Look out for the PUDDLE—A Quality Improvement Initiative to Increase Patient Safety and Interdisciplinary Communication Using Pediatric Early Warning Signs (PEWS)

Purpose/Objectives:

Background: Our institution initiated the Pediatric Early Warning Signs (PEWS) scoring system in May 2020 to help identify patients at higher risk for clinical deterioration; this score utilizes cardiovascular, behavioral, and respiratory components. Nurses were asked to file a PEWS score once per shift. A critical score elicits a “patient-specific huddle,” or “PUDDLE”, to prompt timely nursing and physician assessment of the patient with the creation of a contingency plan at bedside. These events required documentation in the electronic medical record (EMR) after they were conducted. In August 2020, we found there was lack of awareness and knowledge of PEWS scoring amongst nurses and residents. Interdisciplinary formal bedside patient assessments were infrequently performed, and informal assessments were not documented.

Purpose: Our global aim was to improve the communication between residents and nurses about patients at risk for clinical deterioration, thereby improving patient safety. Our SMART aim was to increase the median rate of PUDDLES documentation from 0% to 50% within 4 months.

Design/Methods: We piloted this quality improvement (QI) project on one floor of a 64-bed pediatric hospital and included patients on the Hospital Medicine service. Data was collected daily except weekends and holidays using a data tool that we developed. Our primary outcome measure was the percentage of completed PUDDLE notes. Our process measure was the number of PEWS scores filed per shift. Data was entered into run charts and analyzed frequently for changes in response to interventions. Multiple PDSA cycles were performed with interventions addressing resident and nurse education, EMR changes, and interdisciplinary communication (Figure 1). After we achieved the 50% documentation threshold, we revised our SMART aim to achieve 80%.

Results: The baseline median rate of note completion was 0%, which increased to 58.50% in two months. The median increased to 100% in the following months (Figure 2).

Conclusion/Discussion: By implementing multimodal interventions, we increased the rate of PUDDLE documentation, and therefore bedside patient assessment. Personalized education with frequent communication galvanized resident and nurse support. Changing the EMR parameters to address scoring accuracy and alarm fatigue was also crucial to our success. Future directions include implementation on other geographic units and services to assess for any correlations.