Development and Validation of Ethiopian Pediatric Early Warning Score (EPEWS)



Ethiopia is demonstrating that lowering under-five mortality is possible in low-income counties. This goal was achieved through a combination of factors including: policy changes, technological advancements, and the delivery of improved health services to the rural population, largely through the Health Extension Program (HEP).

While great strides have been made in the public health sector in Ethiopia, less is known about the hospital setting. Specifically, there is limited information about pediatric hospital admissions, mortality patterns, and cause mortality and interventions to decrease mortality in Ethiopian hospitals. There is now some evidence for improvement in outcomes for hospitalized children through support for health workers, structured clinical care, and better use of existing resources. Components of quality improvement strategies are standards, assessment tools, participation, and driving forces.

The early identification of patients at risk of clinical deterioration, matching the severity of illness to the appropriate level of care, and appropriate resource allocation are integral components of high-quality medical care. The validation and implementation of early warning scores will help improve care for hospitalized children.

Early warning scores have been developed to identify patients in the hospital who are at risk for clinical deterioration. Warning scores provide an objective measure of a patient’s clinical condition. The goal of early warning scores is to identify the early signs of cardiopulmonary arrest and to intervene prior to cardiopulmonary arrest, thereby prolonging survival.

Published literature on interventions to improve the quality of clinical care in hospitals in low-income countries is scarce. However, different observational studies, before and after evaluation studies, indicate that early warning scores improve detection of clinical deterioration and hence improve appropriate response systems in hospitals.

The use of emergency assessment tools in developed healthcare systems is relatively well documented. However, their performance is not well validated in resource limited settings where the causes of mortality and morbidity are different. Addressing the low rate of adoption of such systems in such settings might significantly impact on the high mortality observed in these areas of great disease burden.

Objective and Outcomes

The primary objective of this project is to develop and validate a pediatric early warning score which can be used at hospitals in Ethiopia. The expected end outcome is a well validated both paper based and m-Health scoring tool. Over the long term this tool can be modified and be used in health centers and health posts to guide early intervention and referral. The most important addressable impact of this project will be reduction of in hospital mortality.

Study Period and Location

It is a prospective case-control study on children admitted to University of Gondar Hospital pediatric wards from July 2017 to June 2018. Gondar University Hospital (GUH) is located 765 Km from the capital city Addis Ababa in the North West direction. It is the oldest and largest referral hospital in northern Ethiopia with a 400 bed capacity and a very high patient load and turnover. The Department of Pediatrics and child health consists of a neonatal ward, a pediatric emergency ward, a main ward, an oncology ward, a nutrition ward and an intensive care units with an average admission of almost 5000 patients per year.

Implementation Phases

The implementation has two major steps. The first one is the development of early warning score followed by the validation. Clinical data will be collected from the patient’s medical records in prospective case-control study, starting from admission to discharge. Data will be entered and analyzed using Stata 14. After the development and validation of the score the second and major step will be development of user friendly paper based and m-health supported scoring tool.

What makes this a significant innovation is it is an assessment tool which will be used for both inpatient admission and can be used for referral of patients from district hospitals and primary health care centers. The other part of the innovation is it is both paper based and mobile based assessment tool.