title: Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety.
abstract: BACKGROUND
  Early warning scores (EWSs) assign points to clinical observations and generate scores to help clinicians identify deteriorating patients. Despite marginal predictive accuracy in retrospective datasets and a paucity of studies prospectively evaluating their clinical effectiveness, pediatric EWSs are commonly used.
  
  
  OBJECTIVE
  To identify mechanisms beyond their statistical ability to predict deterioration by which physicians and nurses use EWSs to support their decision making.
  
  
  METHODS
  Qualitative study.
  
  
  METHODS
  A children's hospital with a rapid response system.
  
  
  METHODS
  Physicians and nurses who recently cared for patients with false-positive and false-negative EWSs (score failures).
  
  
  METHODS
  Semistructured interviews.
  
  
  METHODS
  Themes identified through grounded theory analysis.
  
  
  RESULTS
  Four themes emerged among the 57 subjects interviewed: (1) The EWS facilitates safety by alerting physicians and nurses to concerning changes and prompting them to think critically about deterioration. (2) The EWS provides less-experienced nurses with vital sign reference ranges. (3) The EWS serves as evidence that empowers nurses to overcome barriers to escalating care. (4) In stable patients, those with baseline abnormal physiology, and those experiencing neurologic deterioration, the EWS may not be helpful.
  
  
  CONCLUSIONS
  Although pediatric EWSs have marginal performance when applied to datasets, clinicians who recently experienced score failures still considered them valuable to identify deterioration and transcend hierarchical barriers. Combining an EWS with a clinician's judgment may result in a system better equipped to respond to deterioration than retrospective data analyses alone would suggest. Future research should seek to evaluate the clinical effectiveness of EWSs in real-world settings.
authors.affiliation: Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. bonafide@email.chop.edu
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Bonafide
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: Roberts
authors.forename: Christine M
authors.initials: CM
authors.lastname: Weirich
authors.forename: Breah
authors.initials: B
authors.lastname: Paciotti
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Tibbetts
authors.forename: Ron
authors.initials: R
authors.lastname: Keren
authors.forename: Frances K
authors.initials: FK
authors.lastname: Barg
authors.forename: John H
authors.initials: JH
authors.lastname: Holmes
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000592:standards; D005260:Female; D057209:Hospital Rapid Response Team / Q000592:standards*; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D008297:Male; D009726:Nurses / Q000639:trends*; D061214:Patient Safety / Q000592:standards*; D010820:Physicians / Q000592:standards*; D010865:Pilot Projects; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D013997:Time Factors