Is Pediatric Early Warning Score (PEWS) Effective in Identifying Children at Risk for Deterioration after Posterior Spinal Fusion for Idiopathic Scoliosis?

Kayla Schlosser
Melanie Morscher, Akron Children's Hospital
Mark Adamczyk MD, Akron Children's Hospital
Kenneth Bono MD, Akron Children's Hospital



Background: The modified Brighton PEWS is an age-based algorithm intended to help identify children at risk for impending deterioration, so that early recognition and intervention, can avoid additional morbidity, including the need for medical codes or transfers to the ICU. Scores range from 0-11, and are calculated based on five clinical assessments including behavior, cardiovascular status, respiratory status, nebulizer use, and emesis. This is the first study to examine the utility of PEWS following posterior spinal fusion in patients with idiopathic scoliosis.

Methods: An IRB-approved retrospective review identified 95 idiopathic scoliosis patients that underwent posterior spinal fusion at a single institution from January 2014 to March 2016, which met inclusion criteria. PEWS were calculated for all patients following their surgery and throughout their hospital stay. Data was collected and analyzed for each case examining the maximum PEWS, including which components of the score were most commonly elevated in these postoperative patients, as well as analyzing the number of nursing communications for both PEWS and non-PEWS related events. The reason for the nursing call to the orthopedic team as well as if any action was taken, was also recorded.

Results: Approximately 10% of patients had a PEWS of 5 or more, signifying they were at “high risk for deterioration” per the modified Brighton PEWS criteria. None of the patients required transfer to the ICU or evaluation by a medical response team. The most common elements that led to an elevated PEWS included cardiovascular and respiratory status. Only 10% of all the nursing notifications required by the PEWS protocol were felt to require some type of medical action. Of the nursing notifications that were not required per PEWS protocol, 51% resulted in some type of medical action.

Conclusion: This is the first study to review the effectiveness of PEWS in patients having undergone posterior spinal instrumented fusion for idiopathic scoliosis. It would appear that PEWS overestimates the risk for impending deterioration in these otherwise healthy patients. Alternate measures or modifying the PEWS to reflect the normal physiologic changes secondary to surgery may reduce unnecessary calls and better identify patients at risk in this population.