Improving Pediatric Emergency Vital Sign Monitoring with an Early Warning Score-Based Protocol

Abstract

Problem: At a 13-bed, community Pediatric Emergency Department (PED), only 45% of high acuity patients were receiving the standard of care for vital sign (VS) monitoring. A national 25.4% increase in PED acuity highlights that lack of frequent and accurate VS monitoring is a significant clinical problem (Masler et al., 2021). Poor VS monitoring has resulted in delay in treatment, missed clinical deterioration, and necessary patient transfer at this PED. Early warning scores improve patient outcomes by guiding decisions such as frequency of monitoring, initiation of treatment, and transfer to appropriate level of care (Huff et al., 2018). Purpose: The purpose of this Quality Improvement (QI) project was to implement a Pediatric Early Warning Score (PEWS)-based VS protocol to improve VS documentation adherence, staff satisfaction, number of transfers to higher level of care, and number of provider reassessments. Methods: A pre- and post- implementation design was utilized to monitor these outcomes over a 14-week period. Pre- implementation data was collected retrospectively between the months of October 2021 and January 2022. The PEWS- based VS protocol included a new policy and procedure, changes to the electronic health record (EHR), the addition of PEWS-based VS order sets, and a PEWS Response Algorithm to guide interventions. Results: VS documentation adherence ranged from 43.9% to 66.7% post-implementation. The average VS adherence rate was 55.1%, demonstrating a 10.1% increase from pre-implementation (45%). PEWS-based VS order set adherence increased by 5.9% from pre-implementation (0%). Adherence to VS monitoring and documentation guidelines was 87% for patients with a PEWS-based VS order set. The number of provider reassessments increased by 39% and transfers to higher level of care decreased by 1.44%. Staff satisfaction scores for VS workflow were unchanged for nurses but increased by 84% for providers after implementation. Conclusion: Overall, VS documentation adherence increased after implementation of the PEWS-based VS protocol with positive patient outcomes. The findings suggest that the utilization of PEWS VS order sets increase adherence with VS monitoring and documentation.