Paediatric Early Warning System (PEWS) Score Key 12+ Years

Hospital Logo Addressograph SCORE 3 2 1 0 1 2 3

Respiratory Rate (bpm)
Respiratory Effort
≤10 10 - 14 15 - 19 20 - 24
Mild / Moderate
25 - 29 ≥30
Severe
Addressograph
Paediatric Observation Chart O2 Therapy (L) ≤2 >2

12+ Years
Ward SpO2 (%) ≤85 86 - 89 90 - 93 ≥94
Heart Rate (BPM) <40 40 - 60 61 - 99 100 - 119 120 - 139 ≥140
Consultant Systolic BP (mmHg) <90 90 - 109 110 - 119 120 - 129 130 - 149 >150
Ward
CRT (seconds) >2 ≤2

Escalation Guide AVPU / CNS Response Alert (A) Voice (V) Pain (P) / Unresponsive (U) Consultant
PEWS does not replace an emergency call
Assessment of Respiratory Effort
Score Minimum Observations Minimum Alert Minimum Response Mild Moderate Severe
1 4 hourly Any trigger should prompt increase in Airway • Stridor on exertion/crying • Mild stridor at rest • Stridor at rest
Nurse in Charge
2 2 - 4 hourly observation frequency as clinically appropriate Behaviour • Normal • Some/intermittent irritability • Increased irritability and/or lethargy
and feeding • Talks in sentences • Difficultly talking/crying • Looks exhausted
3* 1 hourly Nurse in Charge review • Difficultly feeding or eating • Unable to talk or cry
Nurse in Charge + Doctor on call • Unable to feed or eat
4-5 30 minutes Urgent medical review
Respiratory • Mildly increased • Respiratory rate • Respiratory rate in pink zone
Nurse in Charge + Doctor on call • Increased or markedly reduced
6 Continuous Urgent SENIOR medical review rate in blue zone
+ Senior Doctor +/- Consultant respiratory rate as the child tires

≥7 Continuous URGENT PEWS CALL Immediate local response team Accessory • Mild intercostal and • Moderate intercostal and • Marked intercostal, suprasternal
muscle use suprasternal recession suprasternal recession and sternal recession
* Pink score in any parameter merits review • Nasal flaring
Oxygen • No oxygen • Mild hypoxemia • Hypoxemia may not be
PEWS does not replace clinical concern requirement corrected by oxygen corrected by oxygen
• Increasing oxygen requirement

ISBAR Identify Situation Background Assessment Recommendation

Other • Gasping, grunting
• Extreme pallor, cyanosis
Communication Tool • Apnoea

Event Record for PEWS score ≥6

Date Time PEWS Nurse Initials & NMBI Alert

Could this be Sepsis?

If there is clinical suspicion of infection and child appears unwell. INITIATE PAEDIATRIC SEPSIS FORM.
From 4 weeks (or 4 weeks corrected age) to 16 years.

Mochua Print & Design | www.mochuaprint.ie

≥1 Red Flag ≥1 Amber Flag Risk Factor(s)

Immediate Medical Review

Urgent Medical Review

Signs of Shock
Complete Sepsis 6 Bundle Suspected Sepsis
within 1 HOUR Complete Sepsis 6 Bundle within 3 HOURS of suspicion of sepsis

PAEDIATRIC SEPSIS 6 – TAKE 3 AND GIVE 3

Version N4.1 | 2023
 12+ Years

Addressograph
PEWS Score Key

0 1 2 3 Chart Date D D / M M / Y Y
Ward
Consultant
Core Year Date 12/12 Core
Parameters Parameters
Time (24hr) 18:45

Frequency of observations 40
Clinician / Family Concern
Concern Score 0 Concern
35 35
Respiratory 30 30
AB Rate 25 25
AIRWAY (breaths per minute) 20 20
& BREATHING Assess for 15 15
60 seconds
10 10

RR Number 16
RR Score 0 RR Score
Severe Severe
Respiratory Moderate Moderate
Effort Mild Mild
Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen
Nasal Cannula (NC)
Pressure Pressure
Face mask (FM) Therapy >2L >2L
Tracheostomy (T) (L/Mins.)
≤2L ≤2L
HHFNC (H)
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
≥94% 98 ≥94%
90-93% 90-93%
SpO2
(%) 86-89% 86-89%
≤ 85% ≤ 85%
SpO2 Score 0 SpO2 Score
150 150
140 140
130 130
C
CIRCULATION
Heart Rate 120 120
If HR scores 1 or more
consider central CRT (beats per minute) 110 110
and BP and refer to Assess for 100 100
Sepsis 6 Protocol 60 seconds 90 90
80 80
70 70
*HR <60 with no signs of
life - begin CPR and 60 60
call the emergency team 50 50
40 40

HR Number 90
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds) ≤2 ≤2
CRT Score 0 CRT Score
160 160
150 150
140 140
130 130
Blood Pressure
(mmHg) 120 120
Score systolic BP 110 110
100 100
Cuff Size: 90 90
________ 80 80
70 70

BP Number 117
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
Score ‘-’ if not assessed
Alert A
and put a vertical line AVPU Voice V
through column P
D Pain
DISABILITY Unresponsive U
If not Alert, consider GCS AVPU Score 0 AVPU Score
≥40.0 ≥40.0
Temperature
(℃)
39.0 39.0
38.0 38.0
E
EXPOSURE Record
Consider sepsis if as graph 37.0 37.0
temperature <360C or >38.50C
36.0 36.0
Notify doctor if urine output
is <0.5mL/Kg/hr
≤35.0 ≤35.0

Total PEWS score 0 Total PEWS

Reassess within (Mins.) Reassess within
Pain Score
Pain scale in use (✔):
FLACC
Faces Nurse/NMBI
Numeric
 Paediatric Early Warning System (PEWS) Score Key 5-11 Years
Hospital Logo Addressograph SCORE 3 2 1 0 1 2 3
Respiratory Rate (bpm)
Respiratory Effort
≤10 11 - 15 16 - 29 30 - 39
Mild / Moderate
40 - 49 ≥50
Severe
Addressograph
Paediatric Observation Chart O2 Therapy (L) ≤2 >2

5-11 Years
Ward SpO2 (%) ≤85 86 - 89 90 - 93 ≥94
Heart Rate (BPM) <50 50 - 69 70 - 109 110 - 129 130 - 149 ≥150
Consultant Systolic BP (mmHg) <80 80 - 89 90 - 119 120 - 129 130 - 139 >140
Ward
CRT (seconds) >2 ≤2
Consultant
Escalation Guide AVPU / CNS Response Alert (A) Voice (V) Pain (P) / Unresponsive (U)

PEWS does not replace an emergency call

Assessment of Respiratory Effort
Score Minimum Observations Minimum Alert Minimum Response Mild Moderate Severe
1 4 hourly Any trigger should prompt increase in Airway • Stridor on exertion/crying • Mild stridor at rest • Stridor at rest
Nurse in Charge
2 2 - 4 hourly observation frequency as clinically appropriate Behaviour • Normal • Some/intermittent irritability • Increased irritability and/or lethargy
and feeding • Talks in sentences • Difficultly talking/crying • Looks exhausted
3* 1 hourly Nurse in Charge review • Difficultly feeding or eating • Unable to talk or cry
Nurse in Charge + Doctor on call • Unable to feed or eat
4-5 30 minutes Urgent medical review
Respiratory • Mildly increased • Respiratory rate • Respiratory rate in pink zone
Nurse in Charge + Doctor on call • Increased or markedly reduced
6 Continuous Urgent SENIOR medical review rate in blue zone
+ Senior Doctor +/- Consultant respiratory rate as the child tires

≥7 Continuous URGENT PEWS CALL Immediate local response team Accessory • Mild intercostal and • Moderate intercostal and • Marked intercostal, suprasternal
muscle use suprasternal recession suprasternal recession and sternal recession
* Pink score in any parameter merits review • Nasal flaring
Oxygen • No oxygen • Mild hypoxemia • Hypoxemia may not be
PEWS does not replace clinical concern requirement corrected by oxygen corrected by oxygen
• Increasing oxygen requirement

ISBAR Background
• Gasping, grunting
Identify Situation Assessment Recommendation
Other
• Extreme pallor, cyanosis
Communication Tool • Apnoea

Event Record for PEWS score ≥6

Date Time PEWS Nurse Initials & NMBI Alert

Could this be Sepsis?

If there is clinical suspicion of infection and child appears unwell. INITIATE PAEDIATRIC SEPSIS FORM.
From 4 weeks (or 4 weeks corrected age) to 16 years.

Mochua Print & Design | www.mochuaprint.ie

≥1 Red Flag ≥1 Amber Flag Risk Factor(s)

Immediate Medical Review

Urgent Medical Review

Signs of Shock
Complete Sepsis 6 Bundle Suspected Sepsis
within 1 HOUR Complete Sepsis 6 Bundle within 3 HOURS of suspicion of sepsis

PAEDIATRIC SEPSIS 6 – TAKE 3 AND GIVE 3

Version N4.1 | 2023
 5-11 Years

Addressograph
PEWS Score Key

0 1 2 3 Chart Date D D / M M / Y Y
Ward
Consultant

Core Year Date 12/12 Core

Parameters Parameters
Time 18:45

Frequency of observations 40

Clinician / Family Concern

Concern Score 0 Concern
50 50
Respiratory 40 40
30 30
AB
AIRWAY Rate
(breaths per minute)
& BREATHING 20 20
Assess for
15 15
60 seconds
10 10

RR Number 16
RR Score 0 RR Score
Severe Severe
Respiratory Moderate Moderate
Effort Mild Mild
Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen Pressure
Pressure
Nasal Cannula (NC)
Face mask (FM)
Therapy >2L >2L
(L/Mins.)
Tracheostomy (T) ≤2L ≤2L
HHFNC (H)
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
≥94% 98 ≥94%
90-93% 90-93%
SpO2
(%) 86-89% 86-89%
≤ 85% ≤ 85%
SpO2 Score 0 SpO2 Score
150 150
140 140
130 130
C
CIRCULATION Heart Rate
(beats per minute) 120 120
If HR scores 1 or more
consider central CRT Assess for 110 110
and BP and refer to 60 seconds 100 100
Sepsis 6 Protocol
90 90
80 80
70 70
*HR <60 with no signs of
life - begin CPR and 60 60
call the emergency team
50 50
40 40

HR Number 96
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds) ≤2 ≤2
CRT Score 0 CRT Score
150 150
140 140
Blood Pressure 130 130
(mmHg)
Score systolic BP 120 120
110 110
Cuff Size: 100 100
________ 90 90
80 80

BP Number 109
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
Score ‘-’ if not assessed Alert A
and put a vertical line Voice V
through column
AVPU
Pain P
Unresponsive U
D
DISABILITY
If not Alert, consider GCS AVPU Score 0 AVPU Score

Temperature ≥40.0 ≥40.0

(℃) 39.0 39.0
Record 38.0 38.0
E
EXPOSURE
Consider sepsis if as graph 37.0 37.0
temperature <360C or >38.50C
36.0 36.0
Notify doctor if urine output
is <1mL/Kg/hr ≤35.0 ≤35.0

Total PEWS score 0 Total PEWS

Reassess within (Mins.) Reassess within
Pain Score
Pain scale in use (✔):
FLACC
Faces Nurse/NMBI
Numeric
 Paediatric Early Warning System (PEWS) Score Key 1-4 Years
Hospital Logo Addressograph SCORE 3 2 1 0 1 2 3
Respiratory Rate (bpm)
Respiratory Effort
≤15 15 - 19 20 - 39 40 - 49
Mild / Moderate
50 - 59 ≥60
Severe
Addressograph
Paediatric Observation Chart O2 Therapy (L) ≤2 >2

1-4 Years
Ward SpO2 (%) ≤85 86 - 89 90 - 93 ≥94
Heart Rate (BPM) <60 60 - 79 80 - 129 130 - 149 150 - 169 ≥170
Consultant Systolic BP (mmHg) <70 70 - 79 80 - 89 90 - 109 110 - 119 120 - 129 >130
Ward
CRT (seconds) >2 ≤2
Consultant
Escalation Guide AVPU / CNS Response Alert (A) Voice (V) Pain (P) / Unresponsive (U)

PEWS does not replace an emergency call

Assessment of Respiratory Effort
Score Minimum Observations Minimum Alert Minimum Response Mild Moderate Severe
1 4 hourly Any trigger should prompt increase in Airway • Stridor on exertion/crying • Mild stridor at rest • Stridor at rest
Nurse in Charge
2 2 - 4 hourly observation frequency as clinically appropriate Behaviour • Normal • Some/intermittent irritability • Increased irritability and/or lethargy
and feeding • Talks in sentences • Difficultly talking/crying • Looks exhausted
3* 1 hourly Nurse in Charge review • Difficultly feeding or eating • Unable to talk or cry
Nurse in Charge + Doctor on call • Unable to feed or eat
4-5 30 minutes Urgent medical review
Respiratory • Mildly increased • Respiratory rate • Respiratory rate in pink zone
Nurse in Charge + Doctor on call • Increased or markedly reduced
6 Continuous Urgent SENIOR medical review rate in blue zone
+ Senior Doctor +/- Consultant respiratory rate as the child tires

≥7 Continuous URGENT PEWS CALL Immediate local response team Accessory • Mild intercostal and • Moderate intercostal and • Marked intercostal, suprasternal
muscle use suprasternal recession suprasternal recession and sternal recession
* Pink score in any parameter merits review • Nasal flaring
Oxygen • No oxygen • Mild hypoxemia • Hypoxemia may not be
PEWS does not replace clinical concern requirement corrected by oxygen corrected by oxygen
• Increasing oxygen requirement

ISBAR Background
• Gasping, grunting
Identify Situation Assessment Recommendation
Other
• Extreme pallor, cyanosis
Communication Tool • Apnoea

Event Record for PEWS score ≥6

Date Time PEWS Nurse Initials & NMBI Alert

Could this be Sepsis?

If there is clinical suspicion of infection and child appears unwell. INITIATE PAEDIATRIC SEPSIS FORM.
From 4 weeks (or 4 weeks corrected age) to 16 years.

Mochua Print & Design | www.mochuaprint.ie

≥1 Red Flag ≥1 Amber Flag Risk Factor(s)

Immediate Medical Review

Urgent Medical Review

Signs of Shock
Complete Sepsis 6 Bundle Suspected Sepsis
within 1 HOUR Complete Sepsis 6 Bundle within 3 HOURS of suspicion of sepsis

PAEDIATRIC SEPSIS 6 – TAKE 3 AND GIVE 3

Version N4.1 | 2023
 1-4 Years

Addressograph
PEWS Score Key

0 1 2 3 Chart Date D D / M M / Y Y
Ward
Consultant

Core Year Date 12/12 Core

Parameters Parameters
Time 18:45

Frequency of observations 40
Clinician / Family Concern
Concern Score 0 Concern
60 60
Respiratory
50 50
Rate
AB (breaths per minute) 40 40
AIRWAY Assess for 30 30
& BREATHING 60 seconds 20 20
15 15

RR Number 34
RR Score 0 RR Score
Severe Severe
Moderate Moderate
Respiratory Mild Mild
Effort Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen
Nasal Cannula (NC) Pressure Pressure
Face mask (FM) Therapy
(L/Mins.)
>2L >2L
Tracheostomy (T)
HHFNC (H) ≤2L ≤2L
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
≥94% 98 ≥94%
SpO2 90-93% 90-93%
(%) 86-89% 86-89%
≤ 85% ≤ 85%
SpO2 Score 0 SpO2 Score
170 170
160 160
150 150
C
CIRCULATION 140 140
If HR scores 1 or more Heart Rate
(beats per minute) 130 130
consider central CRT
and BP and refer to Assess for 120 120
Sepsis 6 Protocol 60 seconds 110 110
100 100
90 90
80 80
*HR <60 with no signs of 70 70
life - begin CPR and 60 60
call the emergency team
50 50

HR Number 115
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds) ≤2 ≤2
CRT Score 0 CRT Score
140 140
130 130
Blood Pressure
(mmHg) 120 120
Score systolic BP 110 110
100 100
Cuff Size: 90 90
________ 80 80
70 70

BP Number 107
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
Score ‘-’ if not assessed Alert A
and put a vertical line Voice V
AVPU
through column Pain P
Unresponsive U
D
DISABILITY
If not Alert, consider GCS AVPU Score 0 AVPU Score
≥40.0 ≥40.0
Temperature 39.0 39.0
(℃)
38.0 38.0
E
EXPOSURE Record
Consider sepsis if as graph 37.0 37.0
temperature <360C or >38.50C
36.0 36.0
Notify doctor if urine output
is <1mL/Kg/hr ≤35.0 ≤35.0

Total PEWS score 0 Total PEWS

Reassess within (Mins.) Reassess within
Pain Score
Pain scale in use (✔):
FLACC
Faces
Numeric Nurse/NMBI
 Paediatric Early Warning System (PEWS) Score Key 4-11 Months
Hospital Logo Addressograph SCORE 3 2 1 0 1 2 3
Respiratory Rate (bpm)
Respiratory Effort
<15 16 - 29 30 - 49 50 - 59
Mild / Moderate
60 - 69 ≥70
Severe
Addressograph
Paediatric Observation Chart O2 Therapy (L) ≤2 >2

4-11 Months
Ward SpO2 (%) ≤85 86 - 89 90 - 93 ≥94
Heart Rate (BPM) <70 70 - 99 100 - 149 150 - 169 170 - 179 ≥180
Consultant Systolic BP (mmHg) <60 60 - 69 70 - 79 80 - 99 100 - 109 110 - 119 >120
Ward
CRT (seconds) >2 ≤2
Consultant
Escalation Guide AVPU / CNS Response Alert (A) Voice (V) Pain (P) / Unresponsive (U)

PEWS does not replace an emergency call

Assessment of Respiratory Effort
Score Minimum Observations Minimum Alert Minimum Response Mild Moderate Severe
1 4 hourly Any trigger should prompt increase in Airway • Stridor on exertion/crying • Mild stridor at rest • Stridor at rest
Nurse in Charge
2 2 - 4 hourly observation frequency as clinically appropriate Behaviour • Normal • Some/intermittent irritability • Increased irritability and/or lethargy
and feeding • Talks in sentences • Difficultly talking/crying • Looks exhausted
3* 1 hourly Nurse in Charge review • Difficultly feeding or eating • Unable to talk or cry
Nurse in Charge + Doctor on call • Unable to feed or eat
4-5 30 minutes Urgent medical review
Respiratory • Mildly increased • Respiratory rate • Respiratory rate in pink zone
Nurse in Charge + Doctor on call • Increased or markedly reduced
6 Continuous Urgent SENIOR medical review rate in blue zone
+ Senior Doctor +/- Consultant respiratory rate as the child tires

≥7 Continuous URGENT PEWS CALL Immediate local response team Accessory • Mild intercostal and • Moderate intercostal and • Marked intercostal, suprasternal
muscle use suprasternal recession suprasternal recession and sternal recession
* Pink score in any parameter merits review • Nasal flaring
Oxygen • No oxygen • Mild hypoxemia • Hypoxemia may not be
PEWS does not replace clinical concern requirement corrected by oxygen corrected by oxygen
• Increasing oxygen requirement

ISBAR Background
• Gasping, grunting
Identify Situation Assessment Recommendation
Other
• Extreme pallor, cyanosis
Communication Tool • Apnoea

Event Record for PEWS score ≥6

Date Time PEWS Nurse Initials & NMBI Alert

Could this be Sepsis?

If there is clinical suspicion of infection and child appears unwell. INITIATE PAEDIATRIC SEPSIS FORM.
From 4 weeks (or 4 weeks corrected age) to 16 years.

Mochua Print & Design | www.mochuaprint.ie

≥1 Red Flag ≥1 Amber Flag Risk Factor(s)

Immediate Medical Review

Urgent Medical Review

Signs of Shock
Complete Sepsis 6 Bundle Suspected Sepsis
within 1 HOUR Complete Sepsis 6 Bundle within 3 HOURS of suspicion of sepsis

PAEDIATRIC SEPSIS 6 – TAKE 3 AND GIVE 3

Version N4.1 | 2023
 4-11 Months

Addressograph
PEWS Score Key

0 1 2 3 Chart Date D D / M M / Y Y
Ward
Consultant
Core Year Date 12/12 Core
Parameters Parameters
Time 18:45

Frequency of observations 40

Clinician / Family Concern

Concern Score 0 Concern
70 70
60 60
Respiratory
50 50
AB
AIRWAY Rate
(breaths per minute) 40 40
& BREATHING
Assess for 30 30
60 seconds 20 20
15 15

RR Number 38
RR Score 0 RR Score
Severe Severe
Respiratory Moderate Moderate
Effort Mild Mild
Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen
Nasal Cannula (NC)
Pressure Pressure
Face mask (FM) Therapy
(L/Mins.)
>2L >2L
Tracheostomy (T)
HHFNC (H) ≤2L ≤2L
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
≥94% 98 ≥94%
SpO2 90-93% 90-93%
(%) 86-89% 86-89%
≤ 85% ≤ 85%
SpO2 Score 0 SpO2 Score
180 180
170 170
160 160
150 150
C
CIRCULATION
Heart Rate 140 140
If HR scores 1 or more
consider central CRT (beats per minute) 130 130
and BP and refer to Assess for 120 120
Sepsis 6 Protocol 60 seconds
110 110
100 100
90 90
80 80
*HR <60 with no signs of 70 70
life - begin CPR and
60 60
call the emergency team
HR Number 119
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds) ≤2 ≤2
CRT Score 0 CRT Score
130 130
Blood Pressure 120 120
(mmHg) 110 110
Score systolic BP 100 100
90 90
Cuff Size:
80 80
________ 70 70
60 60

BP Number 89
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
Score ‘-’ if not assessed Alert A
and put a vertical line Voice V
through column
AVPU P
Pain
Unresponsive U
D
DISABILITY
If not Alert, consider GCS AVPU Score 0 AVPU Score
≥40.0 ≥40.0
Temperature 39.0 39.0
(℃)
38.0 38.0
E
EXPOSURE
Record
Consider sepsis if 37.0 37.0
temperature <360C or >38.50C as graph
36.0 36.0
Notify doctor if urine output
is <1mL/Kg/hr
≤35.0 ≤35.0

Total PEWS score 0 Total PEWS

Reassess within (Mins.) Reassess within
Pain scale in use (✔): Pain Score
FLACC
Faces
Numeric Nurse/NMBI
 Paediatric Early Warning System (PEWS) Score Key 0-3 Months
Hospital Logo Addressograph SCORE 3 2 1 0 1 2 3
Respiratory Rate (bpm)
Respiratory Effort
≤15 16 - 19 20 - 29 30 - 59 60 - 69
Mild / Moderate
70 - 79 ≥80
Severe
Addressograph
Paediatric Observation Chart O2 Therapy (L) ≤2 >2

0-3 Months
Ward SpO2 (%) ≤85 86 - 89 90 - 93 ≥94
Heart Rate (BPM) <80 80 - 89 90 - 109 110 - 149 150 - 179 180 - 189 ≥190
Consultant Systolic BP (mmHg) ≤45 46 - 49 50 - 59 60 - 79 80 - 99 100 - 109 >110
Ward
CRT (seconds) >2 ≤2
Consultant
Escalation Guide AVPU / CNS Response Alert (A) Voice (V) Pain (P) / Unresponsive (U)

PEWS does not replace an emergency call

Assessment of Respiratory Effort
Score Minimum Observations Minimum Alert Minimum Response Mild Moderate Severe
1 4 hourly Any trigger should prompt increase in Airway • Stridor on exertion/crying • Mild stridor at rest • Stridor at rest
Nurse in Charge
2 2 - 4 hourly observation frequency as clinically appropriate Behaviour • Normal • Some/intermittent irritability • Increased irritability and/or lethargy
and feeding • Talks in sentences • Difficultly talking/crying • Looks exhausted
3* 1 hourly Nurse in Charge review • Difficultly feeding or eating • Unable to talk or cry
Nurse in Charge + Doctor on call • Unable to feed or eat
4-5 30 minutes Urgent medical review
Respiratory • Mildly increased • Respiratory rate • Respiratory rate in pink zone
Nurse in Charge + Doctor on call • Increased or markedly reduced
6 Continuous Urgent SENIOR medical review rate in blue zone
+ Senior Doctor +/- Consultant respiratory rate as the child tires

≥7 Continuous URGENT PEWS CALL Immediate local response team Accessory • Mild intercostal and • Moderate intercostal and • Marked intercostal, suprasternal
muscle use suprasternal recession suprasternal recession and sternal recession
* Pink score in any parameter merits review • Nasal flaring
Oxygen • No oxygen • Mild hypoxemia • Hypoxemia may not be
PEWS does not replace clinical concern requirement corrected by oxygen corrected by oxygen
• Increasing oxygen requirement

ISBAR Background
• Gasping, grunting
Identify Situation Assessment Recommendation
Other
• Extreme pallor, cyanosis
Communication Tool • Apnoea

Event Record for PEWS score ≥6

Date Time PEWS Nurse Initials & NMBI Alert

Could this be Sepsis?

If there is clinical suspicion of infection and child appears unwell. INITIATE PAEDIATRIC SEPSIS FORM.
From 4 weeks (or 4 weeks corrected age) to 16 years.

Mochua Print & Design | www.mochuaprint.ie

≥1 Red Flag ≥1 Amber Flag Risk Factor(s)

Immediate Medical Review

Urgent Medical Review

Signs of Shock
Complete Sepsis 6 Bundle Suspected Sepsis
within 1 HOUR Complete Sepsis 6 Bundle within 3 HOURS of suspicion of sepsis

PAEDIATRIC SEPSIS 6 – TAKE 3 AND GIVE 3

Version N4.1 | 2023
 0-3 Months

PEWS Score Key Addressograph

0 1 2 3 Chart Date D D / M M / Y Y
Ward
Gestational age: Corrected: Y/N
Consultant
Core Year Date 12/12 Core
Parameters Parameters
Time 18:45

Frequency of observations 40

Clinician / Family Concern

Concern Score 0 Concern
80 80
70 70
Respiratory 60 60
Rate 50 50
(breaths per minute)
40 40
AB
AIRWAY Assess for
30 30
& BREATHING 60 seconds
20 20
15 15

RR Number 44
RR Score 0 RR Score
Severe Severe
Moderate Moderate
Respiratory Mild Mild
Effort Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen
Nasal Cannula (NC) Pressure Pressure
Face mask (FM) Therapy >2L >2L
Tracheostomy (T) (L/Mins.)
≤2L ≤2L
HHFNC (H)
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
≥94% 98 ≥94%
90-93% 90-93%
SpO2
(%) 86-89% 86-89%
≤ 85% ≤ 85%
SpO2 Score 0 SpO2 Score
190 190
180 180
170 170
160 160
150 150
C 140 140
CIRCULATION 130 130
If HR scores 1 or more Heart Rate 120 120
consider central CRT (beats per minute)
110 110
and BP and refer to Assess for
100 100
Sepsis 6 Protocol 60 seconds
90 90
80 80
*HR <60 with no signs of 70 70
life - begin CPR and
call the emergency team
60 60

HR Number 124
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds) ≤2 ≤2
CRT Score 0 CRT Score
120 120
110 110
Blood Pressure
(mmHg) 100 100
Score systolic BP 90 90
80 80
Cuff Size: 70 70
________ 60 60
50 50
45 45

BP Number 65
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
Score ‘-’ if not assessed Alert A
and put a vertical line Voice V
through column AVPU
D Pain P
DISABILITY Unresponsive U
If not Alert, consider GCS AVPU Score 0 AVPU Score
≥40.0 ≥40.0
Temperature 39.0 39.0
(℃) 38.0 38.0
E
EXPOSURE
Consider sepsis if Record 37.0 37.0
temperature <360C or >38.50C as graph
36.0 36.0
Notify doctor if urine output
is <1mL/Kg/hr ≤35.0 ≤35.0

Total PEWS score 0 Total PEWS

Reassess within (Mins.) Reassess within
Pain scale in use (✔): Pain Score
FLACC
Faces
Numeric
Nurse/NMBI