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J Hosp Med. 2018 Aug 29:E1-E6. doi: 10.12788/jhm.3066. [Epub ahead of print]

Beyond Reporting Early Warning Score Sensitivity: The Temporal Relationship and Clinical Relevance of "True Positive" Alerts That Precede Critical Deterioration.

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Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, USA.
Department of Nursing, Respiratory Care and Neurodiagnostics, Children's Hospital of Philadelphia Critical Care Center for Evidence and Outcomes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Center for Pediatric Clinical Effectiveness, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia; Pennsylvania, USA.



Clinical deterioration is difficult to detect in hospitalized children. The pediatric Rothman Index (pRI) is an early warning score that incorporates vital signs, laboratory studies, and nursing assessments to generate deterioration alerts.


(1) Evaluate the timing of pRI alerts and clinicians recognizing deterioration or escalating care prior to critical deterioration events (CDEs) and (2) determine whether the parameters triggering alerts were clinically related to deterioration.


CDEs are unplanned transfers to the intensive care unit with noninvasive ventilation, tracheal intubation, and/or vasopressor infusion in the 12 hours after transfer. Using one year of data from a large freestanding children's hospital without the pRI, we analyzed CDEs that would have been preceded by pRI alerts. We (1) compared the timing of pRI alerts to time-stamped notes describing changes in patient status and orders reflecting escalations of care and (2) identified score component(s) that caused alerts to trigger and determined whether these were clinically related to CDE etiology.


Fifty CDEs would have triggered pRI alerts if the pRI had been in use (sensitivity 68%). In 90% of CDEs, the first clinician note reflecting change in patient status and/or the first order reflecting escalation of care preceded the first pRI alert. All of the vital sign and laboratory components of the pRI and 51% of the nursing components were clinically related to the etiology of the CDE.


Evidence that clinicians were aware of deterioration preceded pRI alerts in most CDEs that generated alerts in the preceding 24 hours.


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