Pediatric early warning scores (EWS) have been utilized to assist the identification of children at risk for clinically decompensating, experiencing a cardiac or respiratory arrest, or requiring a transfer to a higher level of care. Although their use is widespread, little consistency exists between tools and research evaluating the effectiveness of these tools is lacking. This quasi-experimental project evaluated twenty-five medical-surgical staff nurses' use and perceptions as well as the inter-rater reliability of a newly modified pediatric EWS tool at a free standing, academic Midwestern pediatric hospital.