Prognostic performance and clinical utility of a modified Brighton pediatric early warning score for 24-h ICU admission in a resource-limited pediatric emergency department.

Pediatric early warning scores (PEWS) are widely used to detect clinical deterioration, yet their prognostic performance and clinical utility in low- and middle-income emergency departments (EDs) remain uncertain. We evaluated a modified Brighton PEWS for predicting 24-h ICU admission in a resource-limited pediatric ED and developed an internally validated time-to-event model. We conducted a 12-month prospective cohort of children aged 1 month-15 years triaged as emergency severity index level 2-3 in a tertiary pediatric ED. Modified Brighton PEWS was recorded at arrival. The primary outcome was ICU admission within 24 h. Time from ED arrival to ICU admission was analysed using Cox regression adjusted for age, sex and comorbidity, with bootstrap internal validation. We compared a PEWS-only model with an enhanced model incorporating routinely available ED variables. Performance was assessed by 24-h calibration, discrimination and clinical utility using decision-curve analyses (DCA). Among 572 children, 157 (27.5%) were admitted to ICU within 24 h. ICU admission occurred in 7.1%, 45.3%, and 53.9% of children with PEWS ≤ 3, 4-5, and ≥ 6, respectively (log-rank p < 0.001). The multivariable time-to-event model showed good discrimination (C-index 0.81) and acceptable 24-h calibration. Baseline PEWS predicted 24-h ICU admission with an AUC of 0.80; a threshold ≥ 4 achieved high sensitivity with reasonable specificity. DCA indicated net benefit of PEWS-based risk stratification across clinically relevant thresholds.

conclusionIn a resource-limited pediatric ED, a modified Brighton PEWS at arrival provided robust prediction of 24-h ICU admission and can underpin risk-stratified escalation pathways. WHAT IS KNOWN: • PEWS are widely used to identify children at risk of clinical deterioration. • Evidence on prognostic accuracy and clinical utility in LMIC pediatric emergency departments remains limited. WHAT IS NEW: • In a resource-limited pediatric ED, a modified Brighton PEWS at arrival predicted 24-h ICU admission. • Decision-curve analysis supported PEWS-based risk stratification across clinically plausible thresholds.