• Respiratory: presence of apnea or cyanosis was absent
from the CHEWS; oxygen flow 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 modified 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
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 flow
rate, baseline cyanosis.
The tool was modified 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 findings, or it was unknown whether this was
normal for the patient (i.e. new admission), the findings
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 final 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 Cardiovascular
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 CCHEWS
score of 0–2 (color code: green) recommends for
clinicians to continue routine care, monitoring and assessments.
A C-CHEWS score of 3–4 (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
• Respiratory: presence of apnea or cyanosis was absent
from the CHEWS; oxygen flow 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 modified 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
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 flow
rate, baseline cyanosis.
The tool was modified 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 findings, or it was unknown whether this was
normal for the patient (i.e. new admission), the findings
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 final 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 Cardiovascular
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 CCHEWS
score of 0–2 (color code: green) recommends for
clinicians to continue routine care, monitoring and assessments.
A C-CHEWS score of 3–4 (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
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