Illness severity, deterioration and track-and-trigger systems — formative SAQs

SAQ 1 — Overnight PEWS rise with incomplete chart (20 marks, ~15 minutes)

A 4-year-old is on the general paediatric ward with viral wheeze on night two. At 02:10 the nurse shows you a rising multi-parameter PEWS. Oxygen requirement has increased. Blood pressure and capillary refill have not been recorded for 6 hours. The mother says, “She is not herself.” The numerical band is still below the hospital’s automatic MET threshold. [1] [2]

Questions

1. Distinguish illness severity, physiological instability, risk of deterioration and failure-to-rescue in this vignette. (4 marks) [1] [2]
2. List the seven BedsidePEWS items and the score range 0–26. State what you must not invent at the bedside. (4 marks) [1] [2]
3. Outline your immediate bedside actions, including how incomplete observations and caregiver concern change escalation. (6 marks) [1] [2]
4. Give a structured MET/senior activation handover in ISBAR form. (3 marks)
5. Name two evidence-based reasons cardiac arrest is a poor sole quality metric here. (3 marks)

Model answer

1. Four axes (4)

• Severity: how ill she looks/feels now (effort, oxygen need, interaction). [1] [2]
• Instability: whether airway/breathing/circulation/consciousness are failing this minute. [1] [2]
• Risk of deterioration: trajectory overnight if support is delayed. [1] [2]
• Failure-to-rescue: system risk if incomplete chart and concern are not acted on. [4] [12]

2. BedsidePEWS (4)
Heart rate; systolic blood pressure; capillary refill; respiratory rate; respiratory effort; SpO2; oxygen therapy; total 0–26. Do not invent local age-band numeric cut-offs or colour thresholds from memory — use the hospital chart. [1] [2]

3. Immediate actions (6) [1] [2]

• Go to the bedside; call for help early; ABCDE while reviewing trend. [1] [2]
• Complete missing BP/CRT if safe; do not wait for a perfect score. [1] [2]
• Treat reversible threats (oxygen delivery, work of breathing, fatigue, glucose if indicated). [1] [2]
• Escalate on concern and trajectory, not only on automatic band — caregiver concern is an independent risk signal. [1] [2]
• Increase observation frequency / senior review / MET per local hybrid rules and clinical judgement. [9] [4]

4. ISBAR (3)
Identity/baseline; Situation (time, rising PEWS, incomplete items, maternal concern); Background (wheeze day 2); Assessment (respiratory threat, possible exhaustion); Recommendation (MET attendance, continuous monitoring, possible HDU). [17]

5. Metrics (3)
Ward arrest/death are rare; Bonafide supports critical deterioration as a proximate outcome; EPOCH used significant clinical deterioration events as a secondary outcome when mortality was unchanged. [3] [12]

SAQ 2 — System design after a near-miss (20 marks, ~15 minutes)

After a near-miss unplanned ICU transfer, the governance committee asks you to defend the hospital’s paediatric early-warning programme using EPOCH, systematic reviews and rapid-response design principles. The hospital has a colour chart but inconsistent family activation and frequent underscoring at night. [1] [2]

Questions

1. Summarise EPOCH’s primary and key secondary results without overclaiming. (5 marks) [1] [2]
2. Explain why “having a PEWS chart” is not the same as an early-warning system or a rapid-response system. (5 marks) [1] [2]
3. List the four consensus limbs of a rapid-response system and map one improvement action to each limb for this hospital. (6 marks) [1] [2]
4. How should caregiver concern and complex chronic disease change programme design? (4 marks)

Model answer

1. EPOCH (5)
Cluster RCT, 21 hospitals, BedsidePEWS vs usual care without severity score. All-cause mortality not significantly different (adjusted OR 1.01, 95% CI 0.61–1.69). Significant clinical deterioration events lower with BedsidePEWS (adjusted rate ratio 0.77, 95% CI 0.61–0.97). Do not claim mortality reduction. [3]

2. Chart vs system (5) [1] [2] Track-and-trigger tool = documentation and score. Early-warning system adds education, escalation recommendations, culture and audit (PUMA/Trubey framing). Rapid-response system adds afferent detection, efferent team, governance and process improvement. A colour chart alone cannot rescue if no one may call or come. [4] [13]

3. Four limbs + actions (6) [1] [2]

• Afferent: fix night-time complete observation standards; electronic hard-stops for missing items. [1] [2]
• Efferent: 24/7 MET with clear activation script including concern criteria. [1] [2]
• Governance: roster education, authority gradient policy, family-activated pathway. [1] [2]
• Process improvement: audit underscoring, response times and critical deterioration, not only arrests. [13] [12]

4. Concern and complexity (4) [1] [2] Proactively ask about caregiver concern; escalate despite low scores (Mills). For medical complexity, document personal baselines, devices and emergency plans so scores are interpreted against the child’s normal. [9] [16]