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Patient safety alert

HSE Paediatric Early Warning System (PEWS) Guidance

Priority 2 - Warning
Issued on: 21/06/2023

Who needs to take action?

This HSE National Patient Safety Alert (NPSA) is for action by all Hospital Group and Hospital CEOs, Directors/ Leads of Quality, Patient Safety & Risk Managers, Heads of Servicefor Quality & Safety Service Improvement, General Managers, Clinical Directors, Directors of Nursing, Chairs Deteriorating Patients Committee / PEWS Committee

What is the issue?

PEWS observation charts and training material currently in use are in need of an urgent update to reflect the recent HSE Sepsis Programme guidance for children and young people. The current PEWS charts may not guide the clinical staff to a diagnosis of sepsis. A HSE PEWS governance group have reviewed the following documents and have made the following interim changes to align with new Sepsis Guidance for Children.

  • Patient observation charts to include updated Sepsis Banner
  • PEWS guidance and training presentations
  • Information for PEWS leads and trainers

What action is required?

  1. Disseminate this HSE National Patient Safety Alert to all staff caring for children in your organisation
  2. Remove existing printed versions of all Paediatric observation charts
  3. Replace existing charts with updated (2023) versions, available at PEWS webpage and also see attached (Types A and B)
    1. Type A is for use in sites/services where there is a Paediatric Medicine Team available 24/7
    2. Type B is for use in sites/services where a Paediatric Medicine Team is not available 24/7
  4. Revise any local training to reflect updated national guidance. The PEWS material previously available online has been adjusted to reflect these changes and can be accessed here: PEWS webpage
  5. Complete three monthly audits following completion of actions 2 & 3 (above) to provide assurance that no old versions of the charts are in circulation

When does the action need to be completed by?

Allowing time for printing and updating of the Paediatric Observation Charts and training material, actions 1-4 should be completed by July 31st 2023

Read the Full Alert

Why is this action required?

The Irish Paediatric Early Warning System (PEWS) National Clinical Guideline No. 12 was published in 2015 and updated in 2016 (PEWS Guidance). Since this time theInternational Sepsis Guidelines for Children Implementation Plan 2021 and Paediatric Sepsis Form (together the Sepsis Guidelines) have been developed and published by the HSE National Clinical Programme for Sepsis. The HSE documentation developed to support staff implement the 2016 PEWS guideline does not currently adhere to the new Sepsis Guidance and, as a result, PEWS training material and PEWS observation charts currently in use across the system are not aligned to the Sepsis Guidance.

What stakeholders were involved in issuing this HSE National Patient Safety Alert?

This alert has been developed collaboratively by the:

  • HSE National Paediatric Early Warning System (PEWS) Interim Governance Group, including representation from;
    • National Clinical Advisor and Group Lead for Children and Young People
    • Faculty of Paediatrics
    • National Quality and Patient Safety Directorate
    • Nurse Leadership representation
    • Children’s Health Ireland
    • Acute Operations representation
    • Sepsis Programme representation
    • Deteriorating Patients Improvement Programme (DPIP)
  • HSE National Patient Safety Alerts Committee

What evidence supports the issuing of this HSE NPSA?

International Sepsis Guidelines for Children

Where can I get further information?

What does it mean for me

HSE National Patient Safety Alerts (NPSA) are high-priority communications about patient safety issues, which require HSE services and HSE funded agencies to take specific action within an identified timeframe. They are developed with relevant people including subject matter experts and patient representatives.