Journal of Pediatric Nursing (2013) 28, 171178

The Cardiac Children's Hospital Early Warning Score

(C-CHEWS)1,2
Mary C. McLellan BSN, RN, CPN a,, Jean A. Connor DNSc, RN, CPNP b
a
Cardiovascular Program Inpatient Unit, Boston Children's Hospital, Boston, MA
b
Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA

Key words:
Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other
Cardiopulmonary arrest;
hospitalized children. Pediatric early warning scoring tools have helped to provide early identification
Cardiopulmonary arrest
and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring.
prevention;
However, the tools have rarely been used and have not been validated in the pediatric cardiac
Cardiac;
population. This paper describes the modification of a pediatric early warning scoring system for
Early warning scores;
cardiovascular patients, the implementation of the tool, and its companion Escalation of Care Algorithm
Rapid response
on an inpatient pediatric cardiovascular unit.
2013 Elsevier Inc. All rights reserved.

Background
Arrest Prevention
PEDIATRIC CARDIOPULMONARY ARRESTS have
been reported in 0.72% of all pediatric inpatient admissions
(Reis, Nadkarni, Perondi, Grisi, & Berg, 2002; Slonim, Patel,
Ruttimann, & Pollack, 1997; Suominen, Olkkola, Voipio,
Korpela, Palo, & Rasanen, 2000) and 5.514% of intensive
care unit (ICU) admissions (Reis et al., 2002; Rhodes et al.,
1999; Suominen et al., 2000) despite diligent monitoring
(Akre, Finkelstein, Erickson, Liu, Vanderbilt, & Billman,
2010; Nadkarni et al., 2006; Reis et al., 2002; Suominen
et al., 2000) and advances in medicine and technology.
Survival to discharge outcomes are poor (1137%) for
children that experience an in-hospital cardiopulmonary
arrest (Brilli et al., 2007; Lopez-Herce et al., 2004; Meaney
1
This paper did not receive any extramural or commercial support.
2
This paper was presented at the Cardiology 2010 conference in
Orlando, FL, in February 2010 as an oral abstract.
Corresponding author: Mary C. McLellan, BSN, RN, CPN.
E-mail address: mary.mclellan@childrens.harvard.edu
(M.C. McLellan).
et al., 2006; Nadkarni et al., 2006; Parra et al., 2000; Reis
et al., 2002; Samson, Berg, & Berg, 2006; Samson, Nadkarni,
et al., 2006; Slonim et al., 1997; Suominen et al., 2000; Tibballs
& Kinney, 2009; Young & Seidel, 1999). Symptoms of
deterioration may be present 612 hours prior to arrest
events, had these symptoms been recognized and treated
sooner, almost two-thirds of in-hospital pediatric cardiopul-
monary arrests may have been prevented (Pearson, Ward-
Platt, Harnden, & Kelly, 2010; Akre et al., 2010; Parshuram,
Hutchinson, & Middaugh, 2009; Schein, Hazday, Pena,
Ruben, & Sprung, 1990; Tibballs & Kinney, 2009; Tume,
2007). Given the dismal survival rate of in-hospital cardiac
arrest, it is critical to develop systems that recognize
predictable clinical warning signs and intervene before
patients reach the point of arrest (VanVoorhis & Willis,
2009, p. 919).
To improve outcomes for patients at risk for clinical
deterioration and cardiopulmonary arrest, hospitals have
been charged by several international committees to
implement systems that identify signicantly abnormal
values and then trigger an immediate treatment response
(Berwick, Calkins, McCannon, & Hackbarth, 2005; DeVita
et al., 2006; Peberdy et al., 2007). Hospitals initiated rapid
response teams (RRTs), also known as patient at risk teams

0882-5963/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pedn.2012.07.009
172 M.C. McLellan, J.A. Connor

(PART), critical care outreach (CCO), or medical emergency
teams (MET), as an adjunct to their code blue teams to
provide this immediate treatment for patients that are
identied as being at risk for deterioration and possible arrest
(Brilli et al., 2007; Hanson et al., 2009; Hillman, Parr,
Flabouris, Bishop, & Stewart, 2001; Hunt et al., 2008;
Salamonson, Kariyawasam, van Heere, & O'Connor, 2001;
Sharek et al., 2007; Tibballs & Kinney, 2009; Tibballs,
Kinney, Duke, Oakley, & Hennessy, 2005; ul-Haque,
Saleem, Zaidi, & Haider, 2010; VandenBerg, Hutchison, &
Parshuram, 2007; VanVoorhis & Willis, 2009; Zenker et al.,
2007). The RRTs are dened as an interdisciplinary group
that resemble Code teams in that they are staffed by health
care professionalsUnlike a Code team, a RRT is summoned
before a code occursto initiate changes in care that prevent
the arrest, or by facilitating transfer to an intensive care unit
(Berwick et al., 2005, p. 324). Pediatric RRTs have been
composed of PICU physicians, ICU RNs, respiratory
therapists, ED physicians and/or a supervisor for patient
placement (Brilli et al., 2007; Hanson et al., 2009; Sharek
et al., 2007; Tibballs & Kinney, 2009; Tibballs et al., 2005;
ul-Haque et al., 2010; VanVoorhis & Willis, 2009;
VandenBerg et al., 2007; Zenker et al., 2007). Pediatric
RRTs typically respond to the bedside within 515 minutes
of activation to assess patients, write orders for any diagnostic
studies or interventions, discuss management with the
primary team, and determine optimal location for the patient
(Brilli et al., 2007; Hanson et al., 2009; Sharek et al., 2007;
Tibballs & Kinney, 2009; Tibballs et al., 2005; ul-Haque
et al., 2010; Zenker et al., 2007). Studies have reported
reduction in pediatric inpatient cardiopulmonary arrests,
reduction in mortality rates, and improved survival outcomes
post-arrest following the implementation of RRTs (Chan,
Jain, Nallmothu, Berg, & Sasson, 2010; Chapman, Grocott,
& Franck, 2010; Hunt et al., 2008; Tibballs & Kinney, 2009).
Activation criteria for when to call RRTs have been
developed by hospitals based upon retrospective reviews
and/or clinician consensus (Brilli et al., 2007). Activation
criteria may be a combination of physiological parameters
and/or subjective assessments. Early warning scoring tools
are tools that may be used as activation triggers for hospitals'
RRTs. There are three types of early warning tools: (1) single
and multiple parameter systems which trigger a response
when one or more parameters achieve a dened threshold;
(2) aggregate systems which weigh observations based upon
abnormality and a summary of the scores are achieved; and
(3) combination systems which have single or multiple
parameter systems with aggregate weighted scoring systems
(Gao et al., 2007).
Pediatric Early Warning Scores
Pediatric early warning scores (PEWS) tools have been
created based on previously developed adult early warning
scoring tools. Pediatrics create a unique challenge in the
development of early warning scoring tools in that vital sign
norms are aged-based whereas in adults these norms are
more nite (Brilli et al., 2007). The PEWS published by
Monaghan (2005) (Figure 1) is an aggregate tool based on
three assessment domains: behavior, cardiovascular and
respiratory with each domains' score ranging from 0 to 3,
with 3 being the highest severity of illness (Monaghan,
2005). Components of the PEWS' domains are based on
bedside physical assessments and do not require familiarity
with the patient or patient's history or clinical values (i.e.
recent laboratory values), which contributes to the ease of
bedside use compared to other pediatric early warning
scoring tools which do require additional patient informa-
tion (Duncan, 2006; Duncan, Hutchison, & Parshuram,
2006; Edwards, Powell, Mason, & Oliver, 2009; Haines,
Perrott, & Weir, 2006; Tibballs, 2006). Nurses complete the
assessment, total the score, and are guided to follow a four-
tiered escalation of actions guide based upon the PEWS
score (Monaghan, 2005; Tucker, Brewer, Baker, Demeritt,

Pediatric Early Warning Score (PEWS)

0 1 2 3 Score
Behavior / Neuro Playing / Sleeping Irritable Lethargic /
appropriate confused OR
reduced
response to pain
Cardiovascular Pink OR Pale OR Grey OR Grey OR
capillary refill capillary refill capillary refill 4 Mottled OR
1-2 seconds 3 seconds seconds OR capillary refill
heart rate > 20 5 seconds OR
above normal heart rate > 30
rate above normal
rate OR
bradycardia
Respiratory Within normal >10 above > 20 above 5 < normal
parameters, no normal normal parameters with
retractions parameters, parameters retractions
using accessory Retractions OR Grunting OR
muscles OR 40 % FiO2 or 50 % FiO2 or
30 % FiO2 or 6+ L/min 8 L/min
3 L/min
Total:

Figure 1 The Pediatric Early Warning Score (PEWS) tool (Monaghan, 2005).
The Cardiac Children's Hospital Early Warning Score (C-CHEWS)
& Vossmeyer, 2008). A separate study of this PEWS tool
demonstrated that critical PEWS scores occurred a median
of 11.5 hours prior to events with the shortest time preceding
the event to be 35 minutes (Akre et al., 2010). This PEWS
was validated in a cohort of pediatric patients admitted to a
general medicine unit, the area under the receiver operating
characteristic curve was 0.89 (95% CI=0.840.94, pb.001)
(Tucker et al., 2008).
In 2008, Children's Hospital Boston, an academic tertiary
pediatric institution, participated in the Child Health
Corporation of America Collaborative, Eliminating Codes
on the Inpatient Units. As part of this collaborative, the
previously mentioned PEWS was modied into the Chil-
dren's Hospital Early Warning Score (CHEWS). The
CHEWS incorporated the PEWS' domains and scoring,
plus the addition of two subjective domains of family
concern and staff concern which add one point each to a half the patient population is less than 1 year of age. Ten of
patient's score if it is present (Kleinman & Romano, 2010).
Higher scores are indicative of higher severity of deteriora-
tion symptoms and will trigger the nurse to activate
resources to the patient's bedside based on a three-tiered,
color-coded Escalation of Care Algorithm (Figure 4). The
patient's nurse is responsible for tallying the score at the time
of vital sign assessment, typically every 4 hours. A colored
indicator (green, yellow or red), representative of the
patient's last CHEWS score, is placed by patients' names
on the unit's locator board providing easy visibility of all the
patients' CHEWS statuses for the unit. The CHEWS system
was rst piloted in 2008 on three surgical units with a total of
90 beds. During the pilot phase there was an increase in ICU
evaluations (non-urgent assessment by an ICU MD or ICU
RN) with an associated decrease in ICU STAT (rapid
assessment by an ICU MD, ICU RN, respiratory therapies
and an intermediate care unit MD) and code blue calls
(Kleinman & Romano, 2010). The tool and algorithm were
implemented throughout the rest of the inpatient medical and
surgical units following the success of the pilot. Based on the
positive evaluation of the CHEWS tool, the hospital's
leadership directed that the tool also be used in the acute care
cardiovascular unit.
Sample and Setting
Pediatric cardiovascular patients have the highest inci-
dence of cardiopulmonary arrests as compared to other
hospitalized children (Berg, Nadkarni, Zuercher, & Berg,
2008; Hunt et al., 2008; Parra et al., 2000; Rhodes et al., 1999;
Samson, Nadkarni, et al., 2006). They are unlike other
pediatric populations whose arrest etiology is typically
respiratory failure and/or circulatory shock (Berg et al.,
2008; Lopez-Herce et al., 2004; Nadkarni et al., 2006; Reis
et al., 2002; Samson, Berg, & Berg, 2006; Samson, Nadkarni
et al., 2006; Tibballs & Kinney, 2009). Instead, cardiac
patients have a different arrest etiology with arrhythmia
accounting for 41% of acute decompensation events (Berg et
173
al., 2008; Parra et al., 2000; Rhodes et al., 1999; Samson,
Nadkarni, et al., 2006). In addition to arrhythmias, children
with cyanotic congenital heart defects may have baseline
cyanosis which would be atypical of other pediatric
populations. The sample population for the validation study
of the original PEWS did not include cardiac patients and
was limited to patients admitted to a single medical unit
(Tucker et al., 2008). With these differences in mind, it was
unclear whether the previous PEWS or CHEWS tools would
be effective for pediatric cardiovascular patients. Therefore it
was important to study the CHEWS tool for feasibility,
relevance, and agreement prior to implementing it in a
pediatric cardiac unit.
Our hospital's cardiovascular unit is a 42-bed cardiac
medical and surgical telemetry unit with patients ranging in
age from newborn to adult. Within this age range more than
the beds are considered higher dependency beds where the
nurse to patient ratio is 1:2, the remaining beds are staffed at
1:3. Patients needing the higher dependency beds are those
who may be less clinically stable, such as those requiring
inotropic support, and require either more nursing care and/
or more frequency assessment.
Purpose
The purpose of this manuscript is to describe the
implementation and subsequent modications of the
CHEWS tool and its companion Escalation of Care
Algorithm for pediatric cardiovascular patients and early
detection of deterioration and prevention of cardiopulmonary
arrests or unplanned transfers to a cardiac ICU (CICU).
Methods
Tool Modification
A pilot study consisting of current electronic health
record documentation and clinician interview was imple-
mented on the cardiac unit. A single staff nurse, qualied
in the use of the CHEWS tool, scored all the patients
(n = 27; observations = 157) on the unit during two
consecutive 12-hour shifts. Scores were based on docu-
mentation in patients' electronic health records. The pilot
study nurse concurrently interviewed the charge nurse and
the patients' nurses, nurse practitioners or fellows and
asked each of them to identify which of the their patients
were most acute and/or had them concerned. Nurses
indicated during the interviews whether patients' families
had concerns or were absent from the bedside and this
information was utilized to score the family concern
domain of the CHEWS. Data from the patients' clinical
events during the pilot, bed assignment (higher dependency
174
Discrepancies between CHEWS and C-CHEWS scores and
patients' clinical presentation
35%
30% 29.6%
25%
20%
15%
10%
7.5%
5%
0%
CHEWS pilot First C-CHEWS
Figure 2 Discrepancies between C-CHEWS scores and patients'
clinical presentation during pilot events of tool and modied tools.
bed or not), and the clinicians' assessments from the
interviews were documented.
The clinicians' assessments, patients' clinical events
during the pilot, bed assignment and the calculated
CHEWS scores were compared. There was consistent
agreement about patients' acuity among the clinicians'
assessments, bed assignments, and clinical events and these
were used to describe the patients' clinical presentations.
Nearly one-third (29.6%, n=8) of the patients had lower
CHEWS scores than the acuity severity of their clinical
presentation should have warranted (Figure 2). Of the
patients that scored too low, three patients were urgently
transferred to the CICU during the pilot, with one being
intubated upon arrival to the CICU. None of the three
patients' CHEWS scores were above a normal range and
M.C. McLellan, J.A. Connor
therefore would not have triggered an escalation of care
response using the CHEWS tool.
An expert multidisciplinary panel from the CICU, ICU
and cardiac unit reviewed the patients' clinical presentations
and CHEWS scores. The following areas were identied as
sources for the score discrepancies:
Behavior: sleeping appropriately was absent from
the CHEWS resulting in sleeping patients unnecessar-
0.0%
Final C-CHEWS
ily scoring 1 point for this behavior.
Cardiovascular: presence of arrhythmia was absent
from the CHEWS; heart rate range limits in the
CHEWS did not account for the wide age range of
patients, especially the newborns and infants.
Respiratory: presence of apnea or cyanosis was absent
from the CHEWS; oxygen ow rates on the CHEWS
was too high for younger patients; and respiratory rate
range limits of the CHEWS did not accommodate the
wide age range of patients, especially the newborns
and infants.
The tool was then modied to account for these variables
and became the Cardiac Children's Hospital Early Warning
Score (C-CHEWS) tool. A second pilot was conducted with
the new C-CHEWS tool using the previously described
methods (n=53; observations=312). Analysis of the data
collection revealed 7.5% (n=4) of the patients' C-CHEWS
scores did not correlate with the acuity of their clinical
picture, however this time it was an equal mix of patients

Cardiac-Childrens Hospital Early Warning Score

0 1 2 3 Score
Behavior/Neuro Playing/sleeping Sleepy, somnolent when Irritable, difficult to console Lethargic, confused, floppy
appropriately not disturbed Increase in patients baseline Reduced response to pain
Alert, at patients seizure activity Prolonged or frequent seizures
baseline Pupils asymmetric or sluggish
Cardiovascular Skin tone Pale Grey Grey and mottled
appropriate for Capillary refill 3-4 seconds Capillary refill 4-5 seconds Capillary refill >5 seconds
patient Mild* tachycardia Moderate* tachycardia Severe* tachycardia
Capillary refill Intermittent ectopy or New onset bradycardia
2 seconds irregular HR(not new) New onset/increase in ectopy,
irregular HR or heart block
Respiratory Within normal Mild* tachypnea/ Moderate* tachypnea/increased Severe* tachypnea
parameters increased WOB (flaring, WOB (flaring, retracting, grunting, RR < normal for age
no retractions retracting) use of accessory muscles) Severe increased WOB (i.e. head
Up to 40% supplemental 40-60 % oxygen via mask bobbing, paradoxical breathing)
oxygen 1-2 L NC > patients baseline need >60 % oxygen via mask
Up to 1L NC > patients Nebs q 1-2 hr > 2 L NC > patients baseline need
baseline need Moderate desaturations < patients Nebs q 30 minutes 1 hr
Mild desaturations < baseline Severe desaturations < patients
patients baseline Apnea requiring repositioning or baseline
Intermittent apnea self- stimulation Apnea requiring interventions other
resolving than repositioning or stimulation
Staff Concern Concerned
Family Concern Concerned or absent
Total

Mild* Moderate* Severe*

Infant 10% for age 15% for age 25% for age
Toddler and Older 10% for age 25% for age 50% for age

Figure 3 The Cardiac Children's Hospital Early Warning Score.

The Cardiac Children's Hospital Early Warning Score (C-CHEWS) 175

either scoring too high or too low (Figure 2). Analysis
revealed that the presence of patients' baseline abnormalities
accounted for these discrepancies:
Behavior: baseline seizures
Cardiovascular: baseline arrhythmias
Respiratory: baseline use of supplemental oxygen ow
rate, baseline cyanosis.
The tool was modied such that should a patient have any
of these pre-existing abnormalities at baseline they would not
score high, whereas if a patient had a new onset of any of
those clinical ndings, or it was unknown whether this was
normal for the patient (i.e. new admission), the ndings
would still generate a higher C-CHEWS score.
The third and last pilot event (n = 20; observations = 119)
with the updated C-CHEWS tool demonstrated 100% of the
C-CHEWS scores matched the acuity of patients' clinical
presentations (Figure 2). The nal version of the C-CHEWS
tool was approved for use on the cardiac unit (Figure 3) and
the Escalation of Care Algorithm (Figure 4) conformed with
existing critical response structures within the Cardiovas-
cular Program.
The Escalation of Care Algorithm is an escalation of
resources to a patient's bedside to assess and treat
deterioration based upon the C-CHEWS score. A C-
CHEWS score of 02 (color code: green) recommends for
clinicians to continue routine care, monitoring and assess-
ments. A C-CHEWS score of 34 (color code: yellow)
instructs the patient's nurse to notify the charge nurse and
patient's resident or nurse practitioner of the elevated score.
These clinicians discuss as a team a treatment plan for the
patient, initiate the plan and increase the frequency of patient
assessments. The unit's charge nurse may consider assigning
the patient a higher dependency bed status, which would
place the patient in a 1:2 patient assignment rather than the
typical 1:3, thereby making it more feasible for the patient's
nurse to increase assessments and monitoring of the patient
and implement the recommended modications to the
treatment plan. If a patient scores a 5 or greater (color
code: red), the same steps are followed as described for color
code yellow (score 34) with the addition of notifying the
patient's attending physician of their patient's elevated C-
CHEWS score. The patient's resident or nurse practitioner
must also examine the patient when they are notied of the
high C-CHEWS score. As a team the clinicians determine if
a CICU evaluation should be activated to assess for CICU
transfer. It is not uncommon for patient's C-CHEWS scores
to remain elevated while the treatment plan is initiated.
Should the score increase during the treatment phase, the
algorithm is activated again.
Implementation of the C-CHEWS Tool
All of the cardiovascular staff were required to complete
a short, computer-based learning module using three case
studies. In addition, this educational material was reinforced
during staff meetings and the unit's monthly newsletter. The
C-CHEWS tool and companion Escalation of Care
Algorithm were posted throughout the unit for reference
before and during implementation. The education initiative
occurred over a 2-month period and all clinical staff knew
the date designated for the tool to go-live and become
standard of care.

Approach to the Deteriorating Patient on Cardiac Inpatient Units:

Escalation of Care: Cardiac - Childrens Hospital Early Warning Score
(C-CHEWS) Assessment Algorithm

02
Continue assessments every 4 hours
(Green)

34 Notify charge nurse and MD/NP Consider a higher

Discuss treatment plan as a team level of care (ICP)
(Yellow)
Increase frequency of assessments

Consider activation of
5 MD/NP evaluation at bedside 8 South Evaluation
Notify attending physician
(Red) via charge nurse and
Discuss treatment plan as a team
possible ICU transfer

For immediate assistance at any time:

CARDIAC CODE (x5-5555)

Figure 4 Escalation of Care Algorithm for the C-CHEWS for the inpatient cardiac ward.
176 M.C. McLellan, J.A. Connor

CHEWS score into the electronic record is that it allows for

trending of scores in relation to patients' vital signs. The
additional assessments help to identify quickly patients that
are trending towards deterioration. Patients' C-CHEWS score
and color code are displayed in real-time on the electronic unit
census (Figure 5) which helps clinicians to immediately
identify the patients who need closer attention.
Audits were done 1-month following the implementation
of C-CHEWS documentation as standard of care. The audits
were performed two to three times per week on 10
randomized patients' charts for a total of 16 weeks to assess
compliance with C-CHEWS documentation and utilization
of the companion algorithm. Staff members were given
feedback about documentation and any processes needing
improvement. They also were asked if there were any system
issues that could be improved. The entire process from the
initial pilot to complete implementation totaled 6 months.

Unplanned CICU Transfers After

Figure 5 Example of C-CHEWS scores and colors displayed on
the electronic unit census.
The C-CHEWS was incorporated into the electronic health
record in anticipation of the unit-based implementation.
Nurses select from a drop-down list the numbered options
that correspond to their patient's assessment in each of the
ve C-CHEWS domains and the software calculates the
score. Based on the score, the nurse follows the C-CHEWS
Escalation of Care Algorithm and documents the actions
taken. Documentation of the C-CHEWS score takes the nurse
less than 10 seconds. The benet of incorporating the C-
C-CHEWS Implementation
The C-CHEWS tool has provided real-time trigger
responses which have activated necessary resources to
pediatric cardiovascular patients who are deteriorating on
the inpatient cardiac unit. Chart review of patients who have
had an unplanned transfer to the CICU or experienced an
arrest on the cardiac unit typically had elevated C-CHEWS
scores. The exception to this nding was patients who
experienced sudden onset of compromising arrhythmia. This
review suggests that the C-CHEWS may be effective in
identifying the majority of patients in the cardiovascular
pediatric population who are at risk for arrest or critical
adverse events earlier to allow for intervention and prevent
such events from occurring.

Unplanned Transfers (Jan 2009-Dec 2010)

18 18

16 16

14
14 Freq per 1000 patient days
# of unplanned transfers

12
12
10
10
8
8
6
6
4
4
2

2 0

0 -2
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-
09 09 09 09 09 09 09 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 10

Transfers to 8S Trans/1000 patient days Mean Trans/1000 patient days LCL UCL

Figure 6 Change in unplanned transfers to the CICU from the cardiac ward before and after C-CHEWS implementation.
The Cardiac Children's Hospital Early Warning Score (C-CHEWS)
In addition, the hospital has been tracking unplanned
transfer events for several years as part of several quality
improvement initiatives. In comparing the rate (transfers per
1000 patient days) of these events 1 year pre- and 1 year post-
C-CHEWS implementation, there has been a reduction in
unplanned transfers (Figure 6). The frequency has largely
remained below the mean number of transfers per 1000
patients. This may suggest that patients are being treated
earlier therefore preventing the necessity of a CICU transfer.
Discussion
Nurses often verbalize that they feel or sense something
is not right with their patient however the subtle differences
in the patient's presentation causing their unease may not be
evident to the physicians as quantiable changes are minimal
and there is nothing obvious to treat (Andrews & Waterman,
2005). An early warning score can be an effective tool for
nurses to use when communicating concern about subtle
changes in the patient as the score provides a common
language between nurses and physician colleagues (Andrews
& Waterman, 2005). Early warning scoring tools provide an
agreed upon framework (algorithm) for escalation of
assessing and treating patients, which can empower nurses
and interns to contact attending physicians more readily
(Andrews & Waterman, 2005).
An objective scoring tool adjusts for familiarity with the
patient and can heighten awareness of slow deterioration.
The C-CHEWS score is calculated using the current vital
signs and clinical assessment of the patient thus providing a
real-time score to the clinician as to whether the patient may
be deteriorating. The score does not rely on further
information (i.e. calculated urine output) obtained away
from the bedside to provide essential or necessary data. This
fact helps to decrease any reliance on knowledge of the
patient, patient's history or level of clinician experience for
interpreting additional data.
Pediatric cardiac patients are at higher risk for cardiopul-
monary arrests than other hospitalized children. Arrest
prevention will improve patient outcomes and survival for
hospitalized pediatric cardiovascular patients. The C-
CHEWS is an early warning scoring tool specic for this
high-risk, vulnerable population and may assist clinicians in
recognizing and treating these patients early and prevent
arrests from occurring.
Limitations
This is a single center experience of an acute pediatric
cardiovascular care unit and may not be generalized to all
pediatric cardiovascular units. Formal validation of the C-
CHEWS tool, including sensitivity and specicity are
needed. At the time of this writing, formal validity testing
is proceeding within the institution for the C-CHEWS tool in
177
both the inpatient cardiac and non-cardiac units with
favorable preliminary data. The institution is also tracking
whether there is a sustainable decrease in unplanned CICU
transfers since the implementation of the C-CHEWS tool and
companion Escalation of Care Algorithm on the cardiac unit.
Conclusions
The C-CHEWS is a tool that was specically created for
identifying pediatric cardiovascular patients at risk for
deterioration, the tool previously used at our hospital was
not effective for this patient population. The C-CHEWS tool
and companion Escalation of Care Algorithm provides a
standardized assessment and approach to deteriorating
patients, ensuring that there is the appropriate dispersal of
resources allocated to the acuity of the patients. Early
activation of resources to at-risk patients' bedsides provides
early treatment of deterioration and may prevent cardiopul-
monary arrests or unplanned CICU transfers.
Acknowledgments
We would like to thank Roger E. Breitbart MD, Jane C.
Romano MS, RN, Monica Kleinman, MD and Suzanne
Reidy MS, RN, NE-BC for participating in the expert multi-
disciplinary panel.
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