Bedside Pediatric Early Warning System

BPEWS

Bedside Pediatric Early Warning

System

1. Age specific record

Select the correct

age specific

documentation

record

Five age groups –

five colours

newborn to less than 3 months

3 months and older but younger than

first b irthday

1 year and younger than 5th birthday

5th birthday and younger 12th

birthday

12th birthday and older

< 3m

3-12m

1-<5yr

5-<12yr

>12yr

2. Time

Ensure to start a

new documentation

record

24 hour format

Start time 0700 or

admission time

Date record

Patient label

3. Display

Orientate

documentation

record

Display to show

16 hours (2 pages

are displayed)

Enhances visual

trending

Clipboard

designed to

facilitate practice

4. Document

Document all 7

critical indicators

Graph on the

upper section,

HR, RR, SBP

••

•

Document

Record on the

lower section

Oxygen Saturation

Oxygen Therapy (Oxygen Unit Oxygen

Mode of Delivery)

Capillary Refill

95%FM

00:30

Heart rate

Graph on the lines

Mark with a dot, X or

actual number

VALUE section if

writing in the value

area top, bottom of

scale, advised to

seek immediate

assistance

172

•

Systolic blood pressure

... Document the

blood pressure

(systolic/diastolic)

….only use the

systolic blood

pressure to

calculate the

Bedside PEWS sub

score for BP

Diastolic blood pressure

Graphed

Important to the clinical picture

Not used to calculate the Bedside PEWS

sub score

Respiratory rate

One minute

observation

Visualize the

chest

Note any apnea

Graph on the

lines

Saturation

Chart the actual number

Chart in the square

88%

Amount of Oxygen

Chart amount of oxygen (L or %)

Chart method of delivery (FM, NP, BB, etc)

Chart even if patient in room air (RA)

60% FM

Respiratory effort

Subjective observation by a trained

health care provider

Respiratory effort

Normal

Normal effort, no apnea, no retraction,

passive expiration

Mild

Mildly increased respiratory effort,

retractions, nasal flaring

Respiratory effort

Moderate

Moderately increase work of breathing,

retraction, nasal flaring, tracheal tug

Severe

Severe respiratory effort, retraction, readily

apparent grunting, nasal flaring, head

bobbing, tracheal tug, accessory muscle use

Capillary Refill Time

Chart the number in seconds

Elevate the limb to just above the level of

the heart

Depress the digit / chest for five seconds

and release.

Count in seconds for the colour to return

to baseline.

4 sec

5. Sub-Score

Determine the sub

score for each of

the 7 critical

indicators

6. Calculate BPEWS score

Calculate the Bedside PEWS score , add

all the 7 critical indicators sub scores

together

min score 0

max score 26

Document the Bedside PEWS score in the

box corresponding to the time.

Scoring questions

Scoring between two colours

If you document a critical indicator which

lands between two colours, you would

score on the darker colour

…To allot the patient the higher

surveillance to ensure reassessment in a

shorter period of time.

Missing Indicator If one indicator is not done: If a frontline health

care provider determines not to assess any single indicator, the previous sub score for the indicator can be used to calculate the Bedside PEWS score at that time.

The previous sub score may only be carried over once and not greater than 4 hour period. If any previous sub score are outside of normal range, it is recommended that the provider assess the patient to achieve a new sub score at the current time.

Other assessments

Lower half of

BPEWS form and

back customized

by each hospital

Temperature

Pain Score

Bromage

Sedation Score

Blank space for

additional nursing

care

Vent Settings

Doctor Review

Initials

Pain Score

Indicate pain score used in dash box beside

pain score

Use age appropriate pain score for age

group

Review pain scores used by hospital

FLACC

Numbers

Faces

Bromage Sedation Score

Modified sedation score for children

Bromage Score

0 = awake

1 = occasionally drowsy, easy to arouse

2 = frequently drowsy, easy to arouse

3 = somnolent, difficult to arouse

S = asleep, easy to arouse, normal

sleep

Doctor review

Completed by the bedside health care

provider

Tick box

Check if any member of the primary team

or medical team has reviewed the patient

at the bedside

Please document in nursing note

7. Score matched care

recommendations (SMCR)

BPEWS

score

0 - 2

Response Initial Subsequent

0 - 2 Vital Sign

Documentation

4 hours 4 hourly

Charge Nurse

Review

Routine Routine

Review by

Primary Team

Routine Routine

Senior Medical

Review

Routine Routine

Additional

Similar Patients

2 or more 2 or more

Vital sign documentation

Recommended next vital sign

documentation on the Bedside PEWS

record

Nurse can do more frequent observation

of patient

Charge nurse review

Charge nurse is a senior nurse on the

inpatient ward who reviews the patient at

the bedside

It does not require the charge nurse to do

a physical assessment, but rather to have

a second set of eyes on the patient

Physician review

Review by primary team = any member of

the admitting service

Senior Medical Review = includes

attending physician, fellow and senior

resident. Fellow and senior must review

with the attending by phone if not in house

Monitoring

Recommended additional monitoring at the bedside if the patient has an increasing Bedside PEWS score

Oxygen saturation

ECG monitoring

Close observation

ICU Consult / RAP Team

Patient Ratio Recommended nurse to patient ratio

Nurse : patient ratio

Additional similar patients to the current patient BPEWS score.

2 or more similar patients with a similar score of 0–2 .

2 or less similar patients with a similar score of 6. Can have other patients with lower scores.

Initial vs. Subsequent

Initial recommendation

…applied to times when the child has their

first score and/or the next score has

progressed or recovered into a new risk

range

Subsequent recommendation

…applied when a child has remained static

at a certain risk range on repeated

assessment

Care recommendation

These recommendations are to be applied

in addition to clinical judgment of the

frontline health care professional providing

patient care. They are not intended to

replace clinical judgment, but rather

augment it.

“matching care with need”

Let’s Review

Bedside PEWS

1. Assess: Patient & 7 critical indicators

2. Document: Bedside PEWS record

3. Use colour to determine sub-scores

4. Calculate the Bedside PEWS score

5. Plan: identification, management plan,

timely referral

Resources for Nursing Staff Education desktop slides

Frequently asked questions

Technical manual

Clipboard

Documentation Record Poster

Age Specific Poster

Information Sheet

Bedside PEWS Team

Contacts

Stollery

Dr. Jon Duff

Dr. Dawn Hartfied

Denise Capito ex 1673

Jackie Ruszkowski ex 3838

SickKids

Dr. Chris Parshuram- [email protected]

Kristen - [email protected]

Karen – [email protected]

Thank you