Illness severity, deterioration and track-and-trigger systems — formative SAQs

SAQ 1 — Overnight PEWS rise with incomplete chart (20 marks, ~15 minutes)

A 4-year-old is on the general paediatric ward with viral wheeze on night two. At 02:10 the nurse shows you a rising multi-parameter PEWS. Oxygen requirement has increased. Blood pressure and capillary refill have not been recorded for 6 hours. The mother says, “She is not herself.” The numerical band is still below the hospital’s automatic MET threshold. ^{[1] [2]}

Questions

1. Distinguish illness severity, physiological instability, risk of deterioration and failure-to-rescue in this vignette. (4 marks) ^{[1] [2]}
2. List the seven BedsidePEWS items and the score range 0–26. State what you must not invent at the bedside. (4 marks) ^{[1] [2]}
3. Outline your immediate bedside actions, including how incomplete observations and caregiver concern change escalation. (6 marks) ^{[1] [2]}
4. Give a structured MET/senior activation handover in ISBAR form. (3 marks)
5. Name two evidence-based reasons cardiac arrest is a poor sole quality metric here. (3 marks)

Model answer

1. Four axes (4)

• Severity: how ill she looks/feels now (effort, oxygen need, interaction). ^{[1] [2]}
• Instability: whether airway/breathing/circulation/consciousness are failing this minute. ^{[1] [2]}
• Risk of deterioration: trajectory overnight if support is delayed. ^{[1] [2]}
• Failure-to-rescue: system risk if incomplete chart and concern are not acted on. ^{[4] [12]}

2. BedsidePEWS (4)
Heart rate; systolic blood pressure; capillary refill; respiratory rate; respiratory effort; SpO2; oxygen therapy; total 0–26. Do not invent local age-band numeric cut-offs or colour thresholds from memory — use the hospital chart. ^{[1] [2]}

3. Immediate actions (6) ^{[1] [2]}

• Go to the bedside; call for help early; ABCDE while reviewing trend. ^{[1] [2]}
• Complete missing BP/CRT if safe; do not wait for a perfect score. ^{[1] [2]}
• Treat reversible threats (oxygen delivery, work of breathing, fatigue, glucose if indicated). ^{[1] [2]}
• Escalate on concern and trajectory, not only on automatic band — caregiver concern is an independent risk signal. ^{[1] [2]}
• Increase observation frequency / senior review / MET per local hybrid rules and clinical judgement. ^{[9] [4]}

4. ISBAR (3)
Identity/baseline; Situation (time, rising PEWS, incomplete items, maternal concern); Background (wheeze day 2); Assessment (respiratory threat, possible exhaustion); Recommendation (MET attendance, continuous monitoring, possible HDU). ^[17]

5. Metrics (3)
Ward arrest/death are rare; Bonafide supports critical deterioration as a proximate outcome; EPOCH used significant clinical deterioration events as a secondary outcome when mortality was unchanged. ^{[3] [12]}