Pediatric patient safety remains a global healthcare priority. Among the most effective tools for early detection of clinical deterioration in hospitalized children is the Pediatric Early Warning Scores (PEWS). Used worldwide, PEWS empowers healthcare teams to intervene before a child’s condition becomes critical—saving lives and improving long-term outcomes.
Pediatric Early Warning Scores (PEWS) are clinical tools designed to monitor hospitalized children for signs of deterioration (Lee et al., 2024). These systems help healthcare providers identify at-risk patients early and initiate timely interventions through structured assessments and escalation protocols.
(For more background, see our blog on the importance of Early Warning Scores.)
The primary goal of PEWS is to detect early signs of physiological decline in children, enabling proactive intervention and reducing preventable emergencies such as in-hospital cardiac arrests or unplanned ICU transfers.
📊 Studies show that clinical deterioration in hospitalized pediatric patients can increase mortality rates by 5%–15% (Rosman et al., 2019).
PEWS systems involve periodic assessments of a child’s (Mills et al., 2021):
a. Vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation)
b. Physical exam findings
c. Behavior and level of consciousness
Each deviation from normal is scored, and a higher cumulative score signals an increased risk of deterioration, triggering actions through a clear escalation protocol.
(Each hospital or system may vary slightly, but generally PEWS uses three key parameters:)
a. Behavior (alertness, crying, response to parents)
b. Cardiovascular (heart rate, capillary refill, color)
c. Respiratory (respiratory rate, oxygen requirement, work of breathing)
✅ Each parameter is scored from 0 (normal) to 3 (severely abnormal).
✅ Total PEWS score = sum of the 3 parameter scores.
Total PEWS Score | Interpretation | Escalation | Clinical Action |
0–2 | Low Risk | Routine Monitoring | Continue standard care |
3–4 | Moderate Risk | Notify Primary Nurse and Doctor | Increase monitoring frequency, reassess |
5–6 | High Risk | Immediate Review by Senior Clinician | Initiate interventions (e.g., oxygen, fluids). Consider ICU consult. |
≥7 | Critical / Emergency | Rapid Response or MET Call | Activate emergency team, transfer to PICU |
An example of a PEWS sheet used in Indonesia can be seen here: EWS Anak dan Bayi.
🔵 Score 0–2 (Low Risk)
🟡 Score 3–4 (Moderate Risk)
🟠 Score 5–6 (High Risk)
🔴 Score ≥7 (Critical Risk)
While each hospital may customize the parameters, scoring, and escalation protocols based on their specific needs, the general flow remains consistent. It typically involves an initial assessment, scoring based on key clinical indicators, interpretation of the total score, and corresponding clinical actions ranging from routine monitoring to activating an emergency response team. This basic framework helps ensure timely interventions to improve patient outcomes.
Key roles of the multidisciplinary team in responding to PEWS alerts include:
Developed in 2020 at Naresuan University Hospital, Thailand, NU-PEWS was tailored for resource-appropriate care using the following indicators:
✅ Consciousness, Heart rate, Capillary refill time, Blood pressure, Respiratory rate, Retraction, Oxygen saturation, Body temperature
Each item is scored from 0–3, with total scores ranging from 0 to 20.
Effectiveness:
Research shows NU-PEWS is a highly accurate tool for detecting deterioration across most medical conditions (except neurological disorders). It has demonstrated greater sensitivity and specificity compared to other scoring tools.
Created by Child Health BC, the BC PEWS initiative offers a standardized, province-wide framework to identify and respond to deterioration in pediatric patients.
Key Components:
✅ Impact:
This study describes the successful implementation of a modified PEWS in UNOP, a pediatric oncology hospital in Guatemala, a resource-limited setting. After implementation, there was 100% compliance with PEWS documentation and an error rate of less than 10%.
✅Key results included:
PEWS has been widely adopted in many hospitals across the country, particularly after the Indonesian Hospital Accreditation Commission (KARS) incorporated it into the National Accreditation Standards (SNARS) Edition 1.1 in 2019.
An example of PEWS implementation in Indonesia can be seen in a study at RSIA Muhammadiyah Probolinggo City. The study, published in STRADA: Jurnal Ilmiah Kesehatan (2022), investigated the relationship between compliance with PEWS application, response time, and patient safety. Conducted among 32 nurses, the study found that 78% adhered to the PEWS protocol, achieved rapid response times, and maintained patient safety standards. The research highlights how PEWS supports early detection of pediatric deterioration and promotes timely clinical intervention.
Despite their benefits, PEWS systems vary in structure and effectiveness depending on: hospital resources, staff training levels, and patient populations.
There is still no global consensus on core PEWS components, scoring thresholds, or escalation triggers. Successful implementation depends on customization, staff training, and continuous evaluation (Fuijkschot et al., 2023 and Roland et al., 2022).
With these, healthcare professionals—especially nurses—are expected to understand the principles of PEWS and follow its implementation guidelines. To ensure proper application, they are encouraged to attend seminars and workshops focused on Pediatric Early Warning Scores (Rusmawati et al., 2022).
1. Patient Assessment and Monitoring:
Nurses conduct physical assessments, including taking vital signs and observing capillary refill time. They also assess the patient’s behavior and general condition.
2. PEWS Score Calculation:
Nurses use the PEWS scoring system to quantify the severity of a child’s condition based on the collected vital signs and observations. This helps in identifying patients who are at higher risk of deterioration.
3. Communication and Collaboration:
Nurses communicate the patient’s PEWS score and clinical status to other members of the healthcare team, including doctors and respiratory therapists, ensuring everyone is aware of the patient’s condition.
4. Patient Advocacy and Education:
Nurses advocate for their patients’ needs and ensure appropriate interventions are initiated based on the PEWS score and clinical findings. They may also educate patients and families about the PEWS system and their child’s condition.
5. Resource Review and Implementation:
Nurses may be involved in reviewing resources available for patient care and implementing strategies to improve PEWS scoring accuracy and effectiveness.
6. Documentation and Reporting:
Nurses meticulously document all assessments, vital signs, PEWS scores, and any interventions provided in the patient’s chart. They also report any significant changes in the patient’s condition or adverse events to the appropriate personnel.
As pediatric hospitals face rising admissions, resource constraints, and evolving disease patterns, the use of PEWS is no longer optional—it’s essential. Hospitals that implement these systems are better positioned to reduce harm, act faster, and save lives.
Technology can further improve PEWS by leveraging advancements such as:
For instance, real-time data automation and triggering alerts have been key factors in the acceptability and effectiveness of systems like DETECT e-PEWS.
DETECT e-PEWS is an electronic observation and decision support system (Saron et al., 2022).
If you’re a healthcare professional working in pediatrics, emergency care, or critical care, mastering PEWS is vital.
📚 Zafyre offers an e-learning course on Early Warning Systems, featuring practical modules on Pediatric Early Warning Scores (PEWS)—aligned with international and local standards, SKP-accredited, and designed for clinical application.
👉 Explore the course here and elevate your readiness to respond before it’s too late.
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