International Journal of

ISSN 2692-5877 Clinical Studies & Medical Case Reports

DOI: 10.46998/IJCMCR.2023.25.000608
Review Article
PAC Score-IT’s Need in Pediatric Units for Qulaity Nursing Care
Mary Anbarasi Johnson*
Professor, Department of in Pediatric Nursing, CMC Vellore, India

*Corresponding author: Mary Anbarasi Johnson, Professor, Department of in Pediatric Nursing, CMC Vellore, India

Received: February 12, 2023 Published: April 03, 2023

Abstract

The potential and ability of sick children to withhold the stress during the time of illness is very low and they can deteriorate
very rapidly as compared to adults, if the intervention is not done at appropriate time. The sick children presenting to Emergency
Services with obvious compromise of the airway, breathing and circulation is transferred to the Intensive Care Unit for further
management. Clinical deterioration of children who are not very sick and are subsequently admitted to the wards might have
unexpected death or unplanned admission to the intensive care unit. The challenge to prevent unexpected clinical deterioration
in the hospital lies in the ability of the health care provider to identify the early warning signs of deterioration and to intervene
at the appropriate time. The number of lives thus saved can be extrapolated to the national mortality and morbidity burden con-
tributed by illness and ICU care. Hence any effort should be analysed and the results can be implemented in a resource limited
country like India. This article highlights the need for usage of PAC SCORE in pediatric units to ensure quality nursing care,
reduce the complications in children and minimise CART calls and PICU admissions.

Keywords: PICU; Cart; PAC Score

Introduction 1. The implementation of CART (Cardiac Arrest Resuscita-

The inpatient hospital cardiac arrests lack the data collection tive Team) /an outreach of the ICU team to resuscitate children
and analysis. Arrest in Pediatrics can be due to three compli- with cardiopulmonary arrest.
cations through the inpatient care- respiratory arrest, severe 2. The use of early warning scores. - developed depending on
bradycardia, and pulseless cardiac arrest [1]. These conditions the relevant predictors of clinical deterioration. It is an objec-
are recorded with varied interchangability. In the early 1990s, tive assessment tool that incorporates the clinical manifesta-
international experts developed the Utstein style for data re- tions that have the greatest impact on patient outcome.
porting of cardiac arrests and resuscitation [2].
Background
The American Heart Association started a National Registry of History of pediatric critical care
Cardiopulmonary Resuscitation (NRCPR) to collect a large da- Pediatric intensive care has been established as a sub-specialty
tabase of hospital cardiac arrests and resuscitation with Utstein of medicine over the past two decades. It grew out of a need
style definitions. The outcome measures are all recorded to de- for increasingly complex pediatric care, long-term manage-
termine any intervention that could have been done for avert- ment of disease, and advancements in medical and surgical
ing a death. Advances in resuscitation care-like BLS courses sub-specialties, as well as, life-sustaining therapies [1]. The
in the decade have resulted inincreasing rates of survival for development of pediatric critical care followed the establish-
patients with out-of-hospital cardiac arrest [3]. ment of pediatric intensive care units or PICUs. The first PICU
was opened in Europe by Goran Haglund in 1955 at Children's
In the in-hospital setting, efforts to improve quality include the Hospital of Goteburg in Sweden [2].
use of routine mock codes, post-resuscitation debriefing, and
defibrillation machine brought by the specialised code person- Advancements in Neonatology and neonatal intensive care,
nel. Code teams respond to sudden arrests that occur in the pediatric general surgery, pediatric cardiac surgery, pediatric
hospital and resuscitate within the window period of 3-5 min anesthesiology lead to its opening because of the need to care
for return of spontaneous circulation. In the hospitalized chil- for critically ill infants and children. Over the next forty years,
dren, 0.7% to 3.5% of them have cardiopulmonary arrest dur- hundreds of PICUs were established in academic institutions,
ing the course of stay, with only 15-36% of children surviving children's hospitals, and community hospitals. In 1981, the So-
the arrest [1]. ciety of Critical Care Medicine, SCCM, which express guide-
lines and standards for adult critical care, recognized pediatric
Despite technological and pharmaceutical advances, the sur- critical care as unique from adults and created a separate sec-
vival rate of the children who have unexpected deterioration tion within the SSCM for their care [2].
after admission has not improved. This unexpected clinical
deterioration can be prevented by the following interventions: Other institutes followed throughout the 80's, by 1990 there
Copyright © All rights are reserved by Mary Anbarasi Johnson* 1
DOI: 10.46998/IJCMCR.2023.25.000608
[Link] Volume 25- Issue 2
were multiple training programs, certification available, and rameter because it is a non-invasive, quick test to help deter-
sub-board on pediatric critical care [2]. Pediatric critical care mine blood flow to the tissues. Heart rate is a crucial piece of
is now seen as a multidisciplinary field that includes a team of assessment in acutely ill pediatric patients because bradycardia
nurse specialists, respiratory therapists, nutritionists, pharma- may be a sign of conductive tissue dysfunction and lead to sud-
cists, social workers, physical therapists, occupational thera- den death.
pist, and other medical professionals. Heart rate (per minute)
1m -1 year 100-180
Development of Pediatric Early Warning Score 1- 3 year 70-110
(PEWS)
4-6 year 70-110
To reduce the occurrence of second-rate care, improve out-
comes, and enhance quality of life, systems to identify adult 7-12 years 70-110
patients at risk for rapid clinical deterioration were established 13-19 years 55-90
based on "early warning signs". These signs brought atten- Respiratory
tion to key clinical parameters that, when affected, encour- Respiratory can be measured by rate, rhythm, characteristics
aged emergent intervention. Modified Early Warning System of breathing, and supplemental oxygen use. Different charac-
(MEWS) is a tool for nurses to help monitor their patients and teristics of breathing are lung sounds, retractions, accessory
improve how quickly a rapidly deteriorating client receives the muscle use, tracheal tug, etc. PEWS uses highly visible and
needed care developed from early warning signs. MEWS helps easily monitored characteristics are used, such as retractions,
increase objectivity and communication within hospitals [3]. that way there is little variation based on in interpretation. Re-
tractions are a sucking in of the skin around the bones of the
Discussion chest and illustrate the additional use of muscle to breath, indi-
Patients with progressing critical illness can be predicted and cated the increased work needed to breath. Similarly, the more
prevented, but failure to identify the signs and lack of prompt Respiration (per minute)
intervention for patients developing acute and critical illness
1 m – 1year 35-40
remain a problem. Care for them is challenging because chil-
dren may be asymptomatic until critically ill. Pediatric patients 1 -3 years 25-30
have unique characteristics and different clinical parameters
4 -6 years 21-23
for each age group; adult parameters and concepts cannot be
applied to the pediatric patient. Children have greater com- 7-12 years 19-21
pensatory mechanisms than adults and can maintain a normal
13-19 years 16-18
blood pressure despite considerable loss of fluid. For example,
a child with sepsis or severe dehydration may seem unaffected supplemental oxygen needed, the less the lungs are providing
and the acute condition is often identified only by the affected adequate oxygenation.
vital parameters [4].
However, their condition deteriorates quickly once compensa- Neurological
tion mechanisms are overwhelmed. In one review, sixty-one Behavior is typically measured by playing, sleeping, irritable,
percent of pediatric cardiac arrests were caused by respiratory and confused or reduced response to pain. This is due to the
failure and twenty-nine percent by shock, which are both pre- fact it is an age-based assessment and pediatric patients have
ventable and potentially reversible causes [5]. Thus, to ensure some form of "playing" as their age-appropriate norm. Wheth-
timely care for pediatric patients and improve outcomes, sys- er it be gurgling and cooing, coloring, or video games, it is
temic assessment of key symptoms and their severity is essen- age-specific behavior to a younger population. Irritability in
tial. children is often a cue that something is wrong, especially in
those unable to communicate verbally due to age or disorder.
Goals: Other scales simply use level of consciousness as they're neu-
• To alert the staff about deterioration in pediatric pa- rological assessment, instead of behavior
tients at the earliest.
• To quickly intervene and reduce the mortality rate. Comorbid factors:
Domains: 1. Oncological conditions
The domains in PACS represents major body systems that are 2. Immunodeficiency
sensory to changes in the body and thus create the criteria to 3. Cardiac diseases
be evaluated in a patient to help identify if they are at risk for 4. Chronic Lung disease
further deterioration. 5. Chronic renal disease
6. Malnutrition
The 3 domains are cardiovascular, respiratory and neurologi-
cal. Paediatric Early Warning Score
Cardiovascular Paediatric Early Warning Score (PEWS) is a tool in which the
Heart rate is commonly used in PEWS, as well as, capillary vital signs or the condition of the patient is given a numerical
refill. However, only few uses blood pressure because it is not value which is graded according to the intensity of variation
considered as reliable of a measure as the other two. As stated from the normal. It helps in the recoding of the variation of
previously, children can maintain a stable blood pressure for each patient from normal in a short span of assessment, in a
much longer than adults. Anatomy and physiology are differ- single sheet of paper. It can be graded and communicated to
ent in infants and children than adults and vary with age, which other health care professional easily.
produces normal ranges for electrocardiograms. Capillary refill
is used across the lifespan as a cardiovascular assessment pa- There are no contraindications and it can be modified based
Citation: Mary Anbarasi Johnson*. PAC Score-IT’s Need in Pediatric Units for Qulaity Nursing Care. IJCMCR. 2023; 25(2): 003

DOI: 10.46998/IJCMCR.2023.25.000608 2
[Link] Volume 25- Issue 2

3
[Link] Volume 25- Issue 2
on the local [Link] parameters like surgery, cardiac Conclusion
parameters etc can be added. The concept of PEWS is a score Currently, multiple PEWS systems are in circulation. They
which increases as the patient variables differ more than the are similar in nature, measuring the same domains, but vary in
normal values and is high when the child is critical. The scores the parameters used to measure the domains. Therefore, some
can depict the severity of have been proven more effective than others, however, all of
illness. them have been statistically significant in improving patient
care times and outcomes. In CMC Vellore in the Pediatric units
Pediatric Early Warning Signs (PEWS) we follow the above mentions pediatric acute score which is
PEWS are clinical manifestations that indicate rapid deteriora- found to be very beneficial in identifying impending compli-
tion in pediatric patients, infancy to adolescence. PEWS Score cations in children, so that preventive measures are taken at
or PEWS System are objective assessment tools that incorpo- the earliest and the PICU admissions and CART calls are pre-
rate the clinical manifestations that have the greatest impact vented or minimized.
on patient outcome. Pediatric intensive care is a subspecialty
designed for the unique parameters of pediatric patients that References
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