open access original research optimising paediatric ... · 2 acobfin etal m open 20199e028796...

1Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796

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Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

Nina Jacob ,1 Yvonne Moriarty ,1 Amy Lloyd,1 Mala Mann,2 Lyvonne N Tume,3 Gerri Sefton,4 Colin Powell,5,6 Damian Roland,7,8 Robert Trubey,1 Kerenza Hood,1 Davina Allen9

To cite: Jacob N, Moriarty Y, Lloyd A, et al. Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2018- 028796).

Received 19 February 2019Revised 11 October 2019Accepted 16 October 2019

For numbered affiliations see end of article.

Correspondence toDr Nina Jacob; Jacobn@ cardiff. ac. uk

Original research

© Author(s) (or their employer(s)) 2019. Re- use permitted under CC BY. Published by BMJ.

ABSTRACTObjective To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.Methods A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.Results Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.Conclusions There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.PROSPERO registration number CRD42015015326.

InTROduCTIOnFailure to recognise and act on signs of clin-ical deterioration in the hospitalised child is an acknowledged safety concern.1 Track and trigger tools (TTT) are a common response to this problem. A TTT consists of sequen-tial recording and monitoring of physiolog-ical, clinical and observational data. When a certain score or trigger is reached then a clin-ical action should occur including, but not limited to, altered frequency of observation, senior review or more appropriate treatment or management. Tools may be paper based or electronic and monitoring can be automated or undertaken manually by staff.

Despite the growing use of TTTs there is limited evidence of their effectiveness as a single intervention in reducing mortality or arrest rates in hospitalised children.2 3 Results from the largest international cluster randomised controlled trial of a TTT (the Bedside Paediatric Early Warning System

Strengths and limitations of this study

► The literature in this field is heterogeneous and bet-ter at identifying system weakness than it is effec-tive improvement interventions. By deploying social theories and a hermeneutic review methodology it was possible to develop a propositional model of the core components of an afferent component paediat-ric early warning system.

► The model is derived from logical inferences draw-ing on the overall evidence synthesis, social theories and clinical expertise, rather than strong empirical evidence of single intervention effectiveness.

► There is a growing consensus of the need to take a whole systems approach to improve the detection and response to deterioration in the inpatient paedi-atric population and this paper offers an evidence- based framework for this purpose.

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2 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796

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Box 1 Mechanisms of translational mobilisation and their application to rescue trajectories14

Object formation—how people draw on the interpretative resources available to them within a strategic action field to create the objects of their practice. Enrolment into an escalation trajectory requires multiple examples of object formation beginning with construction of an indi-vidual as at risk of deterioration and a regime of vital signs monitoring instigated, through recognition that the patient’s physiological status is a cause for concern, to the identification of the patient as requiring a specific intervention. How this is achieved is highly dependent on the features of the local strategic action field.Translation—the processes that enable practice objects to be shared and different understandings accommodated. It points to the actions necessary in order for a patient that is an object of concern for nursing staff to be translated into a clinical priority for the doctor and, if neces-sary, to be translated into the focus of intervention by the emergency response team.Articulation refers to the secondary work processes that align the actions, knowledge and resources necessary for the mobilisation of projects of collective action. It is the work that makes the work, work. Responding to deterioration is time critical and articulation work is nec-essary to ensure the availability of resources and materials to support clinical management. This is not a mundane observation; catastrophic failures in patient safety are often attributed to the lack of function-ing equipment107 and the absence of monitoring equipment has been identified as a factor undermining the implementation of early warning track and trigger tools.48Attending to articulation in rescue trajectories also underlines the temporal ordering of action and the mechanisms required to achieve this, directing improvement efforts towards the or-ganisation’s escalation policy, for example.Reflexive monitoring refers to the processes through which people col-lectively or individually appraise and review activity. In a distributed field of action, reflexive monitoring is the means through which members ac-complish situational awareness108 of an overall project. The importance of situation awareness in rescue trajectories is well recognised, but achieving this is challenging. Reflexive monitoring is conditioned by the wider institutional context which will include a multiplicity of informal and formal mechanisms designed for this purpose: nursing and medical handovers, the ward round, safety briefings. The form, frequency and effectiveness of these processes in supporting detecting and acting on deterioration would need to be taken into account in any improvement initiative.Sensemaking refers to the processes through which agents create or-der in conditions of complexity. It draws attention to how the material and discursive processes by which members organise their work, ac-count for their actions and construct the objects of their practice also give meaning and substance to the institutional components of strategic action fields that shape activity and condition future activity.

(BedsidePEWS)) did not support TTT use to reduce mortality, and highlighted the multifactorial mechanisms involved in detecting and initiating action in response to deterioration.4 These findings lend further weight to a developing consensus about the need to look beyond TTTs to the impact of wider system factors on detecting and responding to deterioration in the inpatient paedi-atric population.2 5–9 This paper reports on a theoreti-cally informed systematic hermeneutic literature review10 to identify the core components and mechanisms of action of successful afferent component early warning systems (EWS) in paediatric hospitals and is one of three linked reviews undertaken as part of a wider UK study commissioned to develop and evaluate an evidence- based paediatric warning system.3 11 It addressed the following question:

What sociomaterial and contextual factors are associated with successful or unsuccessful Paediatric Early Warning Systems (with or without TTTs)?

METhOddesignWe performed a hermeneutic systematic review of the relevant literature. A hermeneutic systematic review is an iterative process, integrating analysis and interpretation of evidence with literature searching and is designed to develop a better understanding of the field.10 The popu-larity of the method is growing in health services research where it has value in generating insights from heteroge-neous literatures that cannot be synthesised through stan-dard review methodology12 and would otherwise produce inconclusive findings (see ref 9). The purpose of the review was not exhaustive aggregation of evidence, but to develop an understanding of the social, material and contextual factors associated with successful or unsuc-cessful paediatric early warning systems (PEWS).

Theoretical frameworkData extraction and interpretation was informed by trans-lational mobilisation theory (TMT)13 14 and normalisa-tion process theory (NPT).15 16 TMT is a practice theory which explains how goal- oriented collaborative activity is mobilised in unpredictable environments (box 1) and how the relevant mechanisms of action are conditioned by the local context. It is well suited for understanding EWS which require the organisation of action in evolving conditions, in a variety of clinical environments, with different teams, skill mixes, resources, structures and technologies. NPT shares the same domain assump-tions as TMT and is concerned with ‘how and why things become, or do not become, routine and normal compo-nents of everyday work’,15 16 directing attention to the preconditions necessary for successful implementation of interventions. The theoretical framework informed our data extraction strategy, interpretation of the evidence and the development of a propositional model of an optimal paediatric early warning system.

Focus of the reviewThe literature in this field identifies four integrated components which work together to provide a safety system for at- risk patients: (1) the afferent component which detects deterioration and triggers timely and appropriate action; (2) the efferent component which consists of the people and resources providing a response; (3) a process improvement component, which includes system auditing and monitoring; and (4) an administra-tive component focusing on organisational leadership



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Figure 1 Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) diagram (adapted from Moher et al109).

and education required to implement and sustain the system.17 Our focus was limited to the afferent compo-nents of the system.

Stages of the reviewStage 1: scoping the literatureLiterature was identified through a recent scoping review,7 team members’ knowledge of the field, hand searches and snowball sampling techniques. The purpose was to (1) inform our review question and eligibility criteria and (2) identify emerging themes and issues. While we drew on several reviews of the literature5 12–14 we always consulted original papers. Data were extracted using data extraction template 1 (online supplementary appendix 1) and analysed to produce a provisional conceptual model of the core components of paediatric early warning systems. Additional themes of relevance were identified: family involvement, situational awareness (SA), struc-tured handover, observations and monitoring and the impact of electronic systems and new technologies.

Stage 2: searching for the evidenceWe undertook systematic searches of the paediatric and adult EWS literature (the goals and mechanisms of collective action in detection and rescue trajectories are the same). For the adult literature we used the same search strategies but added a qualitative filter to limit the scope to studies most likely to yield the level of socioma-terial and contextual detail of value to the review. Liter-ature informing additional areas of interest was located through a combination of systematic and hand searches. Systematic searches (searches 2 and 3) were undertaken in areas where we anticipated locating evidence of the effectiveness of specific interventions to strengthen EWS. Theory- driven searches reflected the conceptual require-ments of the model development.

Systematic searchesA systematic search was initially conducted across a range of databases from 1995 to September 2016 to identify relevant studies on the PEWS literature. This search was updated to cover literature from September 2016 to May 2018. An additional three systematic searches were conducted from 1995 to September 2016 to iden-tify supplementary papers to aid in developing under-standing on the PEWS literature:1. Adult EWS.2. Interventions to improve SA.3. Structured communication tools for handover and

handoff.Detailed information on the search methodology can

be found in online supplementary appendix 2. Grey literature was excluded in order to keep the review manageable.

Theory-driven searchesAdditional theory- driven searches were conducted in the following areas:1. Family involvement.

2. Observations and monitoring.3. The impact of electronic systems.

These were a combination of exploratory, comput-erised, snowball and hand searches. As the analysis progressed, we continued to review new literature on EWS as this was published.

ScreeningAfter removing duplicates 5284 references were identi-fied for screening. A modified Preferred Reporting Items for Systematic Reviews and Meta- Analyses flow diagram is provided (figure 1). Papers were screened by title to assess eligibility and then by full text to assess relevance for data extraction. The PEWS and adult EWS searches were screened by two researchers, searches 2 and 3 were screened by the lead reviewer.

Stage 3: data extraction and appraisalData extraction template 2 (online supplementary appendix 3) was applied to all papers included in the review. As is typical of reviews of this kind, evidential frag-ments and partial lines of inquiry formed the unit of anal-ysis rather than whole papers.18 These fragments were quality assessed according to the contribution they made to the developing analysis rather than assessing the paper as whole through the use of formal appraisal tools. Data extraction and quality appraisal were undertaken concur-rently and double checked by a second reviewer.

Stage 4: developing a propositional modelA propositional model was developed specifying the core ingredients of a paediatric early warning system (table 1). It comprises logical inferences derived from the theo-retical framework and evidence synthesis, informed by



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Table 1 Propositional model

Proposition Conceptual requirements

Detection Detection of deterioration depends on timely and appropriate monitoring of vital signs and relevant risk factors.

At a minimum, this requires: ► Staff are aware of which vital signs need to be monitored. ► Staff are aware of the minimum frequency of observations required for the children in their care.

► Staff are aware of the need to review the frequency of observations for children in their care.

► Staff are aware of additional clinical assessments required for children with prior risk factors.

► Monitoring tasks are allocated to staff members with appropriate skills to conduct them.

► Staff have access to appropriate equipment to accurately monitor vital signs, and conduct other clinical assessments.

► Staff are aware of roles and responsibilities for monitoring. ► Staff have time to conduct accurate, timely and appropriate monitoring of vital signs, alongside other work commitments.

► Staff concern is formally recognised as a valid indicator of deterioration. ► Staff are supported to develop and use their intuition in detecting signs of deterioration.

► Staff understand the value of family concerns in the detection of deterioration. ► Families are involved with defining normal physiological parameters for their child.

► Families receive guidance about what to do if they are concerned that their child’s condition is deteriorating.

► Staff keep families informed about developments in their child’s care and treatment.

Detection Detection of deterioration depends on timely and appropriate recording of signs of deterioration.

At a minimum this requires: ► Staff are aware of the need to record vital signs, family concern and staff concern promptly and accurately.

► Staff are aware of roles and responsibilities for recording vital signs, family concern and staff concern.

► Staff have appropriate skills to accurately record vital signs, family concern and staff concern.

► Staff have access to appropriate equipment to accurately record vital signs, family concern and staff concern.

► There are an appropriate number of staff to carry out required tasks.

Detection Detection of deterioration depends on timely and appropriate interpretation of signs of deterioration.

At a minimum this requires: ► Staff are aware of prior factors that increase children’s risk of deterioration (eg, premature birth).

► Staff are aware of roles and responsibilities for interpreting signs of deterioration. ► Staff take into account vital signs, family concern and staff concern in assessing the condition of children in their care.

► Teams have appropriate skills to discern patterns and trends of signs and symptoms.

► Staff have the opportunity to learn how to interpret signs of deterioration from shadowing more senior staff.

► Care is organised to enable staff to recognise patterns and trends for children. ► Families are in a position to discern patterns of signs and symptoms in their child.

Planning Planning depends on reviewing indicators of deterioration for each patient.

At a minimum this requires: ► For each child, all indicators of deterioration are brought together and kept up to date.

► There is a regular mechanism for reviewing the status of all children in the ward to identify those children who are a concern.

► There is a regular mechanism for reviewing staffing levels and skills mix, workload, acuity and admissions.

Continued



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Proposition Conceptual requirements

Planning Planning depends on staff being aware at ward level of the status of individual patients and the availability of skills and resources, and preparing an appropriate response.

At a minimum this requires: ► There is a regular mechanism for communicating the review of all children, staffing levels and other resources to the rest of the team and senior managers.

► There is a regular mechanism for planning appropriate response to deterioration. ► Senior staff members are allocated responsibility for managing demand and resources.

► Senior staff members are allocated responsibility for communicating response plans.

► There is an action plan for children at risk of deterioration which is shared with families and staff caring for them.

Action Action depends on clear escalation and response processes.

At a minimum this requires: ► A trigger or prompt to act from detection or planning phases. ► Clearly defined graded escalation and response procedures—agreed at organisational level.

► Staff receive guidance about how to escalate and respond. ► Staff understand their roles and responsibilities in the escalation procedure as activators and responders.

► Staff are encouraged and supported in raising concerns. ► Families are encouraged and supported in raising concerns. ► Staff are able to communicate information across professional hierarchies using a structured approach to sharing information.

► Clear structures to support action, including the use of a ‘no false alarms’ policy so staff are not deterred from escalating care.

Action Action depends on evaluation.

At a minimum this requires: ► Escalation and response processes are reviewed to promote learning. ► There is opportunity for staff to discuss differences of opinion in the need for escalation.

► No blame is assigned to those who escalate.

Table 1 Continued

clinical experts on the team. Iterations of the model were developed in collaboration with clinical colleagues. A series of face- to- face meetings were conducted to review structure, wording and applicability to clinical practice.

Patient and public involvementThis review was conducted as part of a larger mixed methods study (ISRCTN 94228292), which used a formal, facilitated parental advisory group. The group comprised parents of children who had experienced an unexpected adverse event in a paediatric unit and provided input which helped shape the broader research questions and wider contextual factors to consider, specifically within the family involvement element of the system. The results of the review will be disseminated to parents through this group.

RESulTSIncluded studiesEighty- two papers were included in the review. Forty- six papers focused on TTT implementation and use in paedi-atric and adult contexts (24 from the paediatric search and the remaining 22 from the adult- focused search); the remaining 36 papers contributed supplementary data on factors related to the wider warning system. See table 2 for a detailed breakdown of this process. No studies

were located that adopted a whole systems approach to detecting and responding to deterioration.

AnalysisIn TMT the primary unit of analysis is the ‘project’, which defines the social and material actors (people, materials, technologies) and their relationships involved in achieving a particular goal. The goals of the afferent paediatric warning system are: first, that the child is identified as at risk and a vital signs monitoring regime instigated; second, that evidence of deterioration is iden-tified through monitoring and categorised as such; and third, that timely and appropriate action is initiated in response to deterioration. Our analysis of the litera-ture suggests that three subsystems within the afferent component of EWS support these processes: the detection of signs deterioration; the planning needed to ensure teams are ready to act when deterioration is detected; and the initiation of timely action. While we have focused on the afferent component, it is important to remember that all elements of the overall safety system (efferent component, process improvement and administrative arm) need to be working in concert in order to maintain an optimal paediatric early warning system. In the next section, we report on the literature in relation to each subsystem.



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Table 2 Screening breakdown

PEWS EWSStructured handover

Situational awareness

Electronic systems

Observations and monitoring

Family involvement

Snowball sample

Database searching

3564 1155 3369 302 – – – –

Additional sources

83 7 150 46 – – – –

Records after duplicates removed

2194 751 2156 199 – – – –

Hand searches

431 – – – 26 20 15 5

Title screening

90 751 2156 199 26 20 15 5

Abstract screening

62 106 N/A N/A 26 20 15 5

Full paper screening

39 65 37 26 26 20 15 5

Included in syntheses

24 22 4 6 10 2 9 5

EWS, early warning system; N/A, not applicable; PEWS, Paediatric Early Warning System.

detectionThe goal of the detection subsystem is to recognise early signs of deterioration, so the child becomes the focus of further clinical attention. This requires, first, that the child is identified as at risk and a vital signs monitoring regime instigated and, second, that the child is identified as showing signs of deterioration.

Despite widespread use, the evidence on TTT effec-tiveness in predicting adverse outcomes in hospitalised children is weak.3 Many TTTs have only been validated retrospectively and postpredictive values were generally low. Studies reporting significant decreases in cardiac arrest calls or mortality had methodological concerns. The literature does suggest that TTTs have value in supporting process mechanisms in the detection subsystem. Vital signs monitoring is undertaken on all hospital inpatients and, like other high- volume routine activity, is often dele-gated to junior staff19–38 who may not have sufficient skills to interpret results.21 22 37 TTTs have value in mitigating these risks: by specifying physiological thresholds that indicate deterioration they take knowledge to the bedside and act as prompts to action19 39 which can lead to a more systematic and frequent approach to monitoring and improved detection of deterioration.40 41

TTT’s effectiveness in fulfilling these functions depends on certain preconditions. The review highlighted that TTT use was impacted by the availability of appropriate and functioning equipment,22 27 29 34 39 42–46 (in)adequate staffing and night- time pressures22 26 29 30 37 40 42–44 47–52 and an appropriately skilled workforce.26 28 36 43 49 50 53–57 On this latter point, while several papers report on education packages to improve the detection of deterioration, the evidence is not robust enough to recommend specific

programmes.23–25 28 30 35 55 58–60 There were also times whereby nursing staff prioritised sleep over waking a patient to take vital signs.46 61

TTTs are also used differently depending on the experi-ence of the user. For juniors, they provide a methodology and structure for monitoring clinical instability and iden-tifying deterioration, whereas more experienced staff reportedly use TTTs as confirmatory technologies.19–32 The importance of professional intuition in detecting deterioration is extensively reported across the litera-ture19–22 26 27 29 31 32 36–40 42 43 45 46 48 50–53 60 62–68 and several authors recommend the inclusion of ‘staff concern’ in tool criteria.26 48 51 57 This is important; TTTs may be of less value in patients with chronic conditions because of altered normal physiology or where subtle changes are difficult to detect.64 It is also the case that TTTs are implemented in contexts governed by competing organi-sational logics which impact on their value and use.43 54 58 For example, Mohammed Iddrisu et al57 show TTTs have limited value immediately after surgery because accept-able vital sign parameters are different in the immediate postoperative period.

There is growing interest in the literature in strategies that facilitate patient and relative involvement in the early detection of deterioration.69 70 Healthcare profes-sionals depend on families to explain their child’s normal physiological baseline and identify subtle changes in their child’s condition but this information is not always systematically obtained.71 72 Some authors propose family involvement in interdisciplinary rounds (This is an edito-rial paper),73 but this requires parents to have detailed information about the signs and symptoms they should be attending to72 and as yet there is little evidence on



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effective strategies for how they might be involved in the detection of deterioration.73

While much of the literature reports on intermittent manual vital signs monitoring and paper- based recording systems, across the developed world there is a growing use of electronic technologies, which have important implications for the wider detection subsystem.74 We considered a number of evaluations of new technologies which indicated that electronic vital signs recording is associated with a number of positive outcomes, particu-larly timeliness and accuracy, when compared with paper- based systems.75 76 They can provide prompts or alerts for monitoring,77–79 which facilitates better recognition of deterioration and is associated with a reduction in mortality.78 80 These studies tend to evaluate new technol-ogies in isolation, however, and do not engage with the literature highlighting alarm fatigue which is known to mitigate effectiveness over time or concerns about over-burdening staff with alerts.81–83 Moreover, the successful implementation of new technologies is conditioned by the local context. For instance, where manual input into an electronic device is required, access to computers is an essential precondition. When computers were not avail-able, staff ‘batch’ the collection of vital signs before data entry, thereby delaying the timely detection of deteriora-tion.27 45 84 In another study where the electronic system was found to be cumbersome and separated the collec-tion and entry of data from the review of vital signs, verbal reports were favoured to ensure timely communication of information.85 See table 3 for a summary of the evidence reported.

PlanningDetecting and responding to deterioration involves the coordination of action in conditions of uncertainty and competing priorities. The goal of the ‘Planning’ subsystem is to ensure the clinical team are ready to act in the event of evidence of deterioration and is reflected in the growing interest in the literature on structures to facilitate team SA, group decisions and planning.62

TTTs have been found to support SA. Their use enabled clinicians to have a ‘bird’s- eye’ view over all admitted patients on a ward as well as encouraging staff to consider projected acuity levels of the ward.86 A number of studies also report on ‘huddles’ in facilitating SA.32 65 87 88 A huddle is a multidisciplinary event scheduled at predeter-mined times where members discuss specific risk factors around deterioration and develop mitigation plans. One study combined the introduction of huddles with a ‘watchstander’, a role fulfilled by a charge nurse or senior resident, whose primary function is to know patients at high risk for deterioration.88 These initiatives were associ-ated with a near 50% reduction in transfers from acute to intensive care determined to be unrecognised situation awareness events. A further strategy identified by Gold-enhar et al describes the use of the ‘watcher’ category to designate a patient as at risk where staff have a ‘gut feeling’ deterioration is likely.87 A recent study used the

category of ‘watcher’ to create a bundle of expectations to standardise communication and contingency plan-ning. Once a patient was labelled ‘a watcher’ a series of five specific tasks, such as documentation of physician awareness of watcher status and that the family had been notified of the change in the patient’s status, needed to be completed within 2 hours.89

Handovers are integral to clinical communication and contribute to SA. The extensive literature on handover indicates that information sharing can be of variable quality47 54 90 and there is growing evidence that structured approaches improve this.30 47 54 63 87 90–94 Ranging from a checklist system91 93 to a cognitive aid developed through consensus,23 94 most of the published interventions are variations of the Situation- Background- Assessment- Recommendation (SBAR) tool.54 90–92 While effective handover depends on communicative forms that extend beyond the information transfer that is typically the focus of structured handover tools,90 in the context of EWS a lack of standardisation allows greater margin for individu-alistic practices and difficulties accessing complementary knowledge and establishing shared understandings.47

There is also a literature on the use of common infor-mation spaces—such as whiteboards—in facilitating SA in the healthcare team.23 33 47 53 55 58 67 These should be in a visible location and colour coded to correspond with the TTT score, where relevant.47 55 58 Electronic systems automate this information and allow information to be reviewed remotely. However, they disconnect vital signs data from the patient and hence other indicators of clin-ical status and access to data is contingent upon the avail-ability of computers.27 45 47 84 95

The literature indicates that SA can be facilitated in different ways in different contexts and it is the relation-ship between system elements that is important.47 In their study on SA in delivery suites, Mackintosh et al discuss the three main supports for SA—whiteboard, handover and coordinator role—and illustrate how these interacted in organisations with strong SA compared with those with reduced levels. Crucially, this ‘interplay’ between the different activities was highly context dependent; ‘the same supports used differently generate different outcomes’ (p 52).47 See table 4 for a summary of the plan-ning evidence.

ActionThe goal of the ‘Action’ subsystem is to initiate appro-priate action in response to evidence of deterioration. The literature suggests that mobilising action across professional boundaries/hierarchies is challenging, with differences in language between doctors and nurses and power dynamics contributory factors.27 40 41 50 52 57 60 96 TTTs are in part a response to the challenges of commu-nication in mobilising action in response to deteriora-tion. By transforming a series of discrete observations into a summative indicator of deterioration—such as a score or a trigger—TTTs ‘translate’ and package the patient’s status into a form that can be readily communicated



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latio

n p

olic

y.

Ele

ctro

nic

syst

ems

The

elec

tron

ic h

ealth

rec

ord

(EH

R)

pro

vid

es a

pro

mp

t to

act

ion.

Bon

afid

e et

al21

US

AS

emis

truc

ture

d in

terv

iew

sG

roun

ded

the

ory

PE

WS

Vita

l sig

ns m

onito

ring

del

egat

ed t

o ju

nior

wor

kers

who

may

not

hav

e th

e kn

owle

dge

to

inte

rpre

t re

sults

. Tra

ck

and

trig

ger

tool

s us

ed t

o co

nfirm

or

iden

tify

det

erio

ratio

n d

epen

din

g on

ex

per

ienc

e an

d p

artic

ular

ly u

sefu

l for

ju

nior

sta

ff.P

rofe

ssio

nal i

ntui

tion

imp

orta

nt fo

r se

nior

sta

ff to

det

ect

det

erio

ratio

n.

Bon

afid

e et

al81

US

AP

rosp

ectiv

e fe

asib

ility

stu

dy

Vid

eo r

ecor

din

g an

d e

lect

roni

c p

atie

nt d

ata

colle

cted

p

rosp

ectiv

ely.

Pra

gmat

ic

obse

rvat

iona

l stu

dy

of V

italP

AC

d

eplo

ymen

t in

tw

o la

rge

hosp

itals

.

Ele

ctro

nic

syst

ems

Ala

rm fa

tigue

—a

bar

rier

to e

scal

atio

n

Bon

afid

e et

al83

US

AV

ideo

rev

iew

and

res

pon

se t

ime

outc

ome

Sta

tistic

al a

naly

sis

PE

WS

Ala

rm fa

tigue

—a

bar

rier

to e

scal

atio

n

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Bra

aten

22U

SA

Doc

umen

t re

view

and

inte

rvie

ws

usin

g th

e p

rinci

ple

s of

cog

nitiv

e w

ork

anal

ysis

Ind

uctiv

e an

d d

educ

tive

form

s of

ana

lysi

s—co

gniti

ve w

ork

anal

ysis

, fra

mew

ork

and

dire

cted

co

nten

t an

alys

is

EW

SV

ital s

igns

mon

itorin

g d

eleg

ated

to

juni

or w

orke

rs w

ho m

ay n

ot h

ave

the

know

led

ge t

o in

terp

ret

resu

lts.

Trac

k an

d t

rigge

r to

ols

used

to

confi

rm

or id

entif

y d

eter

iora

tion

dep

end

ing

on e

xper

ienc

e. P

rofe

ssio

nal i

ntui

tion

imp

orta

nt fo

r m

ore

seni

or s

taff/

whe

n cl

inic

al c

hang

e is

ab

rup

t.Is

sues

aro

und

ava

ilab

ility

of e

qui

pm

ent

and

sta

ffing

.

Bra

dy

and

G

old

enha

r63U

SA

Focu

s gr

oup

s ×

7—he

ld in

gro

ups

of p

artic

ipan

ts w

ith s

imila

r ro

les

Con

stan

t co

mp

aris

onS

ituat

iona

l aw

aren

ess

Pae

dia

tric

ear

ly w

arni

ng s

core

su

pp

lem

entin

g gu

t fe

elin

g b

ut t

hese

w

ere

not

stan

dar

dis

ed.

Bur

ns e

t al

68U

SA

Sem

istr

uctu

red

inte

rvie

ws

wer

e us

ed d

raw

ing

on a

des

crip

tive

phe

nom

enol

ogic

al m

etho

dol

ogy.

Itera

tive

them

atic

ana

lysi

sS

now

bal

l sam

ple

Imp

orta

nce

of p

rofe

ssio

nal i

ntui

tion

is

rep

orte

d.

Chu

a et

al36

Sin

gap

ore

A q

ualit

ativ

e su

rvey

usi

ng c

ritic

al

inci

den

t te

chni

que

Ind

uctiv

e co

nten

t an

alys

isE

WS

Vita

l sig

ns m

onito

ring

is t

he

resp

onsi

bili

ty o

f nur

ses.

The

reg

ular

ity

of t

his

activ

ity c

an le

ad t

o it

bei

ng

view

ed a

s a

mun

dan

e ac

tivity

.Im

por

tanc

e of

‘gut

feel

ing’

and

intu

ition

in

det

ectio

n of

det

erio

ratio

n.

Cio

ffi48

Aus

tral

iaU

nstr

uctu

red

inte

rvie

ws

with

nu

rses

who

had

act

ivat

ed t

he

med

ical

em

erge

ncy

team

(ME

T)

Sim

ple

cod

e an

d r

etrie

veE

WS

Imp

orta

nce

of g

ut fe

elin

g an

d

‘kno

win

g’ y

our

pat

ient

in t

he d

etec

tion

of d

eter

iora

tion.

Imp

orta

nce

of h

avin

g st

aff c

once

rn in

th

e M

ET

crite

rion.

Cio

ffi51

Aus

tral

iaU

nstr

uctu

red

inte

rvie

ws

Sim

ple

cod

e an

d r

etrie

veE

WS

Imp

orta

nce

of g

ut fe

elin

g an

d in

tuiti

on

in r

ecog

nisi

ng d

eter

iora

tion.

Imp

orta

nce

of h

avin

g st

aff c

once

rn in

a

calli

ng c

riter

ia.

Cio

ffi e

t al

42A

ustr

alia

Focu

s gr

oup

s w

ith c

linic

ians

and

nu

rses

exp

lorin

g th

eir

resp

onse

s to

ab

norm

al v

ital s

igns

Con

stan

t co

mp

aris

onE

WS

Intu

ition

imp

orta

nt, p

artic

ular

ly fo

r m

ore

seni

or s

taff

to d

etec

t A

VS

. K

now

ing

your

pat

ient

rep

orte

d a

s ke

y;

know

led

ge a

nd e

xper

ienc

e se

en a

s es

sent

ial.

Tab

le 3

C

ontin

ued

Con

tinue

d



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Aut

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Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Cla

usse

n et

al65

US

AR

etro

spec

tive

revi

ew o

f cal

ls

to t

he r

apid

res

pon

se t

eam

(R

RT)

and

car

dia

c ar

rest

cal

ls

to e

valu

ate

imp

act

of e

vid

ence

- b

ased

gui

del

ines

(pre

inte

rven

tion)

.M

odifi

ed E

arly

War

ning

Sco

re

and

hud

dle

imp

lem

ente

d. E

HR

av

aila

ble

thr

ough

out

to c

omp

are

pre

and

pos

t.

Des

crip

tive

stat

istic

sE

lect

roni

c sy

stem

sP

rofe

ssio

nal i

ntui

tion

used

in

conj

unct

ion

with

the

Mod

ified

Ear

ly

War

ning

Sco

re

Dav

ies

et a

l53U

SA

Sur

vey

look

ing

at b

arrie

rs t

o ra

pid

re

spon

se s

yste

m (R

RS

) act

ivat

ion

Sta

tistic

al a

naly

sis

EW

SP

rofe

ssio

nal i

ntui

tion

used

ove

r R

RS

ac

tivat

ion

crite

ria—

bar

rier

to a

ctiv

atio

n

de

Gro

ot e

t al

62N

ethe

rland

sR

etro

spec

tive

pat

ient

rev

iew

and

se

mis

truc

ture

d in

terv

iew

s w

ith

pro

fess

iona

ls

Des

crip

tive

stat

istic

s an

d

grou

nded

the

ory

PE

WS

Imp

orta

nce

of p

rofe

ssio

nal i

ntui

tion

is

rep

orte

d.

Don

ohue

et

al64

UK

Qua

litat

ive

des

ign

with

crit

ical

in

cid

ent

tech

niq

ue.

Sem

istr

uctu

red

inte

rvie

ws

with

nu

rses

and

the

out

reac

h te

am.

Them

atic

ana

lysi

sE

WS

Imp

orta

nce

of g

ut fe

elin

g an

d in

tuiti

on

in d

etec

ting

det

erio

ratio

n

Dow

ney

et a

l74U

KN

arra

tive

revi

ew‘P

atte

rns

wer

e id

entifi

ed a

nd

tran

slat

ed t

o th

emes

, whi

ch w

ere

furt

her

refin

ed u

sing

an

itera

tive

pro

cess

.’

PE

WS

Driv

e to

war

ds

auto

mat

ed a

lert

s

End

acot

t et

al43

UK

Mix

ed m

etho

ds

case

stu

dy—

sem

istr

uctu

red

inte

rvie

ws

and

au

dit

of c

hart

s

Qua

litat

ive

cont

ent

anal

ysis

and

d

escr

iptiv

e st

atis

tics

Ob

serv

atio

ns a

nd

mon

itorin

gG

ut fe

elin

g im

por

tant

—in

tere

stin

gly

par

ticul

arly

for

nurs

es w

here

as d

octo

rs

soug

ht a

dd

ition

al e

mp

irica

l evi

den

ce t

o b

ack

up in

tuiti

on.

End

acot

t an

d

Wes

tley39

Aus

tral

iaQ

uest

ionn

aire

, in-

dep

th in

terv

iew

s an

d o

bse

rvat

ions

Con

tent

ana

lysi

s an

d c

onst

ant

com

par

ison

EW

SIn

tuiti

on a

nd a

ntic

ipat

ory

skill

s im

por

tant

in d

etec

ting

det

erio

ratio

n

Ent

wis

tle73

US

AE

dito

rial

N/A

Fam

ily in

volv

emen

tLi

ttle

evi

den

ce/n

o ev

alua

tions

of

pol

icie

s or

pra

ctic

es t

hat

enco

urag

e an

d s

upp

ort

fam

ily in

volv

emen

t in

cl

inic

al m

onito

ring.

Pro

pos

e th

e in

nova

tive

pra

ctic

e of

in

terd

isci

plin

ary

roun

ds

whe

re fa

mili

es

are

invi

ted

, and

com

mun

icat

ion

is

dire

cted

to

the

pat

ient

and

fam

ily.

Tab

le 3

C

ontin

ued

Con

tinue

d



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Aut

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Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Faga

n et

al82

US

AO

bse

rvat

iona

l coh

ort

com

par

ison

st

udy

Des

crip

tive

stat

istic

sE

lect

roni

c sy

stem

sC

once

rns

abou

t ov

erb

urd

enin

g st

aff

with

aut

omat

ed a

lert

s.W

hen

cons

ider

ing

the

pat

ient

’s

bas

elin

e, n

ursi

ng s

taff

are

exp

ecte

d

to n

otify

the

pat

ient

’s c

are

pro

vid

er

imm

edia

tely

res

pon

sib

le fo

r th

e p

atie

nt

whe

n th

e vi

tal s

igns

mee

t or

exc

eed

th

e cl

inic

al t

rigge

r.

Gra

edon

and

G

raed

on72

US

A fo

cus

Op

inio

n p

iece

N/A

Fam

ily in

volv

emen

tP

aren

ts t

o ex

pla

in c

hild

’s b

asel

ine.

Nee

d t

o ha

ve d

etai

led

info

rmat

ion

abou

t si

gns

and

sym

pto

ms

that

the

y sh

ould

look

for

that

wou

ld r

equi

re

aler

ting

the

med

ical

tea

m.

Pro

pos

e th

e ne

ed fo

r st

ruct

ured

in

clus

ion

of fa

mily

con

cern

dur

ing

war

d

roun

ds

(saf

ety

wal

krou

nds)

.

Han

ds

et a

l44U

KTh

e vi

tal s

igns

(VS

) and

ear

ly

war

ning

dat

a fo

r al

l inp

atie

nts

for

1 ye

ar t

o in

vest

igat

e p

atte

r ns

of V

S

obse

rvat

ions

col

lect

ed

Sta

tistic

alO

bse

rvat

ions

and

m

onito

ring

Sta

ffing

leve

ls a

nd a

vaila

bili

ty o

f eq

uip

men

t im

ped

e th

e co

llect

ion

of

vita

l sig

ns a

nd e

arly

war

ning

dat

a.N

ight

- tim

e fa

ctor

s al

so p

lay

a ro

le w

ith

a d

ecre

ase

in o

bse

rvat

ions

not

ed.

Hop

e et

al61

UK

Sem

istr

uctu

red

inte

rvie

ws

with

17

regi

ster

ed n

urse

sC

onst

ant

com

par

ativ

e m

etho

d

info

rmed

by

grou

nded

the

ory

Sno

wb

all s

amp

leW

ider

con

text

of n

ight

- tim

e ca

re

cons

ider

ed; t

here

is s

ome

ind

icat

ion

that

sta

ff ar

e m

akin

g a

choi

ce a

nd

prio

ritis

ing

slee

p o

ver

mon

itorin

g.

Jam

es e

t al

37U

KP

osta

l sur

vey

with

hea

lthca

re

assi

stan

ts (H

CA

) usi

ng c

lose

d a

nd

open

que

stio

ns

Des

crip

tive

stat

istic

s an

d c

onte

nt

anal

ysis

of q

ualit

ativ

e d

ata

Ob

serv

atio

ns a

nd

mon

itorin

gFa

ctor

s ot

her

than

the

sco

re u

sed

to

det

ect

det

erio

ratio

n—in

tuiti

on/p

atie

nt’s

ow

n d

escr

iptio

ns.

Vita

l sig

ns m

onito

ring

del

egat

ed t

o ju

nior

sta

ff w

ho m

ay n

ot h

ave

the

skill

s to

inte

rpre

t re

sults

; man

y H

CA

s d

id

not

‘fully

und

erst

and

thi

s ne

urol

ogic

al

asse

ssm

ent

and

it is

imp

licat

ions

for

the

acut

ely

unw

ell p

atie

nt t

hus

resu

lting

in

the

ris

k of

an

inac

cura

te E

arly

w

arni

ng s

core

’ (p

552

).

Jens

en e

t al

46D

enm

ark

Focu

s gr

oup

exp

lorin

g nu

rses

’ ex

per

ienc

es w

ith p

aed

iatr

ic e

arly

w

arni

ng s

core

s

Qua

litat

ive

mea

ning

co

nden

satio

n an

alys

isP

EW

SS

leep

ing

as a

par

t of

car

e id

entifi

ed.

Pro

fess

iona

l int

uitio

n.N

ight

- tim

e p

ress

ures

.

Tab

le 3

C

ontin

ued

Con

tinue

d



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Aut

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Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Jone

s et

al66

Aus

tral

iaQ

uest

ionn

aire

ab

out

und

erst

and

ings

and

bar

riers

to

activ

atin

g a

ME

T

Sim

ple

des

crip

tive

stat

istic

sE

WS

Intu

ition

imp

orta

nt w

hen

det

ectin

g d

eter

iora

tion

Jone

s et

al77

UK

Ele

ctro

nic

cap

ture

of p

hysi

olog

ical

d

ata

to s

ee if

aut

omat

ed c

linic

al

aler

ts in

crea

se c

omp

lianc

e w

ith a

n ea

rly w

arni

ng s

core

and

imp

rove

p

atie

nt o

utco

mes

Sta

tistic

alE

lect

roni

c sy

stem

sE

lect

roni

c sy

stem

s ca

n p

rovi

de

pro

mp

ts o

r al

erts

for

mon

itorin

g vi

tal

sign

s.Th

is s

yste

m d

emon

stra

ted

sig

nific

ant

imp

rove

men

t in

clin

icia

n at

tend

ance

to

pat

ient

s w

ho a

re a

cute

ly il

l with

an

early

war

ning

sco

re o

f 3 a

nd a

bov

e.

Kau

l et

al24

US

AD

escr

iptiv

e cr

oss-

sect

iona

l stu

dy;

nu

rse

and

med

ical

sta

ff su

rvey

Des

crip

tive

stat

istic

sP

EW

SB

enefi

ts o

f Bed

sid

e P

EW

S—

nurs

es

mor

e lik

ely

to id

entif

y ea

rly s

igns

of

det

erio

ratio

n an

d a

gre

ater

ab

ility

to

esca

late

car

e. D

eleg

atio

n to

juni

or s

taff

just

ified

.

Lob

os e

t al

25C

anad

aIm

ple

men

tatio

n re

por

tS

imp

le d

escr

iptiv

e st

atis

tics

PE

WS

Del

egat

ion

to ju

nior

sta

ff.E

duc

atio

n p

acka

ge d

evel

oped

aro

und

th

e R

RS

with

a v

arie

ty o

f inf

orm

al

lect

ures

and

inte

ract

ive

sess

ions

; ‘lu

nch

and

lear

ns’,

‘ed

ucat

ion

coffe

e ca

rts’

and

sim

ulat

ion

pro

gram

mes

for

inst

ance

.

Lyd

on e

t al

40

30

sem

istr

uctu

red

inte

rvie

ws

bas

ed o

n th

e th

eory

of p

lann

ed

beh

avio

ur w

ere

cond

ucte

d.

Que

stio

nnai

re w

ith L

iker

t sc

ale

dev

elop

ed fr

om t

he in

terv

iew

dat

a.

Ded

uctiv

e co

nten

t an

alys

isP

EW

SP

rofe

ssio

nal i

ntui

tion

Mac

kint

osh

et

al38

UK

Eth

nogr

aphi

c p

ersp

ectiv

e;

obse

rvat

ions

, sem

istr

uctu

red

in

terv

iew

s

Dat

a w

ere

ind

uctiv

ely

and

d

educ

tivel

y co

ded

usi

ng N

Viv

o V.

8 an

d o

rgan

ised

the

mat

ical

ly.

EW

SD

eleg

atio

n of

rou

tine

obse

rvat

ion

and

vi

tal s

igns

mon

itorin

g to

juni

or s

taff.

Pro

fess

iona

l int

uitio

n im

por

tant

; ‘k

now

ing

the

pat

ient

’ im

por

tant

for

det

ectin

g su

btle

cha

nges

in a

pat

ient

’s

cond

ition

.

Tab

le 3

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Mac

kint

osh

et

al27

UK

Com

par

ativ

e ca

se s

tud

y—an

R

RS

usi

ng e

thno

grap

hic

met

hod

s in

clud

ing

obse

rvat

ions

, int

ervi

ews

and

doc

umen

tary

rev

iew

Ind

uctiv

e an

d d

educ

tive

cod

ing

faci

litat

ed b

y N

Viv

o. A

lso

used

th

eme

bui

ldin

g an

d s

truc

turin

g m

etho

ds

from

fram

ewor

k an

alys

is

whi

le a

lso

info

rmed

by

othe

r th

eore

tical

fram

ewor

ks s

uch

as

‘tec

hnol

ogy-

in- p

ract

ice’

.

EW

SO

bse

rvat

ions

and

mon

itorin

g d

eleg

ated

to

juni

or s

taff/

HC

As

and

nur

ses—

early

w

arni

ng s

yste

m (E

WS

) leg

itim

ised

d

eleg

atio

n of

the

se t

asks

.Im

por

tanc

e of

pat

tern

rec

ogni

tion

and

in

tuiti

on.

The

TTTs

use

d t

o co

nfirm

or

iden

tify

det

erio

ratio

n an

d a

re p

artic

ular

ly u

sefu

l fo

r ju

nior

sta

ff.

Mac

kint

osh

et

al52

UK

Eth

nogr

aphi

c st

udy

usin

g ob

serv

atio

ns (>

120

hour

s),

sem

istr

uctu

red

inte

rvie

ws

(n=

45)

and

doc

umen

tary

rev

iew

Them

atic

ana

lysi

s w

ith d

ata

anal

ysed

iter

ativ

ely

in a

dd

ition

to

a m

ore

stra

tegi

c an

d p

olic

y-

focu

sed

cod

ing

fram

ewor

k

EW

SP

rofe

ssio

nal i

ntui

tion

imp

orta

nt w

hen

det

ectin

g d

eter

iora

tion

Mas

sey

et a

l67A

ustr

alia

In- d

epth

sem

istr

uctu

red

inte

rvie

ws

Ind

uctiv

e ap

pro

ach—

them

atic

an

alys

isE

WS

Imp

orta

nce

of in

tuiti

on o

r ‘s

ensi

ng

clin

ical

det

erio

ratio

n’

McD

onne

ll et

al26

UK

Sin

gle-

cent

re, m

ixed

met

hod

s,

bef

ore-

and

- aft

er s

tud

y in

clud

ing

a su

rvey

to

mea

sure

cha

nges

in

nur

ses’

kno

wle

dge

aft

er

imp

lem

enta

tion

of a

tra

ck a

nd

trig

ger

syst

em (T

&Ts

). A

lso,

q

ualit

ativ

e in

terv

iew

s.

Sta

tistic

al a

naly

sis

and

the

mat

ic

fram

ewor

k an

alys

isE

WS

T&Ts

use

d t

o co

nfirm

or

iden

tify

det

erio

ratio

n d

epen

din

g on

the

ex

per

ienc

e of

the

use

r. S

pec

ific

obje

ctiv

e in

form

atio

n w

as s

een

as

help

ing

the

resp

onse

arm

prio

ritis

e w

ork

Imp

orta

nce

of p

rofe

ssio

nal i

ntui

tion

or

‘gut

feel

ing’

in d

etec

ting

det

erio

ratio

n.N

eed

for

staf

f con

cern

in T

&Ts

.

McK

ay e

t al

59A

ustr

alia

Pro

spec

tive,

con

trol

led

, bef

ore-

an

d- a

fter

inte

rven

tion

tria

lS

tatis

tical

ana

lysi

sP

EW

SS

pec

ific

educ

atio

n p

acka

ge d

evel

oped

ar

ound

the

pae

dia

tric

ear

ly w

arni

ng s

core

w

hich

ass

ists

in t

he r

ecog

nitio

n of

d

eter

iora

tion

Moh

amm

ed e

t al

75U

KTh

ree

pha

ses;

the

firs

t tw

o w

ere

bas

ed in

a c

lass

room

and

ask

ed

nurs

es t

o ca

lcul

ate

an e

arly

w

arni

ng s

core

from

vig

nett

es

usin

g p

en a

nd p

aper

follo

wed

b

y a

hand

held

com

put

er. T

he

third

pha

se fo

llow

ed t

he p

revi

ous

app

roac

h b

ut w

as b

ased

on

the

war

d a

fter

nur

ses

had

bee

n us

ing

the

dev

ice

for

4 w

eeks

.

Sta

tistic

alE

lect

roni

c sy

stem

sTi

mel

ines

s of

ele

ctro

nic

vita

l sig

ns

reco

rdin

g w

hen

com

par

ed w

ith p

aper

sy

stem

s

Tab

le 3

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Moh

amm

ed

Idd

risu

et a

l57A

ustr

alia

To e

xplo

re n

urse

s’ r

ole

in

reco

gnis

ing

and

res

pon

din

g to

det

erio

ratin

g p

osto

per

ativ

e p

atie

nts

thro

ugh

focu

s gr

oup

s

Them

atic

ana

lysi

sS

now

bal

l sam

ple

Sta

ff co

ncer

n in

too

l crit

eria

use

ful

Pac

iott

i et

al71

US

AS

emis

truc

ture

d in

terv

iew

s w

ith

clin

icia

nsG

roun

ded

the

ory

and

con

stan

t co

mp

aris

onFa

mily

invo

lvem

ent

Phy

sici

ans

dep

end

on

fam

ilies

to

exp

lain

a c

hild

’s b

asel

ine.

Pat

tison

and

E

asth

am29

UK

Mix

ed m

etho

ds

stud

y lo

okin

g at

the

imp

act

of a

crit

ical

car

e ou

trea

ch t

eam

(CC

OT)

Sta

tistic

al a

naly

sis

and

gro

und

ed

theo

ryE

WS

Trac

k an

d t

rigge

r to

ol is

use

d t

o ei

ther

con

firm

or

iden

tify

det

erio

ratio

n d

epen

din

g on

the

exp

erie

nce

of t

he

user

.‘G

ut fe

elin

g’/in

tuiti

on im

por

tant

—p

atie

nt a

pp

eara

nce

ofte

n an

imp

orta

nt

sign

in d

etec

ting

det

erio

ratio

n.

Rad

esch

i et

al60

Italy

Mul

ticen

tre

surv

ey t

o id

entif

y th

e at

titud

es a

nd b

arrie

rs t

o M

ET

utili

satio

n

Sta

tistic

al a

naly

sis

EW

SIn

tuiti

on (p

hysi

cal a

pp

eara

nce

imp

orta

nt) i

n d

etec

ting

det

erio

ratio

n

Sch

mid

t et

al78

UK

Ret

rosp

ectiv

e an

alys

is o

f dat

a co

llect

ed r

outin

ely.

Pra

gmat

ic

obse

rvat

iona

l stu

dy

of V

italP

AC

d

eplo

ymen

t in

tw

o la

rge

hosp

itals

.

Sta

tistic

al a

naly

ses

Ele

ctro

nic

syst

ems

Ele

ctro

nic

syst

ems

pro

vid

e p

rom

pts

for

aler

ts, f

acili

tate

bet

ter

reco

gniti

on o

f d

eter

iora

tion

and

are

ass

ocia

ted

with

re

duc

ed m

orta

lity.

Sef

ton

et a

l76U

KC

ontr

olle

d s

tud

y of

vita

l sig

ns

doc

umen

tatio

n an

d p

aed

iatr

ic

early

war

ning

Sco

reca

lcul

atio

n an

d

a su

rvey

of a

ccep

tab

ility

Des

crip

tive

stat

istic

sP

EW

SE

rror

s in

pap

er- b

ased

doc

umen

tatio

n w

ere

foun

d; i

ncor

rect

age

- sp

ecifi

c ch

art

used

; ina

ccur

ate

doc

umen

tatio

n of

val

ues

and

plo

ttin

g of

tre

nds;

in

corr

ect

scor

e ca

lcul

atio

n. In

co

mp

aris

on, t

he e

rror

rat

e us

ing

the

elec

tron

ic s

core

was

low

.

She

arer

et

al31

Aus

tral

iaA

mix

ed m

etho

ds

stud

yIte

rativ

e co

din

gE

WS

Imp

orta

nce

of p

rofe

ssio

nal i

ntui

tion

Søn

ning

et

al41

Nor

way

Que

stio

nnai

re o

f a s

amp

le o

f sta

ff w

ho u

se a

pae

dia

tric

ear

ly w

arni

ng

scor

e

Des

crip

tive

stat

istic

sP

EW

SA

pp

reci

ate

that

a p

aed

iatr

ic e

arly

w

arni

ng s

core

enc

oura

ges

a sy

stem

atic

ap

pro

ach

to m

onito

ring.

Ste

vens

on a

nd

Nils

son85

Sw

eden

Qua

litat

ive;

focu

s gr

oup

s w

ith 2

1 re

gist

ered

nur

ses

Con

tent

ana

lysi

s of

inte

rvie

ws

Ele

ctro

nic

syst

ems

Verb

al r

epor

ts w

ere

favo

ured

ove

r th

e el

ectr

onic

sys

tem

.

Ste

war

t et

al32

Sw

eden

Mix

ed m

etho

ds.

Ret

rosp

ectiv

e re

view

of r

ecor

ds

and

nur

se- l

ed

focu

s gr

oup

s.

Sta

tistic

al a

naly

sis

and

con

tent

an

alys

isE

WS

Intu

ition

stil

l pla

ys a

par

t—th

e ‘s

core

’ w

as r

arel

y th

e si

ngle

det

erm

inin

g fa

ctor

in a

ctiv

atio

n b

ut r

athe

r p

rom

pte

d

nurs

es t

o ga

ther

ad

diti

onal

info

rmat

ion.

Tab

le 3

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Sub

be

et a

l80U

KA

bef

ore-

and

- aft

er s

tud

y of

an

elec

tron

ic a

utom

ated

ad

viso

ry V

S

mon

itorin

g an

d n

otifi

catio

n sy

stem

. E

leva

ted

sco

res

wer

e re

laye

d t

o an

RR

T.

Sta

tistic

al a

naly

sis

Sno

wb

all s

amp

leA

utom

ated

ver

sus

mon

itorin

g as

soci

ated

with

a d

ecre

ase

in m

orta

lity

Wag

er e

t al

84U

SA

Ob

serv

atio

nal s

tud

yD

escr

iptiv

e st

atis

tics

Ele

ctro

nic

syst

ems

Bat

chin

g of

pat

ient

dat

a w

here

by

the

care

pro

vid

er h

and

writ

es t

he p

atie

nt’s

vi

tal s

igns

and

up

load

s it

to t

he

com

put

er a

t a

late

r tim

e is

com

mon

, es

pec

ially

as

the

com

put

ers

are

ofte

n b

usy.

Ind

ivid

ual t

able

t P

Cs

seem

to

elim

inat

e th

is fr

om o

ccur

ring.

Wat

son

et a

l45U

SA

Mix

ed m

etho

ds,

ret

rosp

ectiv

e m

edic

al r

ecor

d o

bse

rvat

ions

and

ob

serv

atio

ns o

f nur

se in

tera

ctio

ns

in 1

min

blo

cks

Ob

serv

atio

n an

alys

is, a

lthou

gh

this

is n

ot d

escr

ibed

, and

st

atis

tical

ana

lysi

s

PE

WS

Info

rmat

ion

r ela

ting

to t

rans

fer

to

elec

tron

ic s

yste

ms—

dis

tanc

e th

e ‘e

yes’

of t

he n

urse

s fr

om t

he p

atie

nt;

bat

chin

g.In

tuiti

on.

Whe

atle

y34U

KE

thno

grap

hic

app

roac

h;

par

ticip

ant

obse

rvat

ion

and

se

mis

truc

ture

d in

terv

iew

s

Them

atic

and

con

tent

ana

lysi

sO

bse

rvat

ions

and

m

onito

ring

The

regu

larit

y of

vita

l sig

ns m

onito

ring

may

als

o le

ad t

o it

bec

omin

g vi

ewed

as

mun

dan

e p

ract

ice

that

can

be

del

egat

ed t

o he

alth

care

ass

ista

nts.

Wor

kpla

ce p

ress

ure/

equi

pm

ent

failu

res

affe

ct q

ualit

y of

ob

serv

atio

ns.

AV

S, a

bno

rmal

vita

l sig

ns; N

/A, n

ot a

pp

licab

le; T

TT, t

rack

and

trig

ger

tool

.

Tab

le 3

C

ontin

ued



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Tab

le 4

S

umm

ary

of p

lann

ing

evid

ence

Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Ab

raha

m e

t al

91U

SA

Pre

/pos

tpro

spec

tive

stud

yTh

e q

ualit

y an

d c

omp

lete

ness

of

the

hand

off n

ote—

bot

h to

ols—

was

as

sess

ed b

y a

mul

tipro

fess

iona

l ro

und

.

Str

uctu

red

ha

ndov

erVa

lue

of a

che

cklis

t to

ol fo

r ha

ndov

er

Bra

dy

and

G

old

enha

r63U

SA

.Fo

cus

grou

ps

×7—

held

in g

roup

s of

p

artic

ipan

ts w

ith s

imila

r ro

les

Con

stan

t co

mp

aris

onS

ituat

iona

l aw

aren

ess

Hud

dle

use

ful t

o p

roac

tivel

y id

entif

y an

d p

lan

for

risk.

Str

uctu

re t

o su

pp

ort

hand

over

imp

orta

nt.

Bra

dy

et a

l88U

SA

Sta

tistic

al p

roce

ss c

ontr

ol c

hart

sS

ituat

iona

l aw

aren

ess

Hud

dle

s le

d b

y a

wat

chst

and

er c

harg

e nu

rse.

Whe

n ris

k is

id

entifi

ed t

he t

eam

dis

cuss

ed t

his

and

dev

elop

ed a

pla

n to

m

itiga

te r

isk.

Cla

usse

n et

al65

US

AR

etro

spec

tive

revi

ew

of c

alls

to

the

rap

id

resp

onse

tea

m (R

RT)

an

d c

ard

iac

arre

st c

alls

to

eva

luat

e im

pac

t of

evi

den

ce- b

ased

gu

idel

ines

Des

crip

tive

stat

istic

sE

lect

roni

c sy

stem

sTh

e hu

dd

le w

as s

een

as u

sefu

l and

was

cal

led

as

a p

atie

nt’s

st

atus

was

cha

ngin

g to

‘red

’ so

that

all

team

mem

ber

s w

ere

info

rmed

.

Dav

ies

et a

l53U

SA

Sur

vey

look

ing

at

bar

riers

to

rap

id

resp

onse

sys

tem

(RR

S)

activ

atio

n

Sta

tistic

al a

naly

sis

EW

SA

ctiv

atio

n cr

iteria

dis

pla

yed

aro

und

the

hos

pita

l

Dem

mel

et

al58

US

AD

iscu

ssio

n of

the

set

- up

and

imp

lem

enta

tion

of a

pae

dia

tric

ear

ly

war

ning

sco

ring

tool

an

d a

n as

soci

ated

al

gorit

hm

Rap

idP

lan-

Do-

Stu

dy-

Act

(PD

SA

) cyc

les

wer

e im

ple

men

ted

usi

ng s

mal

l tes

ts

of c

hang

e. T

he d

ata

from

the

PD

SA

cy

cles

wer

e co

ntin

uous

ly c

olle

cted

, an

alys

ed a

nd r

evie

wed

with

the

m

ultid

isci

plin

ary

staf

f and

pla

nnin

g te

am a

nd u

sed

to

give

ong

oing

d

irect

ion

to t

he im

ple

men

tatio

n p

lan.

PE

WS

Imp

orta

nce

of c

omm

on in

form

atio

n sp

aces

and

dis

pla

y of

ac

tivat

ion

crite

ria t

hrou

ghou

t th

e ho

spita

l

Con

tinue

d



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Aut

hor

Co

untr

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etho

do

log

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rch

area

Evi

den

ce c

ont

rib

utio

n

Don

ahue

et

al92

US

AFo

cus

grou

p e

valu

atio

n of

a t

rain

ing

pro

gram

me

whi

ch w

as d

evel

oped

to

teac

h p

arap

rofe

ssio

nals

S

ituat

ion-

Bac

kgro

und

- A

sses

smen

t-

Rec

omm

end

atio

n (S

BA

R) c

omm

unic

atio

n to

ol

Not

cle

arS

truc

ture

d

hand

over

Valu

e of

a s

truc

ture

d a

pp

roac

h to

han

dov

er.

Ad

apta

tion

of t

he S

BA

R t

ool f

or h

and

over

.

Enn

is23

Irela

ndD

escr

iptio

n of

im

ple

men

tatio

n of

p

aed

iatr

ic e

arly

war

ning

sc

ore

and

sub

seq

uent

au

dit

(pro

spec

tive

coho

rt o

bse

rvat

iona

l st

udy)

Sim

ple

des

crip

tive

stat

istic

s of

nu

mb

ers

of c

hild

ren

trig

gerin

g th

e p

aed

iatr

ic e

arly

war

ning

sco

re

and

com

plia

nce

with

esc

alat

ion

pro

toco

l

PE

WS

Com

mon

info

rmat

ion

spac

es im

por

tant

and

dis

pla

y of

ac

tivat

ion

crite

ria t

hrou

ghou

t th

e ho

spita

l.U

sefu

lnes

s of

ISB

AR

as

a co

mm

unic

atio

n to

ol.

Gol

den

har

et

al87

US

AS

emis

truc

ture

d

inte

rvie

ws

and

focu

s gr

oup

s to

dev

elop

a

dee

per

und

erst

and

ing

of a

new

ly im

ple

men

ted

hu

dd

le s

yste

m

Con

stan

t co

mp

aris

onS

ituat

iona

l aw

aren

ess

Imp

orta

nce

of t

he h

udd

le—

emp

ower

men

t an

d s

ense

of

com

mun

ity; f

acili

tate

d g

reat

er a

nd b

ette

r in

form

atio

n sh

arin

g.E

ach

hud

dle

par

ticip

ant

was

ask

ed t

o sy

stem

atic

ally

rep

ort

on

pat

ient

s in

the

ir un

its w

ho t

hey

thou

ght

wou

ld d

eter

iora

te in

th

e ne

ar fu

ture

and

to

lab

el t

hem

as

‘wat

cher

s’, a

skin

g se

nior

nu

rses

and

phy

sici

an le

ads

to c

oach

cha

rge

nurs

es o

n ho

w t

o in

tegr

ate

thei

r p

erce

ptio

ns in

to a

n in

form

al s

ever

ity o

f illn

ess

asse

ssm

ent

(com

pre

hens

ion)

and

tra

inin

g th

e cl

inic

ians

on

how

to

use

the

info

rmat

ion

to fa

cilit

ate

pre

dic

tion

and

pla

nnin

g fo

r at

- ris

k p

atie

nts

(pro

ject

ion)

.

Tab

le 4

C

ontin

ued

Con

tinue

d



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Co

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etho

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Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Mac

kint

osh

et

al47

UK

Eth

nogr

aphi

ctw

o- st

age

pro

cess

of

ligh

tly s

truc

ture

d

obse

rvat

ions

follo

wed

b

y a

mor

e fo

cuse

d

per

iod

of d

ata

gene

ratio

n to

tes

t an

d

elab

orat

e th

e ou

tcom

es

from

sta

ge 1

Initi

al t

hem

atic

ana

lysi

s an

d s

earc

h fo

r ne

gativ

e ca

ses

Situ

atio

nal

awar

enes

sFo

r te

ams

with

a s

tron

g le

vel o

f situ

atio

n aw

aren

ess

(SA

), ke

y su

pp

orts

wer

e al

l use

d in

a b

alan

ced

and

sup

por

tive

man

ner

to g

athe

r an

d d

isse

min

ate

info

rmat

ion

whi

ch s

erve

d t

o p

rom

ote

a cu

lture

of s

hare

d o

wne

rshi

p a

nd a

pro

activ

e m

odel

of

wor

kloa

d m

anag

emen

t, w

ith t

emp

orar

y d

isru

ptio

ns t

o th

e m

odel

eas

ily a

ccom

mod

ated

.W

hite

boa

rd—

whe

n us

ed e

ffect

ivel

y w

as a

vita

l mea

ns

for

sup

por

ting

SA

. It

pro

vid

es t

eam

s w

ith a

sna

psh

ot o

f a

cons

tant

ly c

hang

ing

wor

kloa

d, t

he t

eam

’s a

ctiv

ity le

vels

and

re

sour

ce a

vaila

bili

ty. W

orkl

oad

at

times

com

pro

mis

ed it

s ef

fect

iven

ess.

And

irre

spec

tive

of w

orkl

oad

s, lo

catio

n an

d

loca

l tra

diti

ons

had

a b

earin

g on

its

use

and

use

fuln

ess.

Whi

teb

oard

s ne

ed t

o b

e in

a v

isib

le lo

catio

n.Im

por

tant

ly, t

he in

terp

lay

bet

wee

n th

ese

key

sup

por

ts fo

r S

A

will

var

y d

epen

din

g on

the

con

text

; the

sam

e su

pp

orts

use

d

diff

eren

tly w

ill n

atur

ally

pro

duc

e d

iffer

ent

outc

omes

.H

and

over

too

k m

any

form

s: s

truc

ture

d a

nd in

form

al;

pro

fess

ion

spec

ific

and

inte

rpro

fess

iona

l; p

artic

ipat

ory

or a

on

e- w

ay t

rans

mis

sion

of i

nfor

mat

ion.

The

ef fe

ctiv

enes

s of

SA

w

as d

epen

den

t on

the

form

tha

t ha

ndov

er t

ook—

who

was

p

rese

nt, c

ontr

ibut

ions

mad

e, in

form

atio

n re

laye

d. S

A w

as

mor

e lik

ely

to b

e co

mp

rom

ised

whe

n ke

y p

eop

le w

ere

abse

nt.

Sen

ior

staf

f coo

rdin

ator

imp

orta

nt fo

r S

A a

nd b

ecam

e co

mp

rom

ised

if t

hey

wer

e la

rgel

y fo

cuse

d o

n p

rovi

din

g p

atie

nt

care

.

Mac

kint

osh

et

al27

UK

Com

par

ativ

e ca

se

stud

y—an

RR

S u

sing

et

hnog

rap

hic

met

hod

s in

clud

ing

obse

rvat

ions

, in

terv

iew

s an

d

doc

umen

tary

rev

iew

Ind

uctiv

e an

d d

educ

tive

cod

ing

faci

litat

ed b

y N

Viv

o. A

lso

used

th

eme

bui

ldin

g an

d s

truc

turin

g m

etho

ds

from

fram

ewor

k an

alys

is

whi

le a

lso

info

rmed

by

othe

r th

eore

tical

fram

ewor

ks s

uch

as

‘tec

hnol

ogy-

in- p

ract

ice’

.

EW

SA

vaila

bili

ty o

f eq

uip

men

t w

as a

n is

sue

whe

re t

he t

rack

and

tr

igge

r to

ol (T

TT) w

as e

lect

roni

c.E

lect

roni

c sy

stem

s he

lped

HC

As

and

nur

sing

sta

ff to

sha

re

und

erst

and

ings

, pla

nnin

g an

d m

anag

e th

eir

wor

kloa

d.

Mas

sey

et a

l67A

ustr

alia

In- d

epth

sem

istr

uctu

red

in

terv

iew

sIn

duc

tive

app

roac

h—th

emat

ic

anal

ysis

EW

SC

omm

on in

form

atio

n sp

aces

use

ful.

Dis

pla

y of

act

ivat

ion

crite

ria t

hrou

ghou

t ho

spita

l.

Tab

le 4

C

ontin

ued

Con

tinue

d



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Aut

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Co

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log

yA

naly

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Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

McC

rory

et

al54

US

AP

rosp

ectiv

e,

pre

inte

rven

tiona

l and

p

ostin

terv

entio

nal

stud

y to

eva

luat

e th

e ed

ucat

iona

l int

erve

ntio

n of

tea

chin

g A

BC

- SB

AR

(a

irway

, bre

athi

ng,

circ

ulat

ion

follo

wed

by

situ

atio

n,b

ackg

roun

d,

asse

ssm

ent,

and

re

com

men

dat

ion)

Two

blin

ded

rev

iew

ers

asse

ssed

52

vid

eo- r

ecor

ded

han

dof

fs fo

r in

clus

ion,

ord

er a

nd e

lap

sed

tim

e to

es

sent

ial h

and

off i

nfor

mat

ion

usin

g a

scor

ing

tool

.

Str

uctu

red

ha

ndov

erIn

form

atio

n sh

arin

g fo

r ha

ndov

ers

is o

f var

iab

le q

ualit

y.A

mor

e st

ruct

ured

ap

pro

ach

will

imp

rove

info

rmat

ion

shar

ing

and

the

refo

re s

ituat

iona

l aw

aren

ess—

‘with

out

a st

ruct

ured

ha

nd- o

ff to

ol, p

aed

iatr

ic in

tern

s ov

erem

pha

sise

bac

kgro

und

in

form

atio

n an

d le

ave

the

reas

on fo

r th

e ca

ll d

elay

ed’.

Ad

apta

tion

of t

he S

BA

R t

ool t

o in

clud

e A

BC

—us

eful

ness

of

this

.

Mul

lan

et a

l93U

SA

Des

crip

tive

obse

rvat

iona

l stu

dy

Che

cklis

ts w

ere

eval

uate

d fo

r ra

tes

of u

se, c

omp

letio

n an

d

iden

tifica

tion

of p

oten

tial s

afet

y ev

ents

.

Situ

atio

nal

awar

enes

sTh

e va

lue

of m

ore

stru

ctur

ed a

pp

roac

h to

info

rmat

ion

shar

ing

and

situ

atio

nal a

war

enes

s.U

ses

a ch

eckl

ist

hand

over

sys

tem

for

phy

sici

ans.

Che

cklis

t ite

ms

focu

sed

on

the

stat

us o

f the

pat

ient

, ED

pro

vid

ers

and

ho

spita

l res

ourc

es. A

‘Rea

d- D

o’ fo

rmat

was

des

igne

d.

Par

ker

et a

l89U

SA

Man

ual r

evie

w o

f all

elig

ible

pat

ient

rec

ord

sD

escr

iptiv

e st

atis

tics

PE

WS

Exa

mp

le o

f a b

und

le a

roun

d t

he ‘w

atch

er’ c

ateg

ory

with

five

co

mp

onen

ts t

hat

need

ed t

o b

e co

mp

lete

d w

ithin

2 h

ours

of a

p

atie

nt b

eing

des

igna

ted

as

such

.

Pea

rson

and

D

unca

n30U

KB

rief r

evie

w o

f the

ev

iden

ce b

ase

surr

ound

ing

pae

dia

tric

ea

rly w

arni

ng s

core

s

N/A

PE

WS

Valu

e of

a m

ore

stru

ctur

ed a

pp

roac

h to

com

mun

icat

ion—

advo

cate

the

use

of a

sha

red

com

mun

icat

ion

mod

el, s

uch

as

SB

AR

, to

com

mun

icat

e fin

din

gs t

o su

per

iors

.

Pez

zole

si e

t al

90U

KD

elp

hi s

tud

y fo

r to

ol

dev

elop

men

tD

escr

iptiv

e st

atis

tics.

Han

dov

ers

wer

e an

alys

ed a

nd

rate

d a

ccor

din

g to

a m

easu

re o

f es

sent

ial s

kills

.

Situ

atio

nal

awar

enes

sIn

form

atio

n on

han

dov

er—

can

be

of v

aria

ble

qua

lity.

Mos

t ha

ndov

er t

ools

are

ad

apta

tions

of S

BA

R) c

omm

unic

atio

n to

ol.

Imp

orta

nt t

o re

mem

ber

tha

t ha

ndov

er fa

cilit

ates

tea

mw

ork

and

thi

s hi

nges

on

com

mun

icat

ive

form

s th

at e

xten

d b

eyon

d

the

info

rmat

ion

tran

sfer

tha

t is

typ

ical

ly t

he fo

cus

of s

truc

ture

d

hand

over

too

ls.

Ran

dha

wa

et

al55

US

AD

escr

iptio

n of

the

im

ple

men

tatio

n p

roce

ss

with

car

dio

pul

mon

ary

arre

st (C

PA) s

tatis

tics

bef

ore

and

aft

er

imp

lem

enta

tion

Onc

e a

cycl

e fr

om t

he

imp

lem

enta

tion

has

bee

n co

mp

lete

d t

his

is e

valu

ated

and

th

en a

noth

er c

ycle

beg

ins.

PE

WS

Whi

teb

oard

s p

lace

d in

a c

entr

al lo

catio

n d

isp

laye

d s

core

s of

al

l pat

ient

s so

tha

t st

aff c

ould

qui

ckly

ass

ess

whi

ch p

atie

nts

wer

e at

hig

h ris

k fo

r d

eter

iora

tion.

Act

ivat

ion

crite

ria d

isp

laye

d t

hrou

ghou

t th

e ho

spita

l.

Tab

le 4

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Ste

war

t et

al32

Sw

eden

Mix

ed m

etho

ds.

R

etro

spec

tive

revi

ew o

f re

cord

s an

d n

urse

- led

fo

cus

grou

ps.

Sta

tistic

al a

naly

sis

and

con

tent

an

alys

isE

WS

Hud

dle

—th

e sc

ore

was

use

d d

urin

g th

e d

aily

bed

‘hud

dle

’ w

ith t

he n

ursi

ng a

dm

inis

trat

ors

to e

valu

ate

curr

ent

unit

acui

ty,

det

erm

ine

staf

fing

need

and

pre

par

e fo

r an

y tr

ansf

ers.

Van

Voor

his

and

Will

is33

US

AD

iscu

ssio

n p

aper

hi

ghlig

htin

g th

e p

roce

ss

of d

evel

opin

g a

pae

dia

tric

RR

S

N/A

PE

WS

Dis

pla

y of

act

ivat

ion

crite

ria t

hrou

ghou

t th

e ho

spita

l on

lany

ard

s an

d u

se o

f whi

teb

oard

s us

eful

de

Vrie

s et

al86

Net

herla

nds

Sem

istr

uctu

red

in

terv

iew

Qua

litat

ive

cont

ent

anal

ysis

PE

WS

Pae

dia

tric

ear

ly w

arni

ng s

core

/TTT

is u

sed

to

sup

por

t si

tuat

iona

l aw

aren

ess.

Use

of a

sco

re e

nab

les

clin

icia

ns t

o ha

ve a

'bird

’s- e

ye' v

iew

ove

r ad

mitt

ed p

atie

nts.

Wag

er e

t al

84U

SA

Ob

serv

atio

nal s

tud

y.E

xplo

red

the

tim

elin

ess

and

qua

lity

of v

ital

sign

s d

ata

ente

red

by

thre

e d

iffer

ent

reco

rdin

g m

etho

ds.

Des

crip

tive

stat

istic

sE

lect

roni

c sy

stem

sB

atch

ing

of p

atie

nt d

ata

whe

reb

y th

e ca

re p

rovi

der

han

dw

rites

th

e p

atie

nt’s

vita

l sig

ns a

nd u

plo

ads

it to

the

com

put

er a

t a

late

r tim

e is

com

mon

, esp

ecia

lly a

s th

e co

mp

uter

s ar

e of

ten

bus

y.

Wat

son

et a

l45U

SA

Mix

ed m

etho

ds,

re

tros

pec

tive

med

ical

re

cord

ob

serv

atio

ns

and

ob

serv

atio

ns o

f nu

rse

inte

ract

ions

Ob

serv

atio

n an

alys

is, a

lthou

gh t

his

is n

ot d

escr

ibed

, and

sta

tistic

al

anal

ysis

PE

WS

Ava

ilab

ility

of e

qui

pm

ent

is a

fact

or.

Wei

ss e

t al

94C

anad

aA

ran

dom

ised

co

ntro

lled

tria

l in

an

acad

emic

pae

dia

tric

in

tens

ive

care

uni

t (P

ICU

) of 2

0 ha

ndov

er

even

ts

Diff

eren

ces

bet

wee

n in

terv

entio

n an

d c

ontr

ol g

roup

s w

ere

asse

ssed

us

ing

the

Man

n- W

hitn

ey t

est

and

m

ultiv

aria

te li

near

reg

ress

ion.

Str

uctu

red

ha

ndov

erVa

lue

of a

mor

e st

ruct

ured

ap

pro

ach

to s

upp

ort

info

rmat

ion

shar

ing—

a co

gniti

ve a

id t

o fa

cilit

ate

hand

over

tha

t p

rom

pte

d

resi

den

ts t

o tr

ansm

it th

is in

form

atio

n. T

he h

and

over

aid

was

no

t lin

ked

to

hosp

ital i

nfor

mat

ion

syst

ems—

so t

his

had

to

be

com

ple

ted

by

hand

bef

ore

hand

over

.H

and

over

is a

n op

por

tuni

ty fo

r le

arni

ng a

nd p

rofe

ssio

nal

soci

alis

atio

n.

Won

g et

al95

UK

Des

crip

tion

of u

ser-

fo

cuse

d d

esig

n p

r oce

ss fo

r us

e of

el

ectr

onic

mon

itorin

g an

d n

umb

ers

of

obse

rvat

ions

tak

en

usin

g th

e sy

stem

. A

ccep

tab

ility

q

uest

ionn

aire

.

Des

crip

tive

stat

istic

s on

the

nu

mb

er o

f ob

serv

atio

ns r

ecor

ded

us

ing

the

SE

ND

sys

tem

and

the

nu

mb

er o

f act

ive

user

s

Ele

ctro

nic

syst

ems

Dev

elop

men

t of

a fl

exib

le e

lect

roni

c sy

stem

whi

ch e

nab

led

st

aff t

o ha

ve a

n ov

ervi

ew o

f pat

ient

s—re

flect

ions

on

dis

conn

ectio

n

ED

, em

erge

ncy

dep

artm

ent;

EW

S, e

arly

war

ning

sys

tem

; HC

A, h

ealth

care

ass

ista

nt; N

/A, n

ot a

pp

licab

le.

Tab

le 4

C

ontin

ued



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enabling individual- level clinical data to be synthesised, made sense of and shared.19–29 33 39 41 42 46 48 50 51 56 62 66 74 86 One study, however, found that TTTs were regarded as a nursing tool and were therefore not valued by clini-cians. Consequently, nurses encountered difficulties in summoning a response.46

Several studies also report on the use of SBAR in this context. Like TTTs, SBAR translates information into a form that provides structure, consistency and predictability when presenting patient information. SBAR has been shown to help establish common language and expecta-tions, minimising differences in training, experience and hierarchy and facilitating nurse–clinician communica-tion. While several papers advocate combining SBAR with TTTs,23 25 27 30 35 45 50 none specifically evaluated SBAR use. Mackintosh et al highlight that audit data suggest resis-tance to SBAR, with others cautioning that overextending SBAR use carries the risk of SBAR fatigue and attenuation of its effects.27

Structured communication tools like TTTs and SBAR do not solve all the challenges of acting in response to evidence of deterioration. Barriers to action were widely reported in the literature where these tools were in place. These include: a general disinclination to seek help,19–22 25 27 29 31 36–39 42 48 50 51 56 64 67 concerns about appearing inadequate in front of colleagues20 22 36 38 50 67 and failure of staff to invest in the escalation or calling criteria.21 22 49 A number of papers also reported nega-tive attitudes to rapid response team (RRT) or medical emergency team (MET) use in the efferent compo-nent of safety systems. METs and RRTs operate outside the immediate medical team and create different issues in paediatric warning systems than when the escala-tion response is managed by the treating team. These include a reluctance to activate because of the perceived busyness of paediatric intensive care unit or medical staff,20 29 39 48 50 51 because previous expectations about an appropriate response were not met, or a sense that the situation was under control (particularly when the physio-logical instability is in the area of expertise of the treating team).22 29 31 38 42 50 52 64

No literature reported on successful interventions to facilitate RRT use, but several propose strategies to support escalation where there was no designated response team in place in the efferent component. These include informal peer support, where inexperienced staff team up with more experienced staff21 29 50 64 67; clear struc-tures to support action and a supportive culture that does not penalise individual decision- making, including the use of a ‘no false alarms’ policy so staff are not deterred from escalating care.21 29 36 73 Senior leadership is consis-tently identified as important8 20–23 25 27 30 32 33 35 47 52 58 66 67; lack of support from superiors meant that staff are less likely to escalate and more likely to adhere to hierarchies within the current system.25 40 66 There is some evidence to suggest that any escalation policy should be linked to an administrative arm that reinforces the system, measures outcomes and works to ensure an effective system.27 30

There is a small literature on family involvement in the Action subsystem. Several studies report on Condition- Help, a programme developed in the USA to support families to directly activate an RRT if they have concerns about their child’s condition. Families are also becoming increasingly recognised as playing a key role in the acti-vation of RRTs in Australia.97 Research has evaluated the appropriateness of calls that were made by patients or relatives33 97–101 but has not considered why calls were not made.70 Involving family members in escalation demands vigilance, requiring them to take a proactive and inter-active role with staff with potentially some degree of confrontation, particularly if challenging the appro-priateness of decisions taken.73 97 Families need both cognitive and emotional resources to raise concerns that involve negotiating hierarchies and boundaries.35 70 The literature points to a degree of professional resistance to family involvement in activation, with reports of physi-cian concern that their role would be undermined, that resources would be stretched with an increase in calls and that it might divert attention away from those in need71 97 99 102 103 although these fears are not supported by the evidence.71 102 104 See table 5 for a summary of the evidence relating to the action component of the model.

Synthesis and model developmentThe literature in this field is heterogeneous and stronger on the sociomaterial barriers to successful afferent component paediatric early warning systems than it is on solutions. While a number of different single interven-tions have been proposed and some have been evaluated, there is limited evidence to recommend their use beyond the specific clinical contexts described in the papers. This reflects both the weight and quality of the evidence, the extent to which paediatric systems are conditioned by the local clinical context and also the need to attend to the relationship between system components and interven-tions which work in concert not in isolation. There is also a growing realisation in the quality improvement field that an intervention that has been successful in one context does not necessarily produce the same results elsewhere which cautions against a ‘one size fits all’ approach.105 106

While it is not possible to make empirical recommen-dations for practice, a hermeneutic review methodology enabled the generation of theoretical inferences about the core components of an optimal paediatric early warning system. These model components are logical inferences derived from an overall synthesis of the evidence, informed by our theoretical framework and clinical expertise. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action (see table 1).

dISCuSSIOnThis paper reports on one of three linked reviews under-taken as part of a wider UK study commissioned to develop and evaluate an evidence- based national paediatric early



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Tab

le 5

S

umm

ary

of a

ctio

n ev

iden

ce

Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Ad

elst

ein

et a

l49A

ustr

alia

Pro

spec

tive

com

par

ison

of

rap

id r

esp

onse

te

am (R

RT)

crit

eria

b

reac

hes

Sta

tistic

alE

WS

Day

/nig

ht d

iffer

ence

s in

act

ivat

ion

iden

tified

.N

urse

s m

ay n

ot u

nder

stan

d w

hat

is r

equi

red

for

activ

atio

n.S

taff

not

inve

stin

g in

cal

ling

crite

ria.

Alm

bla

d e

t al

8S

wed

enR

etro

spec

tive

revi

ew o

f the

el

ectr

onic

pat

ient

re

cord

and

a

cont

ext a

sses

smen

t of

the

wor

k en

viro

nmen

t us

ing

the

Alb

erta

Con

text

To

ol

Sta

tistic

alS

now

bal

l sam

ple

Sen

ior

lead

ersh

ip c

onsi

sten

tly id

entifi

ed a

s im

por

tant

.

And

rew

s an

d W

ater

man

19U

KIn

terv

iew

s an

d

obse

rvat

ions

Gro

und

ed t

heor

yE

WS

Trac

k an

d t

rigge

r to

ols

(TTT

) act

as

pro

mp

ts t

o ac

tion.

TTT

used

to

over

com

e ch

alle

nges

in c

omm

unic

atio

n an

d p

artic

ular

ly v

alua

ble

for

juni

or s

taff.

Neg

ativ

e at

titud

e to

war

ds

calli

ng fo

r he

lp.

Ast

roth

et

al50

US

AS

emis

truc

ture

d

inte

rvie

ws

with

nu

rses

Cod

ing

cate

gorie

s w

ere

gene

rate

d fr

om t

he d

ata,

an

d c

onse

nsus

on

final

th

emes

was

ach

ieve

d

thro

ugh

an it

erat

ive

pro

cess

.

EW

SS

ituat

ion

und

er c

ontr

ol—

no n

eed

to

esca

late

or

per

ceiv

ed b

usin

ess

of m

edic

al s

taff

dis

cour

aged

sta

ff fr

om R

RT

activ

atio

n.S

taff

enco

urag

ed t

o us

e th

eir

intu

ition

whe

n ac

tivat

ing

the

RR

T.C

once

rn a

bou

t fe

elin

g in

adeq

uate

in fr

ont

of c

olle

ague

s a

bar

rier

to R

RT

activ

atio

n.In

exp

erie

nced

sta

ff te

amin

g up

—le

d t

o st

aff t

rust

ing

thei

r ow

n ju

dge

men

t.Tr

aditi

onal

hie

rarc

hies

a b

arrie

r to

RR

T ac

tivat

ion—

nurs

es m

ore

likel

y to

cal

l the

att

end

ing

phy

sici

an r

athe

r th

an a

ctiv

ate

the

RR

T.

Azz

opar

di e

t al

20A

ustr

alia

Sur

vey

Sta

tistic

al a

naly

sis

PE

WS

Sco

re r

arel

y th

e d

eter

min

ing

fact

or in

esc

alat

ion—

wou

ld

not

esca

late

for

a p

atie

nt w

ho lo

oked

wel

l but

wou

ld

esca

late

for

a p

atie

nt t

hey

wer

e w

orrie

d a

bou

t ev

en if

no

t tr

igge

ring.

Neg

ativ

e at

titud

e to

war

ds

calli

ng fo

r he

lp—

feel

ing

inad

equa

te/p

erce

ived

bus

ines

s of

pae

dia

tric

inte

nsiv

e ca

re u

nit

had

an

imp

act

on d

octo

rs e

scal

atin

g b

ut n

ot

nurs

es.

Sen

ior

lead

ersh

ip is

imp

orta

nt w

hen

imp

lem

entin

g a

ME

T.

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Bav

are

et a

l104

US

AR

etro

spec

tive

obse

rvat

iona

l stu

dy

of r

apid

res

pon

se

even

ts

Des

crip

tive

stat

istic

sP

EW

SA

ll fa

mily

- act

ivat

ed R

RT

had

ap

pro

pria

te c

linic

al

trig

gers

with

the

mos

t co

mm

on b

eing

unc

ontr

olle

d

pai

n. M

ore

than

hal

f of F

amily

- Ini

tiate

d p

edia

tric

rap

id

resp

onse

(FIR

R) h

ad a

vita

l sig

ns c

hang

e th

at s

houl

d

have

qua

lified

clin

icia

n- R

RT

activ

atio

n. S

even

ty- s

ix p

er

cent

FIR

Rs

need

ed a

t le

ast

one

or m

ore

inte

rven

tions

. Tw

enty

- sev

en p

er c

ent

of fa

mily

- ini

tiate

d R

RTs

nee

ded

tr

ansf

er t

o in

tens

ive

care

uni

t co

mp

ared

with

60%

tr

ansf

er r

ate

for

clin

icia

n R

RTs

.

Bog

ert

et a

l98U

SA

Imp

lem

enta

tion

of C

ond

ition

Hel

p

(Con

diti

onH

)

Des

crip

tive

stat

istic

sFa

mily

in

volv

emen

tIm

ple

men

tatio

n of

Con

diti

onH

.C

ond

ition

H b

eing

ad

dre

ssed

dur

ing

dai

ly r

ound

s.

Bon

afid

e et

al21

US

AS

emis

truc

ture

d

inte

rvie

ws

Gro

und

ed t

heor

yP

EW

SD

isin

clin

atio

n to

see

k he

lp a

nd c

once

rns

abou

t ap

pea

ring

inad

equa

te in

fron

t of

col

leag

ues.

Info

rmal

pee

r su

pp

ort.

Sen

ior

lead

ersh

ip im

por

tant

.

Bra

aten

22U

SA

Doc

umen

t re

view

an

d in

terv

iew

s us

ing

the

prin

cip

les

of c

ogni

tive

wor

k an

alys

is

Ind

uctiv

e an

d d

educ

tive

form

s of

ana

lysi

s—co

gniti

ve

wor

k an

alys

is, f

ram

ewor

k an

d d

irect

ed c

onte

nt

anal

ysis

EW

SIs

sues

aro

und

ava

ilab

ility

of e

qui

pm

ent

and

sta

ffing

.N

egat

ive

attit

ude/

del

ays

arou

nd c

allin

g fo

r he

lp w

ith

staf

f nee

din

g to

just

ify e

scal

atio

n. O

ther

fact

ors

imp

act

on t

his

incl

udin

g th

e p

erce

ptio

n th

at t

he s

ituat

ion

is

und

er c

ontr

ol/p

erce

ived

bus

ines

s of

phy

sici

ans/

not

wan

ting

to a

pp

ear

inad

equa

te.

Bra

dy

et a

l88U

SA

.S

tatis

tical

pro

cess

con

trol

ch

arts

Situ

atio

nal

awar

enes

sC

once

rns

abou

t re

sour

ces

rep

orte

d

Bra

dy

et a

l102

US

AA

ret

rosp

ectiv

e co

hort

stu

dy

look

ing

at t

he

asso

ciat

ion

bet

wee

n fa

mily

and

cl

inic

ian

activ

atio

ns

and

tra

nsfe

r to

the

in

tens

ive

care

uni

t fo

llow

ing

a M

ET

call

Qua

lity

imp

rove

men

t m

etho

ds

and

sta

tistic

al

pro

cess

con

trol

cha

rts

wer

e us

ed t

o as

sess

the

rat

e of

fa

mily

act

ivat

ion

of M

ETs

.

Fam

ily

invo

lvem

ent

Dire

ct m

echa

nism

for

fam

ilies

to

activ

ate

a M

ET.

Con

cern

s fr

om c

linic

ians

ab

out

a fa

mily

- act

ivat

ed M

ET

over

bur

den

ing

the

syst

em a

re u

nfou

nded

.

Chu

a et

al36

Sin

gap

ore

A q

ualit

ativ

e su

rvey

us

ing

criti

cal

inci

den

t te

chni

que

Ind

uctiv

e co

nten

t an

alys

isE

WS

Sta

ff fe

lt th

at t

hey

had

not

bee

n ed

ucat

ed t

o an

ad

equa

te le

vel—

trai

ning

lack

ing.

Neg

ativ

e at

titud

e to

war

ds

calli

ng fo

r he

lp—

fear

s of

ap

pea

ring

inad

equa

te.

Tab

le 5

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Cio

ffi48

Aus

tral

iaU

nstr

uctu

red

in

terv

iew

s w

ith

nurs

es w

ho h

ad

activ

ated

the

m

edic

al e

mer

genc

y te

am (M

ET)

Sim

ple

cod

e an

d r

etrie

veE

WS

Rel

ucta

nce

to a

ctiv

ate—

dou

btin

g ab

ility

; fea

rs o

f ap

pea

ring

inad

equa

te; d

ecis

ions

mad

e b

ased

on

the

per

ceiv

ed a

vaila

bili

ty o

f res

ourc

es/b

usin

ess

of m

edic

al

staf

f/tim

e of

day

all

had

an

imp

act

on d

ecis

ions

to

activ

ate

the

ME

T.Im

por

tanc

e of

hav

ing

staf

f con

cern

in t

he M

ET

crite

rion.

Cio

ffi51

Aus

tral

iaU

nstr

uctu

red

in

terv

iew

sS

imp

le c

ode

and

ret

rieve

EW

SIm

por

tanc

e of

hav

ing

staf

f con

cern

in a

cal

ling

crite

ria.

Rel

ucta

nce

to a

ctiv

ate—

bus

ines

s of

war

d a

fact

or.

Cio

ffi e

t al

42A

ustr

alia

Focu

s gr

oup

s w

ith c

linic

ians

and

nu

rses

exp

lorin

g th

eir

resp

onse

s to

ab

norm

al v

ital s

igns

Con

stan

t co

mp

aris

onE

WS

Ava

ilab

ility

of e

qui

pm

ent

an is

sue/

staf

fing

pre

ssur

es;

staf

f una

ble

to

carr

y ou

t ro

utin

e m

onito

ring

that

wou

ld

enab

le t

he d

etec

tion

of a

bno

rmal

vita

l sig

ns (A

VS

)/es

cala

tion

ham

per

ed b

ecau

se o

f diffi

culty

find

ing

the

app

rop

riate

sen

ior

per

son.

. ME

T cr

iteria

use

d t

o co

nfirm

or

iden

tify

det

erio

ratio

n d

epen

din

g on

exp

erie

nce.

Neg

ativ

e at

titud

e to

war

ds

aski

ng fo

r he

lp—

lack

of

con

fiden

ce q

uest

ioni

ng p

eers

/fea

r of

bei

ng

rep

riman

ded

/fee

ling

the

situ

atio

n w

as u

nder

con

trol

.

de

Gro

ot e

t al

62N

ethe

rland

sR

etro

spec

tive

pat

ient

rev

iew

and

se

mis

truc

ture

d

inte

rvie

ws

with

p

rofe

ssio

nals

Des

crip

tive

stat

istic

s an

d

grou

nded

the

ory

PE

WS

Eas

ily a

pp

roac

hab

le n

urse

s an

d p

hysi

cian

s, a

s w

ell a

s go

od c

omm

unic

atio

n, w

ere

cons

ider

ed t

o b

e vi

tal f

or

timel

y in

terv

entio

n in

cas

es o

f clin

ical

det

erio

ratio

n in

p

aed

iatr

ic p

atie

nts.

Faci

litat

ors

for

the

imp

lem

enta

tion

of r

egis

trat

ion

ofp

aed

iatr

ic e

arly

war

ning

sco

re in

clud

ed t

he in

tegr

atio

n of

sco

res

into

the

ele

ctro

nic

pat

ient

rec

ord

s.

Dea

n et

al99

US

ATw

o- ye

ar

refle

ctio

n fo

llow

ing

imp

lem

enta

tion

of

Con

diti

onH

Des

crip

tive

stat

istic

sFa

mily

in

volv

emen

tC

ond

ition

H c

riter

ia fo

r ac

tivat

ion.

Con

cern

tha

t fa

mily

- act

ivat

ed R

RS

cou

ld d

iver

t at

tent

ion

away

from

res

ourc

es.

Clin

icia

n in

volv

emen

t im

por

tant

.D

aily

‘pat

ient

rou

nds’

invo

lvin

g p

atie

nts

and

fam

ilies

is

usef

ul.

Pat

ient

s an

d fa

mili

es h

ave

acce

ss t

o re

leva

nt

info

rmat

ion

and

und

erst

and

the

med

ical

info

rmat

ion

and

ca

re p

lans

.

Tab

le 5

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Dem

mel

et

al58

US

AD

iscu

ssio

n of

th

e se

t- up

and

im

ple

men

tatio

n of

a p

aed

iatr

ic

early

war

ning

sc

orin

g to

ol a

nd

an a

ssoc

iate

d

algo

rithm

Rap

idP

lan-

Do-

Stu

dy-

Act

(PD

SA

) cy

cles

wer

e im

ple

men

ted

us

ing

smal

l tes

ts o

f cha

nge.

PE

WS

Ed

ucat

ion

pac

kage

dev

elop

ed a

roun

d t

he h

isto

ry a

nd

dev

elop

men

t of

pae

dia

tric

ear

ly w

arni

ng s

core

s al

ong

with

the

rat

iona

le fo

r an

d t

he g

oals

of t

he in

itiat

ive.

The

sc

orin

g p

roce

ss w

as e

xpla

ined

and

how

it w

ould

be

inte

grat

ed in

to r

outin

e nu

rsin

g as

sess

men

ts; n

orm

al v

ital

sign

par

amet

ers

wer

e re

view

ed.

Imp

orta

nce

of c

omm

on in

form

atio

n sp

aces

and

dis

pla

y of

act

ivat

ion

crite

ria t

hrou

ghou

t th

e ho

spita

l.S

enio

r le

ad c

omm

itmen

t an

d im

por

tanc

e of

cha

mp

ions

in

tegr

al fo

r im

ple

men

tatio

n.

Don

ohue

et

al64

UK

Qua

litat

ive

des

ign

with

crit

ical

inci

den

t te

chni

que

.S

emis

truc

ture

d

inte

rvie

ws

with

nu

rses

and

the

ou

trea

ch t

eam

.

Them

atic

ana

lysi

sE

WS

Som

e re

sist

ance

to

esca

latio

n—cl

inic

ians

pre

ferr

ing

to

dea

l with

pat

ient

pro

ble

ms

with

in t

heir

own

team

.In

exp

erie

nced

sta

ff te

amin

g up

with

mor

e ex

per

ienc

ed

staf

f onc

e p

atie

nt d

eter

iora

tion

was

rec

ogni

sed

.

Dow

ney

et a

l74U

KN

arra

tive

revi

ew‘P

atte

rns

wer

e id

entifi

ed

and

tra

nsla

ted

to

them

es,

whi

ch w

ere

furt

her

refin

ed

usin

g an

iter

ativ

e p

roce

ss.’

PE

WS

Imp

act

on c

omm

unic

atio

n—p

acka

ging

info

rmat

ion.

Fa

cilit

ates

com

mun

icat

ion

acro

ss h

iera

rchi

es.

End

acot

t an

d W

estle

y39A

ustr

alia

Que

stio

nnai

re, i

n-

dep

th in

terv

iew

s an

d o

bse

rvat

ions

Con

tent

ana

lysi

s an

d

cons

tant

com

par

ison

EW

SA

rt o

f ref

erra

l im

por

tant

—us

ing

the

right

lang

uage

and

su

gges

ting

actio

ns t

hat

wou

ld b

e ac

cep

tab

le t

o th

e d

octo

r.A

vaila

bili

ty o

f eq

uip

men

t a

fact

or.

Neg

ativ

e at

titud

e to

war

ds

calli

ng fo

r he

lp; e

scal

atio

n d

epen

den

t on

per

ceiv

ed c

apab

ility

of m

edic

al s

taff.

Enn

is23

Irela

ndD

escr

iptio

n of

im

ple

men

tatio

n of

pae

dia

tric

ear

ly

war

ning

sco

re a

nd

sub

seq

uent

aud

it (p

rosp

ectiv

e co

hort

ob

serv

atio

nal

stud

y)

Sim

ple

des

crip

tive

stat

istic

s of

num

ber

s of

chi

ldre

n tr

igge

ring

the

pae

dia

tric

ea

rly w

arni

ng s

core

and

co

mp

lianc

e w

ith e

scal

atio

n p

roto

col

PE

WS

Str

uctu

red

ed

ucat

ion

and

tra

inin

g p

rogr

amm

e on

the

us

e of

Iden

tify-

Situ

atio

n- B

ackg

roun

d- A

sses

smen

t-

Rec

omm

end

atio

n (IS

BA

R) a

nd p

aed

iatr

ic e

arly

war

ning

sc

ore

was

pro

vid

ed a

nd n

urse

man

ager

/sta

ff nu

rse

in

char

ge s

houl

d r

evie

w a

ny e

duc

atio

nal r

equi

rem

ents

in

com

ple

ting

the

pae

dia

tric

ear

ly w

arni

ng s

core

p

artic

ular

ly fo

r re

lief s

taff.

Com

mon

info

rmat

ion

spac

es im

por

tant

and

dis

pla

y of

ac

tivat

ion

crite

ria t

hrou

ghou

t th

e ho

spita

l.U

sefu

lnes

s of

ISB

AR

as

a co

mm

unic

atio

n to

ol.

Sen

ior

lead

com

mitm

ent—

pae

dia

tric

ear

ly w

arni

ng

scor

e m

anag

emen

t p

olic

y d

evel

oped

/sen

ior

staf

f p

rom

ote

and

rei

nfor

ce u

se o

f the

too

l

Tab

le 5

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Ent

wis

tle73

US

AE

dito

rial

N/A

Fam

ily

invo

lvem

ent

Litt

le e

vid

ence

/no

eval

uatio

ns o

f pol

icie

s or

pra

ctic

es

that

enc

oura

ge a

nd s

upp

ort

fam

ily in

volv

emen

t in

cl

inic

al m

onito

ring.

Pro

pos

e th

e in

nova

tive

pra

ctic

e of

inte

rdis

cip

linar

y ro

und

s w

here

fam

ilies

are

invi

ted

, and

com

mun

icat

ion

is

dire

cted

to

the

pat

ient

and

fam

ily.

Ger

dik

et

al10

3U

SA

Rou

tine

dat

a co

llect

ion

for

num

ber

of R

RT

calls

and

the

res

ult

of t

hese

act

ivat

ions

an

d p

atie

nt/f

amily

su

rvey

rel

atin

g to

R

RT

activ

atio

n

Sta

tistic

al a

naly

sis

Fam

ily

invo

lvem

ent

Dire

ct m

echa

nism

for

fam

ilies

to

activ

ate

the

RR

T.B

arrie

rs t

o fa

mily

act

ivat

ion

high

light

ed, s

pec

ifica

lly

pro

fess

iona

l res

ista

nce.

Phy

sici

an a

nd le

ader

ship

sup

por

t im

por

tant

to

over

com

e b

arrie

rs.

Gill

et

al97

Aus

tral

iaC

omm

enta

ry

dra

win

g to

geth

er

fam

ily- c

entr

ed

care

con

cep

ts, t

he

Nat

iona

l Saf

ety

and

Q

ualit

y H

ealth

care

S

ervi

ce (N

SQ

HS

) S

tand

ard

sand

the

d

evel

opm

ent

of

fam

ily- i

nitia

ted

car

e in

Aus

tral

ia

N/A

PE

WS

Fam

ily- a

ctiv

ated

RR

Ts n

ow in

crea

sing

ly c

omm

on in

A

ustr

alia

. In

the

first

inst

ance

, fam

ilies

nee

d t

o b

e aw

are

of t

he p

olic

y.S

tres

s th

e im

por

tanc

e of

und

erst

and

ing

the

num

ber

and

na

ture

of t

he c

all.

Rep

orts

on

heal

th p

rofe

ssio

nal’s

res

ista

nce

to it

.Fa

mili

es n

eed

vig

ilanc

e to

esc

alat

e ca

re. N

eed

res

ourc

es

in o

rder

to

nego

tiate

hie

rarc

hies

and

bou

ndar

ies.

Gre

enho

use

et a

l100

US

A fo

cus

Dis

cuss

ion

abou

t th

e im

ple

men

tatio

n of

Con

diti

onH

Des

crip

tive

stat

istic

sFa

mily

in

volv

emen

tA

pp

rop

riate

ness

of c

alls

is r

epor

ted

rat

her

than

why

the

y ar

e m

ade.

Not

e so

me

scep

ticis

m a

nd w

arin

ess

amon

g nu

rses

and

p

hysi

cian

s.

Hue

ckel

et

al10

1U

SA

Scr

ipte

d fa

mily

te

achi

ng a

bou

t R

RT

activ

atio

n at

th

e tim

e of

pat

ient

ad

mis

sion

from

C

ond

ition

H

Des

crip

tive

stat

istic

s ab

out

del

iver

y of

ed

ucat

iona

l p

rogr

amm

e an

d R

RT

call-

ou

t; s

urve

y te

stin

g fa

mily

un

der

stan

din

g

Fam

ily

invo

lvem

ent

Des

crip

tion

of C

ond

ition

Hel

p.

Ap

pro

pria

tene

ss o

f cal

ls is

rep

orte

d r

athe

r th

an w

hy t

hey

are

mad

e.

Jam

es e

t al

37U

KP

osta

l sur

vey

with

hea

lthca

re

assi

stan

ts (H

CA

) us

ing

clos

ed a

nd

open

que

stio

ns

Des

crip

tive

stat

istic

s an

d c

onte

nt a

naly

sis

of

qua

litat

ive

dat

a

Ob

serv

atio

ns

and

mon

itorin

gW

orkl

oad

and

war

d d

istr

actio

ns a

bar

rier

to a

ctiv

atio

n,

such

as

time

spen

t lo

catin

g eq

uip

men

t.D

isin

clin

atio

n to

see

k he

lp fr

om s

enio

r st

aff/

clin

icia

ns.

Tab

le 5

C

ontin

ued

Con

tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Jens

en e

t al

46D

enm

ark

Focu

s gr

oup

ex

plo

ring

nurs

es’

exp

erie

nces

with

a p

aed

iatr

ic e

arly

w

arni

ng s

core

Qua

litat

ive

mea

ning

co

nden

satio

n an

alys

isP

EW

SP

aed

iatr

ic e

arly

war

ning

sco

re a

s a

nurs

ing

tool

and

th

eref

ore

not

valu

ed b

y m

edic

—no

uni

vers

al la

ngua

ge

bec

ause

of t

his;

‘whe

n yo

u ca

ll an

d s

ay t

hat

they

hav

e a

scor

e of

5, t

hen

they

don

't k

now

wha

t 5

mea

ns’ (

FG2

P1)

.

Kau

l et

al24

US

AD

escr

iptiv

e cr

oss-

se

ctio

nal s

tud

y;

nurs

e an

d m

edic

al

staf

f sur

vey

Des

crip

tive

stat

istic

sP

EW

SN

oted

tha

t th

e sc

ore

pro

vid

es a

‘uni

vers

al la

ngua

ge’ a

nd

inte

rdis

cip

linar

y co

mm

unic

atio

n

Lob

os e

t al

25C

anad

aIm

ple

men

tatio

n d

iscu

ssio

nS

imp

le d

escr

iptiv

e st

atis

tics

PE

WS

Situ

atio

n- B

ackg

roun

d- A

sses

smen

t- R

ecom

men

dat

ion

(SB

AR

) hel

ps

esta

blis

h a

com

mon

lang

uage

and

gui

de

esca

late

d e

vent

s.N

egat

ive

attit

ude

tow

ard

s ca

lling

for

help

—tr

aditi

onal

hi

erar

chie

s a

bar

rier

to a

ctiv

atio

n/co

ncer

ns a

bou

t co

mm

unic

atio

n b

etw

een

prim

ary

and

res

pon

din

g te

am.

No

fals

e al

arm

s an

d d

ebrie

fing

usef

ul.

Imp

orta

nce

of c

ham

pio

ns (u

sing

a s

ocia

l mar

ketin

g ap

pro

ach)

to

enco

urag

e ‘in

ter-

pro

fess

iona

l col

lab

orat

ion

& a

dvi

sory

gro

up t

o he

lp e

stab

lish

a se

nse

of

owne

rshi

p’.

Lack

of s

upp

ort

from

sup

erio

rs m

eans

less

like

ly t

o es

cala

te.

Tab

le 5

C

ontin

ued

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tinue

d



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Aut

hor

Co

untr

yM

etho

do

log

yA

naly

sis

Sea

rch

area

Evi

den

ce c

ont

rib

utio

n

Mac

kint

osh

et a

l27U

KC

omp

arat

ive

case

stu

dy—

a ra

pid

res

pon

se

syst

em (R

RS

) us

ing

ethn

ogra

phi

c m

etho

ds

incl

udin

g ob

serv

atio

ns,

inte

rvie

ws

and

d

ocum

enta

ry

revi

ew

Ind

uctiv

e an

d d

educ

tive

cod

ing

faci

litat

ed b

y N

Viv

o.

Als

o us

ed t

hem

e b

uild

ing

and

str

uctu

ring

met

hod

s fr

om fr

amew

ork

anal

ysis

w

hile

als

o in

form

ed b

y ot

her

theo

retic

al fr

amew

orks

suc

h as

‘tec

hnol

ogy-

in- p

ract

ice’

.

EW

SA

vaila

bili

ty o

f eq

uip

men

t an

issu

e w

here

the

TTT

was

el

ectr

onic

.G

ave

juni

or s

taff

licen

ce t

o es

cala

te c

are.

Ad

diti

onal

ly, ‘

whi

le s

tand

ard

isat

ion

of p

ract

ice

clea

rly

has

its b

enefi

ts, i

t al

so c

omes

at

a co

st t

hat

thes

e to

ols

atte

nuat

e lo

wer

leve

l sta

ff’s

aut

horit

y an

d a

bili

ty

to p

ersu

ade

staf

f hig

her

up in

the

org

anis

atio

n of

the

cr

edib

ility

of t

heir

know

led

ge’ (

p 1

43).

Effo

rts

to d

evel

op ju

nior

sta

ff’s

com

mun

icat

ion

and

cl

inic

al u

nder

stan

din

g ne

ed t

o ac

know

led

ge p

ower

d

ynam

ics

at p

lay.

Use

fuln

ess

of S

BA

R c

omm

unic

atio

n to

ol a

s p

art

of

the

esca

latio

n p

olic

y as

rep

orte

d b

y st

aff (

not

seen

in

actio

n).

Neg

ativ

e at

titud

e to

war

ds

esca

latio

n—d

ifficu

lty in

su

mm

onin

g a

resp

onse

.S

enio

r le

ad c

omm

itmen

t to

pat

ient

saf

ety

was

im

por

tant

. Zer

o to

lera

nce

for

card

iac

arre

st w

as

cham

pio

ned

by

seni

or s

taff.

Nig

ht- t

ime/

out-

of- h

ours

pre

ssur

es id

entifi

ed.

Mac

kint

osh

et a

l38U

KE

thno

grap

hic

per

spec

tive;

ob

serv

atio

ns,

sem

istr

uctu

red

in

terv

iew

s

Dat

a w

ere

ind

uctiv

ely

and

d

educ

tivel

y co

ded

and

or

gani

sed

the

mat

ical

ly.

EW

SN

egat

ive

attit

ude

tow

ard

s se

ekin

g he

lp. E

scal

atin

g ca

re

outs

ide

the

par

amet

ers

mar

ked

by

a tr

ack

and

trig

ger

tool

pro

ved

diffi

cult;

pow

er s

trug

gles

iden

tified

—ju

nior

st

aff h

ave

diffi

culty

per

suad

ing

mor

e se

nior

sta

ff of

the

cr

edib

ility

of t

heir

know

led

ge.

Diffi

culti

es in

act

ivat

ion

acro

ss p

rofe

ssio

nal b

ound

arie

s.

Mas

sey

et a

l67A

ustr

alia

In- d

epth

se

mis

truc

ture

d

inte

rvie

ws

Ind

uctiv

e ap

pro

ach—

them

atic

ana

lysi

sE

WS

Com

mon

info

rmat

ion

spac

es u

sefu

l. D

isp

lay

of

activ

atio

n cr

iteria

thr

ough

out

hosp

ital.

Gen

eral

neg

ativ

e at

titud

e to

war

ds

calli

ng fo

r he

lp—

app

earin

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r co

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Tab

le 5

C

ontin

ued

Con

tinue

d



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Aut

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istic

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alua

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t—cu

lture

of s

upp

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pro

mot

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by

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ing

adm

inis

trat

ors.

Tab

le 5

C

ontin

ued

Con

tinue

d



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Aut

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ses

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ss o

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litat

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e ‘n

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ture

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de

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uctu

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ly w

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l45U

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etho

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re

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pec

tive

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ical

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serv

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ns a

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rvat

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of

nurs

e in

tera

ctio

ns

in 1

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cks

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serv

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ilab

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, not

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.

Tab

le 5

C

ontin

ued



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warning system.3 Drawing on TMT and NPT, we have synthesised and analysed the findings from the review to develop a propositional model to specify the core compo-nents of optimal afferent component paediatric early warning systems. While there is a growing consensus of the need to think beyond TTTs to consider the whole system, no frameworks exist to support such an approach. Clinical teams wishing to improve rescue trajectories should take a whole systems perspective focused on the constellation of factors necessary to support detection, planning and action and consider how these relation-ships can be managed in their local setting. TTTs have value in paediatric early warning systems but they are not the sole solution and depend on certain precondi-tions for their use. An emerging literature highlights the importance of planning and indicates that combina-tions of interventions may facilitate situation awareness. Professional judgement is also important in detecting and acting on deterioration and the evidence points to the importance of a wider organisational culture that is supportive of this. Innovative approaches are needed to support family involvement in all aspects of paediatric early warning systems, which are sensitive to the cognitive and emotional resources this requires. System effective-ness requires attention to the sociomaterial relationships in the local context, senior support and leadership and continuous monitoring and evaluation. New technolo-gies, such as moving from paper- based to electronic TTTs, have important implications for all three subsystems and critical consideration should be given to their wider impacts and the preconditions for their integration into practice.

limitations of the reviewThe literature in this field is heterogeneous and better at identifying system weakness than it is effective improve-ment interventions. It was only by deploying social theo-ries and a hermeneutic review methodology did it prove possible to develop a propositional model of the core components of an afferent component paediatric early warning system. This model is derived from logical infer-ences drawing on the overall evidence synthesis, social theories and clinical expertise, rather than strong empir-ical evidence of single intervention effectiveness. Conse-quently, there is a growing consensus of the need to take a whole systems approach to improve the detection and response to deterioration in the inpatient paediatric population.

COnCluSIOnFailure to recognise and act on signs of deterioration is an acknowledged safety concern1 and TTTs are a common response to this problem. There is, however, a growing recognition of the importance of wider system factors on the effectiveness of responses to deterioration.5 7 We have reviewed a wide literature and analysed this using social theories to develop a propositional model of an optimal

afferent component paediatric early warning system that can be used as a framework for paediatric units to evaluate their current practices and identify areas for improve-ment. TTT use should be driven by the extent to which teams think that they will help improve the effectiveness of their system as a whole.

Author affiliations1Centre for Trials Research, Cardiff University, Cardiff, UK2University Library Services, Cardiff University, Cardiff, UK3Faculty of Health and Applied Sciences (HAS), University of the West of England Bristol, Bristol, UK4Alder Hey Children's NHS Foundation Trust, Liverpool, UK5Department of Pediatric Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar6Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK7Emergency Department, Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK8SAPPHIRE Group, University of Leicester Department of Health Sciences, Leicester, UK9School of Healthcare Sciences, Cardiff University, Cardiff, UK

Twitter Yvonne Moriarty @YvonneCMoriarty, Mala Mann @SysReviews and Damian Roland @damian_roland

Acknowledgements The authors acknowledge the contribution of Dr Heather Strange to the review. The authors also extend their thanks to the parental advisory group who have helped shape the broader questions of the research study as well as offer guidance on wider contextual factors to consider within the overall paediatric early warning system.

Contributors NJ: screening and review of papers; led the theoretical synthesis of the literature; contributed to model development; preparation and writing of the manuscript (with DA). YM: screening and review of papers; contributed to model development; contributed to the drafting of the manuscript. AL: led the model development (with DA); contributed to the drafting of the manuscript. MM: conceived and led the systematic search strategies; review of manuscript. LNT, GS, CP, DR: screening and review of papers; contributed clinical expertise; contributed to model development; contributed to the drafting of the manuscript. RT: screening and review of manuscript. KH: contributed to model development; contributed to the drafting of the manuscript. DA: conceived and designed the review; led the theoretical framing and analysis; screening and review of papers; led the model development (with AL); and led the writing of the manuscript (with NJ).

Funding This study is funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) programme (12/178/17).

disclaimer The views and opinions expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https:// creativecommons. org/ licenses/ by/ 4. 0/.

ORCId idsNina Jacob http:// orcid. org/ 0000- 0002- 3240- 4179Yvonne Moriarty http:// orcid. org/ 0000- 0002- 7608- 4699



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