Background: Paediatric Early Warning Systems (PEWS) are widely used to recognise deterioration on children’s wards, yet effects on hard outcomes vary, and routine pathways seldom operationalise caregiver concern. We evaluated whether adding a structured, parent-led component to standard PEWS improves early recognition and escalation.
Methods: We conducted a pragmatic multicentre implementation study across general paediatric wards using a stepped transition from usual care (clinician-led PEWS) to the intervention (PEWS plus a brief, pictorial Parent-Led Early Warning Score, P-LEWS) embedded in routine observation rounds and mapped to clear escalation thresholds. Eligible participants were inpatients aged 0-17 years and their primary caregivers. The primary outcome was early deterioration within 24 h (composite of urgent clinician review beyond usual thresholds, unplanned rapid response activation, unplanned PICU transfer, or in-hospital mortality). Secondary outcomes included timeliness metrics and diagnostic performance. Mixed-effects models adjusted for clustering and case-mix.
Results: Among 15, 933 admissions (control 7, 842; intervention 8, 091), baseline characteristics were balanced. The primary composite occurred less often with PEWS+P-LEWS than with PEWS alone (5. 6% vs 7. 2%; adjusted OR 0. 77, 95% CI 0. 67-0. 89; p=0. 001). Median time from first parent concern to clinician review fell from 42 to 24 minutes (p<0. 001), and time from first positive score to escalation call fell from 64 to 41 minutes (p<0. 001). Mortality was rare and unchanged (0. 10% vs 0. 12%; p=0. 54). Discrimination for the composite improved with the combined model (AUROC 0. 80) versus PEWS only (0. 74) or P-LEWS only (0. 68). Implementation fidelity increased over time (P-LEWS completion 78%→88% of observation rounds), family-activated escalation rose modestly (1. 2→1. 9 per 1, 000 patient-days) with 66% resulting in clinician action, and parent time burden remained low (~1. 7 minutes per round). Effects were directionally larger in infants and in families requiring language support.
Conclusions: Integrating a concise, structured parent-led score into routine PEWS improved early recognition and timeliness of escalation and enhanced predictive performance without increasing alert burden. Findings support systematic operationalisation of caregiver concern within paediatric ward safety systems.
International Journal of Paediatrics and Geriatrics
