Assessing children who are acutely ill in general practice using the National PEWS and LqSOFA clinical scores: a retrospective cohort study

Abstract

Background: Clinical tools are needed in general practice to help identify children who are seriously ill. The Liverpool quick Sequential Organ Failure Assessment (LqSOFA) was validated in an emergency department and performed well. The National Paediatric Early Warning System (PEWS) has been introduced in hospitals throughout England with hopes for implementation in general practice.

Aim: To validate the LqSOFA and National PEWS in general practice.

Design and setting: Secondary analysis of 6703 children aged <5 years presenting to 225 general practices in England and Wales with acute illnesses, linked to hospital data.

Method: Variables from the LqSOFA and National PEWS were mapped onto study data to calculate score totals. A primary outcome of admission within 2 days of GP consultation was used to calculate sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUC).

Results: A total of 104/6703 children were admitted to hospital within 2 days (pre-test probability 1.6%) of GP consultation. The sensitivity of the LqSOFA was 30.6% (95% confidence interval [CI] = 21.8% to 41.0%), with a specificity of 84.7% (95% CI = 83.7% to 85.6%), PPV of 3.0% (95% CI = 2.1% to 4.4%), NPV of 98.7% (95% CI = 98.4% to 99.0%), and AUC of 0.58 (95% CI = 0.53 to 0.63). The sensitivity of the National PEWS was 81.0% (95% CI = 71.0% to 88.1%), with a specificity of 32.5% (95% CI = 31.2% to 33.8%), PPV of 1.9% (95% CI = 1.5% to 2.5%), NPV of 99.1% (95% CI = 98.4% to 99.4%), and AUC of 0.66 (95% CI = 0.59 to 0.72).

Conclusion: Although the NPVs appear useful, owing to low pre-test probabilities rather than discriminative ability, neither tool accurately identified admissions to hospital. Unconsidered use by GPs could result in unsustainable referrals.

Keywords: child health; clinical prediction rule; early warning score; general practice; retrospective studies; triage.

Figure 1.

Graph demonstrating score frequencies for the LqSOFA and National PEWS. The majority of children are scoring either zero or one point. LqSOFA = Liverpool quick Sequential Organ Failure Assessment. National PEWS = National Paediatric Early Warning System. ^a For the LqSOFA, the scores >2 have been combined to adhere with the ‘small data’ reporting requirements of the Secure Anonymised Information Linkage (SAIL) Databank. For the National PEWS, the scores >8 have been combined.

Figure 2.

Sample cohorts for National PEWS analysis. PEWS = Paediatric Early Warning System.