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The pediatric early warning score (PEWS) tool helps providers to detect subtle clinical deterioration in non-intensive care unit pediatric patients and intervene early to prevent significant adverse outcomes. Although widely used in general pediatrics, limited studies report on its validation; none report on use with burn-injured patients. New York-Presbyterian/Weill Cornell Medical Center modified a general PEWS system to a burn-specific PEWS and integrated its use into standard practice. This study investigated the external validity of the PEWS process in clinical practice. Fifty cases of patients aged 0 to 15.9 years admitted between January 2012 and June 2013, whose length of stay (LOS) more than 3 days were selected for review from this cohort of n equal to 187. Demographics, total PEWS and score changes, and compliance with PEWS documentation and with resultant interventions were reviewed. Continuous variables are presented as mean ± SD, P less than 0.05. Mean age, burn size, and LOS were 3.2 ± 3.3 years, 4.8 ± 5.7%, and 9.8 ± 7.0 days; 26% required grafting, and 50% were male. No mortalities occurred. One thousand six hundred and twelve PEWS from 1745 opportunities were documented (92.4%). For all PEWS (n = 1612) and PEWS greater than 0 (n = 912), means were 0.9 ± 1.2 and 1.6 ± 1.2, respectively. Among the 162 PEWS increase events, intake (54.1%) and output (4.5%) parameters increased most commonly. Of these, 129 PEWS increases (79.6%) were followed by an intervention that most commonly included text notation of score increase (93.7%), physician/physician assistant notification (70.5%), and feeding-tube insertion (25.6%). Patients with PEWS greater than 0 had similar age, LOS, and larger burn size (5.2% vs 1.4%, P < 0.05) than those with PEWS equal to 0. Compliance with PEWS performance and resultant actions based on score increases are high. Data support that even small changes in burn-injury specific PEWS stimulate provider discussion and intervention and support its validation; further studies on its effect on practice are warranted.

A foundational skill in burn surgery is tangential excision (TE). The purpose of this study was to develop a simulation model for TE, hypothesizing that simulation could be used in surgical training. TE simulation was created using the TE knife, foam, mineral oil, and base. Subjects, surgeons, or surgeons in training, were given a pre- and post-task questionnaire about experience with TE. Subjects were divided into three TE experience groups: novice--none, intermediate--some, and expert--TE in current or past practice. The task was to excise pre-marked rectangles, generating four excisional products (EPs). Evaluators blindly assessed performance by EP analysis using a novel scoring tool and reviewed videos using a modified objective structured assessment of technical skill (OSATS) rubric. Inter-rater reliabilities and P values were obtained, comparing Novice and Intermediate with Expert scores. Forty subjects completed the study: 16 were identified as TE novices, 17 as intermediates, and seven as experts. All EPs and videos were reviewed blindly by two evaluators using the EP scoring tool and OSATS methodology, respectively. Intraclass correlation coefficients were calculated to measure inter-rater reliabilities, which were acceptable (ICC => 0.42) for OSATS, time, and EP analysis: border and texture. Statistical differences between Novice and Expert scores were found (P < .0100, P < .0200, P < .0025, and P < .0005, respectively). Statistical differences between Intermediate and Expert scores were also found (P < .0100, P < .0200, P < .0100, and P < .0025, respectively). Post-simulation survey results showed experts 86% of the time agreeing or strongly agreeing that the simulation was similar to the clinical skin and 100% felt it would be a useful for training before clinical performance. Simulation for TE was successfully created to blindly discern level of TE experience. Participants agreed that simulation could play an essential role in burn surgical training.