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The use of early warning scoring systems has become commonplace over recent years. This is reflected in the recent NICE guidance on acutely ill patients in hospital. 1 Evaluation of such systems has taken place in clinical settings such as adult acute medical admissions units, 2 postoperative surgical wards 3 and, more recently, the emergency department (ED). 4 5 Existing paediatric early warning scoring systems have concentrated on hospitalised patients 6 - 9 and may be less useful for initial assessment in the ED. The aim of this study was to design and validate a scoring system to identify children attending the ED in need of urgent medical assessment and appropriate intervention.
METHODS
A Paediatric Advanced Warning Score (PAWS) chart was designed. The chart uses physiological parameters (respiratory rate, work of breathing, oxygen saturation, temperature, capillary refill, heart rate and conscious level), taking into account age-related differences between normal values. In each parameter, increasing deviation from the normal is given a greater score. The scores for all of the different parameters are cumulated to produce a single numerical value ( figs 1 and 2 ). The more abnormal the physiological parameters recorded, the higher the PAWS score obtained. The normal values used in the chart were taken from the Advanced Paediatric Life Support (APLS) guidelines. 10
We completed a pilot study to validate the scoring system by performing a retrospective analysis of children attending the ED of James Cook University Hospital, Middlesbrough. Fifty consecutive patients who required admission directly from the ED to the paediatric intensive care unit (PICU) between 1 September 2003 and 1 September 2005 were identified. This list was obtained from a database of all admissions kept on the PICU. A control group of 50 consecutive children who were admitted from the ED to the general paediatric ward within the same time period was also identified from the ward admission book. The ED cards for both groups were obtained and the PAWS scores were calculated, based on data recorded at presentation to the ED. Children whose cards could not be located were excluded from the study. As some data were likely to be missing from the cards, a decision was made that missing values would be assumed to be normal. We then...