Fellows journal Club
Fellow: Hanna Siddiqui, UCLA Mattel Children’s Hospital
Article: Lockwood J, Reese J, Wathen B, et. al. The Association Between Fever and Subsequent Deterioration Among Hospitalized Children With Elevated PEWS. Hospital Pediatrics. 2019. 9(3):170-178
Summary: In this article, the authors recognize hospitalized children who require unplanned transfer to the ICU experience worse clinical outcomes. They conducted a retrospective cohort study to determine if there is an association between fever and subsequent deterioration in 176 hospitalized children with a total of 220 elevated Pediatric Early Warning Score (PEWS). Primary bivariable analysis and secondary multivariable analysis compared clinical and demographic characteristics between patients with and without unplanned ICU transfers and critical deterioration events(CDEs). In conclusion, febrile patients with an elevated PEWS >4 were less likely to experience an unplanned ICU transfer compared to those without a fever. Moreover, the risk of CDE 12 hours after PEWS elevation, went up 50% with every 1-point increase in total PEWS. Ultimately, PEWS may not include all relevant clinical factors needed to make efficient decisions on escalation of care and further studies are required.
What are the key strengths of the article? The study design addressed concerns of physician behavior as a cause of increase ICU transfers by creating a secondary outcome to assess subsequent critical deterioration events and initiation of a life-sustaining intervention after transfer. In addition, to capture the difficulty of behavior assessments with PEWS overnight and the differences in normal heart rate ranges, a nighttime event was noted. Furthermore, in the analysis, the authors applied Poisson regression with robust error variance to calculate relative risks in order to improve accuracy of standard error and confidence intervals with increasing outcome incidence.
Are there any limitations or flaws in the article? One limitation is the study took place during the winter season, where 56% of the patients had a viral respiratory infection. Since fever is an expected part of a viral infection, these patients may be overrepresented. Furthermore, the study population may not reflect other general pediatric wards in the country. There was a small sample size in a single institution where higher acuity interventions are used on the floor. Lastly, the marginally significant adjusted relative risk comparing fever to unplanned ICU transfer in the multivariable analysis is not reliable because the upper confidence limit crossed one.
What is the major takeaway message? Fever is likely one of many clinical variables to confound interpretation of PEWS, therefore limiting its utility as stand-alone trigger tool for care escalation. A powered study on association between additional clinical factors and patient outcomes may improve current PEWS and create a novel illness severity score. This study may offer care teams the ability to make more informed decisions at the point of care by offering evidence on impact of fever on both PEWS and patient outcomes.
Describe how this article should impact our practice: In an era of greater reliance on technology, physicians should advocate the use of PEWS embedded in many of our EMR systems. The use of PEWS redirects care team members’ attention to patients at risk for deterioration, empowers nurses to escalate care, and standardizes language to reduce rates of cardiopulmonary arrests. By analyzing PEWS outcomes at our own institutions, we can modify the scoring system to better allocate hospital resources, and decrease morbidity and mortality.
Article: Lockwood J, Reese J, Wathen B, et. al. The Association Between Fever and Subsequent Deterioration Among Hospitalized Children With Elevated PEWS. Hospital Pediatrics. 2019. 9(3):170-178
Summary: In this article, the authors recognize hospitalized children who require unplanned transfer to the ICU experience worse clinical outcomes. They conducted a retrospective cohort study to determine if there is an association between fever and subsequent deterioration in 176 hospitalized children with a total of 220 elevated Pediatric Early Warning Score (PEWS). Primary bivariable analysis and secondary multivariable analysis compared clinical and demographic characteristics between patients with and without unplanned ICU transfers and critical deterioration events(CDEs). In conclusion, febrile patients with an elevated PEWS >4 were less likely to experience an unplanned ICU transfer compared to those without a fever. Moreover, the risk of CDE 12 hours after PEWS elevation, went up 50% with every 1-point increase in total PEWS. Ultimately, PEWS may not include all relevant clinical factors needed to make efficient decisions on escalation of care and further studies are required.
What are the key strengths of the article? The study design addressed concerns of physician behavior as a cause of increase ICU transfers by creating a secondary outcome to assess subsequent critical deterioration events and initiation of a life-sustaining intervention after transfer. In addition, to capture the difficulty of behavior assessments with PEWS overnight and the differences in normal heart rate ranges, a nighttime event was noted. Furthermore, in the analysis, the authors applied Poisson regression with robust error variance to calculate relative risks in order to improve accuracy of standard error and confidence intervals with increasing outcome incidence.
Are there any limitations or flaws in the article? One limitation is the study took place during the winter season, where 56% of the patients had a viral respiratory infection. Since fever is an expected part of a viral infection, these patients may be overrepresented. Furthermore, the study population may not reflect other general pediatric wards in the country. There was a small sample size in a single institution where higher acuity interventions are used on the floor. Lastly, the marginally significant adjusted relative risk comparing fever to unplanned ICU transfer in the multivariable analysis is not reliable because the upper confidence limit crossed one.
What is the major takeaway message? Fever is likely one of many clinical variables to confound interpretation of PEWS, therefore limiting its utility as stand-alone trigger tool for care escalation. A powered study on association between additional clinical factors and patient outcomes may improve current PEWS and create a novel illness severity score. This study may offer care teams the ability to make more informed decisions at the point of care by offering evidence on impact of fever on both PEWS and patient outcomes.
Describe how this article should impact our practice: In an era of greater reliance on technology, physicians should advocate the use of PEWS embedded in many of our EMR systems. The use of PEWS redirects care team members’ attention to patients at risk for deterioration, empowers nurses to escalate care, and standardizes language to reduce rates of cardiopulmonary arrests. By analyzing PEWS outcomes at our own institutions, we can modify the scoring system to better allocate hospital resources, and decrease morbidity and mortality.
Fellow: Hanna Siddiqui MD, MPH | UCLA Mattel Children’s Hospital
Fellow Accomplishments/Current Work: My current research projects as a Pediatric Hospital Medicine Fellow include medical education on pediatric delirium, and also analyzing hospitalized children who have received continuous vancomycin infusion therapy. Additionally, I have the wonderful opportunity to volunteer with UMMA Clinic and Islah LA, providing free healthcare and advocating for healthy living to underserved communities in southern California.
Future plans: I am excited to state I will be staying at UCLA as a Hospitalist to pursue my career at an institution where there is a thirst for knowledge encouraging us to be students for life.
Fun Fact: Since the age of 18, I’ve lived in different places including Los Angeles, Washington DC, New York City, Oakland, Newcastle upon Tyne in the United Kingdom, and the Caribbean islands. When I visit a new city, I enjoy biking through different neighborhoods and absorb its culture, beauty, and diversity. My favorite memories including biking in Marrakech and Paris.
Fellow Accomplishments/Current Work: My current research projects as a Pediatric Hospital Medicine Fellow include medical education on pediatric delirium, and also analyzing hospitalized children who have received continuous vancomycin infusion therapy. Additionally, I have the wonderful opportunity to volunteer with UMMA Clinic and Islah LA, providing free healthcare and advocating for healthy living to underserved communities in southern California.
Future plans: I am excited to state I will be staying at UCLA as a Hospitalist to pursue my career at an institution where there is a thirst for knowledge encouraging us to be students for life.
Fun Fact: Since the age of 18, I’ve lived in different places including Los Angeles, Washington DC, New York City, Oakland, Newcastle upon Tyne in the United Kingdom, and the Caribbean islands. When I visit a new city, I enjoy biking through different neighborhoods and absorb its culture, beauty, and diversity. My favorite memories including biking in Marrakech and Paris.
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