title: Can paediatric early warning scores (PEWS) be used to guide the need for hospital admission and predict significant illness in children presenting to the emergency department? An assessment of PEWS diagnostic accuracy using sensitivity and specificity.
abstract: OBJECTIVE
  Designed to detect early deterioration of the hospitalised child, paediatric early warning scores (PEWS) validity in the emergency department (ED) is less validated. We aimed to evaluate sensitivity and specificity of two commonly used PEWS (Brighton and COAST) in predicting hospital admission and, for the first time, significant illness.
  
  
  METHODS
  Retrospective analysis of PEWS data for paediatric ED attendances at St Mary's Hospital, London, UK, in November 2012. Patients with missing data were excluded. Diagnoses were grouped: medical and surgical. To classify diagnoses as significant, established guidelines were used and, where not available, common agreement between three acute paediatricians.
  
  
  RESULTS
  1921 patients were analysed. There were 211 admissions (11%). 1630 attendances were medical (86%) and 273 (14%) surgical. Brighton and COAST PEWS performed similarly. hospital admission: PEWS of ≥3 was specific (93%) but poorly sensitive (32%). The area under the receiver operating curve (AUC) was low at 0.690. Significant illness: for medical illness, PEWS ≥3 was highly specific (96%) but poorly sensitive (44%). The AUC was 0.754 and 0.755 for Brighton and COAST PEWS, respectively. Both scores performed poorly for predicting significant surgical illness (AUC 0.642). PEWS ≥3 performed well in predicting significant respiratory illness: sensitivity 75%, specificity 91%.
  
  
  CONCLUSIONS
  Both Brighton and COAST PEWS scores performed similarly. A score of ≥3 has good specificity but poor sensitivity for predicting hospital admission and significant illness. Therefore, a high PEWS should be taken seriously but a low score is poor at ruling out the requirement for admission or serious underlying illness. PEWS was better at detecting significant medical illness compared with detecting the need for admission. PEWS performed poorly in detecting significant surgical illness. PEWS may be particularly useful in evaluating respiratory illness in a paediatric ED.
authors.affiliation: Imperial College Faculty of Medicine, London, UK Department of Emergency Medicine, St Mary's Hospital, London, UK.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Lillitos
authors.affiliation: Imperial College Faculty of Medicine, London, UK Department of Emergency Medicine, St Mary's Hospital, London, UK.
authors.forename: Graeme
authors.initials: G
authors.lastname: Hadley
authors.affiliation: Imperial College Faculty of Medicine, London, UK Department of Emergency Medicine, St Mary's Hospital, London, UK.
authors.forename: Ian
authors.initials: I
authors.lastname: Maconochie
mesh_terms: D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D042241:Early Diagnosis; D004636:Emergency Service, Hospital / Q000592:standards; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008131:London; D008297:Male; D010343:Patient Admission / Q000592:standards*; D010372:Pediatrics / Q000379:methods / Q000592:standards*; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014218:Triage / Q000379:methods*
keywords: clinical assessment, education; clinical assessment, effectiveness; diagnosis; emergency department; paediatrics