Table 1 Candidate items evaluated for Bedside PEWS score
From: Development and initial validation of the Bedside Paediatric Early Warning System score
Item | Item sub-score | ||||
|---|---|---|---|---|---|
Age group | 0 | 1 | 2 | 4 | |
Heart rate | 0–3 months | >110 and <150 | ≥ 150 or ≤ 110 | ≥ 180 or ≤ 90 | ≥ 190 or ≤ 80 |
3–12 months | >100 and <150 | ≥ 150 or ≤ 100 | ≥ 170 or ≤ 80 | ≥ 180 or ≤ 70 | |
1–4 years | >90 and <120 | ≥ 120 or ≤ 90 | ≥ 150 or ≤ 70 | ≥ 170 or ≤ 60 | |
4–12 years | >70 and <110 | ≥ 110 or ≤ 70 | ≥ 130 or ≤ 60 | >150 or ≤ 50 | |
>12 years | >60 and <100 | ≥ 100 or ≤ 60 | ≥ 120 or <50 | ≥ 140 or ≤ 40 | |
Systolic blood pressure | 0–3 months | >60 and <80 | ≥ 80 or ≤ 60 | ≥ 100 or ≤ 50 | ≥ 130 or ≤ 45 |
3–12 months | >80 and <100 | ≥ 100 or ≤ 80 | ≥ 120 or ≤ 70 | ≥ 150 or ≤ 60 | |
1–4 years | >90 and <110 | ≥ 110 or ≤ 90 | ≥ 125 or ≤ 75 | ≥ 160 or ≤ 65 | |
4–12 years | >90 and <120 | ≥ 120 or ≤ 90 | ≥ 140 or ≤ 80 | ≥ 170 or ≤ 70 | |
>12 years | >100 and <130 | ≥ 130 or ≤ 100 | ≥ 150 or ≤ 85 | ≥ 190 or ≤ 75 | |
Capillary refill | <3 sec | ≥ 3 sec | |||
Pulses | Normal | Weak | Doppler or bounding | Absent | |
Bolus fluid | No | Yes | |||
Respiratory | 0–3 months | >29 and <61 | ≥ 61 or ≤ 29 | ≥ 81 or ≤ 19 | ≥ 91 or ≤ 15 |
rate | 3–12 months | >24 or <51 | ≥ 51 or ≤ 24 | ≥ 71 or ≤ 19 | ≥ 81 or ≤ 15 |
1–4 years | >19 or <41 | ≥ 41 or ≤ 19 | ≥ 61 or ≤ 15 | ≥ 71 or ≤ 12 | |
4–12 years | >19 or <31 | ≥ 31 or ≤ 19 | ≥ 41 or ≤ 14 | ≥ 51 or ≤ 10 | |
>12 years | >11 or <17 | ≥ 17 or ≤ 11 | ≥ 23 or ≤ 10 | ≥ 30 or ≤ 9 | |
Respiratory effort | Normal | Mild increase | Moderate increase | Severe increase/any apnoea | |
Saturation | >94 | 91–94 | ≤ 90 | ||
Oxygen therapy | Room air | Any – <4 L/min or <50% | ≥ 4 L/min or ≥ 50% | ||
Level of consciousness | Normal Consolable Rouseable Bromage 0,1,S | Bromage score 2–3 Irritable | |||
Temperature °C | ≥ 36 and ≤ 38.5 | <36 or >38.5 | <35 or >40 | ||