Research and commentary

Advantages of paper versus electronic versions of paediatric early warning scoring systems

Recommended to assist nurses in detecting deterioration in children PEWS systems have been heralded as a panacea for poor record keeping of vital signs observations

Recommended to assist nurses in detecting deterioration in children PEWS systems have been heralded as a panacea for poor record keeping of vital signs observations

Picture: Alamy

Sefton G, Lane S, Killen R et al (2017) Accuracy and efficiency of recording pediatric early warning scores using an electronic physiological surveillance system compared with traditional paper-based documentation. Computers, Informatics, Nursing. 35, 5, 228-236.

Background and aim

Paediatric early warning scores (PEWS) are recommended to assist clinicians in recognising early signs of deterioration. This feasibility study explored whether electronic recording of PEWS improved accuracy and decreased recording time.


A purposeful sample of nurse, healthcare assistants and medical students recorded the PEWS of five vignettes of vital signs and clinical observation using paper and electronic charting. The order of charting (paper then electronic or electronic then paper) was randomised and each participant acted on their own control. The accuracy and time taken for each participant to record the PEWS using these approaches was assessed and compared. Vignettes were conducted in a classroom setting away from the clinical environment.


A total of 23 staff participated. Accuracy of vital sign recording was greater with electronic charting (98.5% versus 85.6%, P<.02). Eight cases (7%) were erroneously recorded on paper charts, which were the wrong age for the vignette. Errors were also observed in documenting (3.3%) and plotting (4.2%) observations. The accuracy of PEWS calculation was also improved with electronic charting (94.6% versus 55.7%, P<.001). Five cases did not have a paper-based PEWS value recorded despite having all the relevant information. The time taken to record PEWS was significantly less using electronic charting (68 versus 98 seconds, P.001).


Electronic charting of vital signs and automated calculation of PEWS demonstrated superior performance in this small, non-clinical trial. A high proportion of paper-based PEWS were inaccurate, despite the study being conducted in optimal conditions, away from the distractions and interruptions of a busy ward. Paper recording was also slower, consuming nursing time, which could be used on other tasks. Electronic charting could offer opportunities to standardise surveillance of sick children in hospital and reduce adverse events.

Electronic calculation of PEWS can save nurses’ time

Identifying hospitalised children who are deteriorating is a complex process. Traditionally vital sign and clinical assessment has been the primary method to detect signs of deterioration. Evidence however indicates that these can be poorly recorded or misinterpreted, leading to missed opportunities to intervene. Early warning scores were heralded as a panacea to address this issue, however widespread benefits have not, as yet, been realised.

This may be due to the inaccurate and incomplete recording of PEWS. The reasons why PEWS may be inaccurately recorded is not clear, but it is unlikely to be a simple issue of the inadequate mental maths skills of staff, as some have suggested (Weeks et al 2013). More recent evidence indicates that chart design, human factors and safety culture may all have an influence (Christofidis et al 2013, Odell 2011).

Electronic calculation of PEWS may offer a way forward. Despite technology being a part of our daily lives, healthcare has, in many ways, been slow to embrace the opportunities it may offer. This study raises the possibility that incorporating technology into nurses’ daily tasks may be a more effective way forward. The authors estimate that 60 minutes of nursing time a day could be saved if electronic charting was introduced on a 20-bed ward. The greater benefit may be in increased accuracy of PEWS, which may offer increased opportunity to identify children who are deteriorating and intervene to prevent adverse events – such as cardiac arrest and death.

This study provides valuable evidence that healthcare technology should be used to support nurses to work smarter not harder. This may be particularly appropriate currently given the shortfall in the number or nurses and the increasing pressure on practitioners to do more with less.



  • Christofidis MJ, Hill A, Horswill MS et al (2013) A human factors approach to observation chart design can trump health professionals' prior chart experience. Resuscitation. 84, 5, 657-665.
  • Odell M (2011) Human factors and patient safety: Changing roles in critical care. Australian Critical Care. 24, 4, 215-217.
  • Weeks KW, Sabin M, Pontin D et al (2013) Safety in numbers: an introduction to the Nurse Education in Practice series. Nurse Education in Practice. 13, 2, e4-e10.

Compiled by Susan Chapman, Gulf regional clinical manager, Great Ormond Street Hospital for Children, London, on behalf of the RCN’s Research in Child Health community

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