluation
Ariane Willems, Hospital for Sick Children University of Toronto
Malika Hazim, Hospital for Sick Children University of Toronto
Bernard Wenderickx, Hospital for Sick Children University of Toronto
Afrothite Kotsakis, Saint John Regional Hospital
Sarah Gander, IWK Health Centre
Wendy Harris, IWK Health Centre
Joanna Holland, Centre Universitaire de Santé McGill, Hôpital de Montreal Pour Enfants
Julie MacLean, Centre Universitaire de Santé McGill, Hôpital de Montreal Pour Enfants
Darlene Boliver, Centre Universitaire de Santé McGill, Hôpital de Montreal Pour Enfants
Samara Zavalkoff, Université Laval
Maryse Dagenais, Université Laval
Sarah Shea, Université Laval

Document Type

Conference Proceeding

Publication Date

3-13-2018

Journal

JAMA - Journal of the American Medical Association

Volume

319

Issue

10

First Page

1002

Last Page

1012

URL with Digital Object Identifier

10.1001/jama.2018.0948

Abstract

IMPORTANCE: There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. OBJECTIVE: To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. DESIGN, SETTING, AND PARTICIPANTS: A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. INTERVENTIONS: The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. RESULTS: Among 144539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P =.96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P =.03). CONCLUSIONS AND RELEVANCE: Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality.

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