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JAMA. 2018 Mar 13;319(10):1002-1012. doi: 10.1001/jama.2018.0948.

Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial.

Author information

1
Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada.
2
Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada.
3
Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.
4
Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.
5
Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
6
Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
7
Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada.
8
Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
9
Division of Pediatric Intensive Care, Centre Hospitalier Universitaire de Ste-Justine, Montreal, Quebec, Canada.
10
Montreal Children's Hospital, Montreal, Quebec, Canada.
11
Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
12
Neuroscience and Mental Health Research Program, SickKids Research Institute, Toronto, Ontario, Canada.
13
Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
14
Johns Hopkins Hospital, Baltimore, Maryland.
15
Stollery Children's Hospital, University of Alberta, Edmonton, Canada.
16
St Mary's Imperial Healthcare, London, England.
17
British Columbia Children's Hospital, Vancouver, Canada.
18
Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Canada.
19
Department of Medicine, University Health Network and Mt Sinai Hospital, Toronto, Ontario, Canada.

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 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 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.

Trial Registration:

clinicaltrials.gov Identifier: NCT01260831.

PMID:
29486493
PMCID:
PMC5885881
DOI:
10.1001/jama.2018.0948
[Indexed for MEDLINE]
Free PMC Article

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