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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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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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Tab
le 3
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eter
iora
tion
dep
end
ing
on
exp
erie
nce.
Use
ful f
or ju
nior
sta
ff.V
ital s
igns
mon
itorin
g d
eleg
ated
to
juni
or s
taff.
Bel
lom
o et
al79
Inte
rnat
iona
l: U
SA
, Sw
eden
, U
K, N
ethe
rland
s,
Aus
tral
ia
Bef
ore-
and
- aft
er m
ultic
entr
ed
inte
rnat
iona
l con
trol
led
tria
lA
utom
ated
vita
l sig
ns m
onito
ring
and
ear
ly w
arni
ng s
core
ca
lcul
ated
, int
erna
tiona
l stu
dy,
b
lind
ed t
rial,
hosp
itals
ret
aine
d
own
early
war
ning
sco
re a
nd
esca
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
9Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
10 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
11Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
12 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
13Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
14 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
15Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
16 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
17Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
Co
untr
yM
etho
do
log
yA
naly
sis
Sea
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
18 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
19Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
Co
untr
yM
etho
do
log
yA
naly
sis
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
20 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
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MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
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Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
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MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
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Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
23Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
24 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
25Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
26 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
27Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
Con
tinue
d
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
28 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
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
g in
adeq
uate
in fr
ont
of o
ther
s.Im
por
tanc
e of
lead
ersh
ip s
upp
ort.
Pee
r su
pp
ort—
wou
ld o
ften
con
sult
thei
r co
lleag
ues.
Tab
le 5
C
ontin
ued
Con
tinue
d
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
29Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
Co
untr
yM
etho
do
log
yA
naly
sis
Sea
rch
area
Evi
den
ce c
ont
rib
utio
n
McC
abe
et a
l35U
KO
pin
ion
pie
ce
abou
t le
sson
s to
b
e le
arnt
from
the
ad
ult
exp
erie
nce
of
imp
lem
entin
g ea
rly
war
ning
sys
tem
s
N/A
PE
WS
Sp
ecifi
c ed
ucat
ion
pac
kage
nee
ded
on
how
to
use
an e
arly
war
ning
sys
tem
(EW
S) a
nd o
n b
asic
cl
inic
al a
sses
smen
t, g
uid
ance
and
sta
ndar
dis
atio
n of
ob
serv
atio
n an
d m
onito
ring.
Ad
voca
te s
ituat
iona
l si
mul
ated
sce
nario
ed
ucat
ion
and
e- l
earn
ing.
Hig
hlig
ht t
he u
sefu
lnes
s of
com
mun
icat
ion
tool
s su
ch
as S
BA
R fo
r es
tab
lishi
ng r
oles
and
res
pon
sib
ilitie
s,
enga
ging
the
m in
mak
ing
an a
pp
rop
riate
man
agem
ent
pla
n th
at c
an, i
f nec
essa
ry, b
e es
cala
ted
.S
enio
r le
ad c
omm
itmen
t ke
y—re
flect
ed in
res
ourc
es
and
ed
ucat
ion—
to im
pro
ve t
he s
afet
y an
d q
ualit
y of
ca
re o
f hos
pita
lised
pat
ient
s.Fa
mili
es n
eed
to
be
emp
ower
ed t
o re
que
st a
pat
ient
re
view
.
McD
onne
ll et
al26
UK
Sin
gle-
cent
re,
mix
ed m
etho
ds
bef
ore-
and
- aft
er
stud
y in
clud
ing
a su
rvey
to
mea
sure
ch
ange
s in
nur
ses’
kn
owle
dge
aft
er
imp
lem
enta
tion
of
a tr
ack
and
trig
ger
syst
em (T
&Ts
). A
lso,
qua
litat
ive
inte
rvie
ws.
Sta
tistic
al a
naly
sis
and
th
emat
ic fr
amew
ork
anal
ysis
EW
SR
ollin
g ed
ucat
ion
pro
gram
me
for
all n
urse
s on
the
re
cogn
ition
and
res
pon
se t
o d
eter
iora
ting
pat
ient
s an
d
an o
verv
iew
of t
he T
&Ts
.W
orkp
lace
pre
ssur
es; n
urse
s co
ncer
ned
tha
t th
ey c
ould
no
t al
way
s su
mm
on a
tim
ely
resp
onse
from
doc
tors
/ni
ght-
time
pre
ssur
es a
lso
iden
tified
.N
eed
for
staf
f con
cern
in T
&Ts
.
Mon
agha
n28U
K fo
cus
Com
men
tary
on
the
dev
elop
men
t of
the
B
right
on p
aed
iatr
ic
early
war
ning
sco
re
and
set
ting
up a
p
aed
iatr
ic c
ritic
al
care
out
reac
h te
am
Sim
ple
des
crip
tive
stat
istic
s of
all
activ
atio
ns, a
ctio
ns
and
out
com
es d
urin
g th
e fir
st 3
mon
ths
of
imp
lem
enta
tion
PE
WS
Ed
ucat
ion-
bas
ed m
odel
was
dev
elop
ed t
o as
sist
in
reco
gnis
ing
det
erio
ratio
n.Te
mp
orar
y st
aff/
wor
kpla
ce p
ress
ures
imp
act
on s
taff
’s
abili
ty t
o d
etec
t d
eter
iora
tion.
Tab
le 5
C
ontin
ued
Con
tinue
d
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
30 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
Co
untr
yM
etho
do
log
yA
naly
sis
Sea
rch
area
Evi
den
ce c
ont
rib
utio
n
Pac
iott
i et
al71
US
AS
emis
truc
ture
d
inte
rvie
ws
with
cl
inic
ians
to
exp
lore
phy
sici
ans’
vi
ewp
oint
s on
fa
mili
es fa
cilit
atin
g th
e id
entifi
catio
n of
chi
ldre
n w
ith
a d
eter
iora
ting
cond
ition
Gro
und
ed t
heor
y an
d
cons
tant
com
par
ison
Fam
ily
invo
lvem
ent
Con
cern
s th
at r
esou
rces
wou
ld b
e d
iver
ted
aw
ay w
ith
an in
crea
se in
cal
ls—
not
sup
por
ted
Pat
tison
and
Eas
tham
29U
KM
ixed
met
hod
s st
udy
look
ing
at t
he
imp
act
of a
crit
ical
ca
re o
utre
ach
team
(C
CO
T)
Sta
tistic
al a
naly
sis
and
gr
ound
ed t
heor
yE
WS
Ava
ilab
ility
of e
qui
pm
ent
an is
sue/
wor
kloa
d.
Neg
ativ
e at
titud
e to
war
ds
calli
ng fo
r he
lp—
situ
atio
n un
der
con
trol
/war
d b
usin
ess.
Inex
per
ienc
ed s
taff
team
ing
up/c
heck
ing
with
pee
rs
bef
ore
calli
ng t
he C
CO
T.
Pea
rson
and
Dun
can30
UK
Brie
f rev
iew
of
the
evid
ence
b
ase
surr
ound
ing
the
pae
dia
tric
ea
rly w
arni
ng
scor
e to
geth
er
with
refl
ectio
ns
from
the
ir ow
n ex
per
ienc
es fr
om
the
Birm
ingh
am
Chi
ldre
n’s
Hos
pita
l
N/A
PE
WS
Team
tra
inin
g an
d e
duc
atio
n is
imp
orta
nt in
crea
sing
co
nfid
ence
in t
he u
se o
f med
ical
lang
uage
and
em
pow
erin
g b
edsi
de
care
rs. ‘
Alth
ough
doi
ng
obse
rvat
ions
is fu
ndam
enta
l to
nurs
ing
pra
ctic
e m
any
… h
ave
not
bee
n ta
ught
a s
truc
ture
d a
pp
roac
h to
as
sess
men
t.’ A
dvo
cate
a s
imul
ated
env
ironm
ent.
Valu
e of
a m
ore
stru
ctur
ed a
pp
roac
h to
co
mm
unic
atio
n—ad
voca
te t
he u
se o
f a s
hare
d
com
mun
icat
ion
mod
el s
uch
as S
BA
R t
o co
mm
unic
ate
find
ings
to
sup
erio
rs.
Nee
d fo
r se
nior
com
mitm
ent—
cultu
ral c
hang
e m
ay b
e re
qui
red
to
ensu
re m
anag
emen
t su
pp
ort
(refle
cted
in
reso
urce
s an
d e
duc
atio
n)/im
por
tanc
e of
cha
mp
ions
.
Sal
amon
son
et a
l56A
ustr
alia
Sur
vey
with
clo
sed
an
d o
pen
que
stio
ns
to e
xam
ine
per
cep
tions
of a
nd
satis
fact
ion
with
the
M
ET
Des
crip
tive
stat
istic
s an
d
cont
ent
anal
ysis
EW
SN
eed
for
mor
e ed
ucat
ion
on d
eter
iora
tion
iden
tified
.N
egat
ive
attit
ude
tow
ard
s as
king
for
help
; att
itud
e of
M
ET
team
a b
arrie
r to
act
ivat
ion.
Tab
le 5
C
ontin
ued
Con
tinue
d
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
31Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
Co
untr
yM
etho
do
log
yA
naly
sis
Sea
rch
area
Evi
den
ce c
ont
rib
utio
n
She
arer
et
al31
Aus
tral
iaA
mul
timet
hod
st
udy;
a p
oint
pre
vale
nce
surv
ey;
a p
rosp
ectiv
e au
dit
of a
ll p
atie
nts
exp
erie
ncin
g a
card
iac
arre
st,
unp
lann
ed in
tens
ive
care
uni
t (IC
U)
adm
issi
on o
r d
eath
ov
er a
n 8-
wee
k p
erio
d.
Str
uctu
r ed
in
terv
iew
s w
ith s
taff
to e
xplo
re c
ogni
tive
and
soc
iocu
ltura
l b
arrie
rs t
o ac
tivat
ion.
Itera
tive
cod
ing
EW
SA
deq
uate
sta
ffing
and
a la
ck o
f bed
s on
crit
ical
car
e le
ads
to a
failu
re t
o ac
tivat
e th
e R
RS
.S
core
rar
ely
the
sing
le d
eter
min
ing
fact
or in
act
ivat
ion
des
pite
the
fact
tha
t st
aff r
ecog
nise
d p
atie
nts
met
ac
tivat
ion
crite
ria. D
ata
from
the
poi
nt p
reva
lenc
e st
udy
confi
rm t
his
as o
nly
one
pat
ient
had
a s
erio
us a
dve
rse
even
t.N
egat
ive
attit
ude
tow
ard
s ca
lling
for
help
—si
tuat
ion
und
er c
ontr
ol; t
reat
ing
team
had
exp
ertis
e to
tre
at
(par
ticul
arly
whe
n th
e p
hysi
olog
ical
inst
abili
ty w
as in
the
ar
ea o
f exp
ertis
e of
the
tre
atin
g te
am).
Trad
ition
al (i
ntra
pro
fess
iona
l clin
ical
) hie
rarc
hies
a b
arrie
r to
act
ivat
ion.
Søn
ning
et
al41
Nor
way
Que
stio
nnai
re o
f a
sam
ple
of s
taff
who
us
e a
pae
dia
tric
ea
rly w
arni
ng s
core
Des
crip
tive
stat
istic
sP
EW
SN
urse
s ga
in s
elf-
confi
den
ce. M
ore
effe
ctiv
e co
mm
unic
atio
n.
Ste
war
t et
al32
Sw
eden
Mix
ed m
etho
ds.
R
etro
spec
tive
revi
ew o
f rec
ord
s an
d n
urse
- led
focu
s gr
oup
s.
Sta
tistic
al a
naly
sis
and
co
nten
t an
alys
isE
WS
The
RR
S w
as v
alua
ble
for
juni
or s
taff
esca
latin
g ca
re
acro
ss h
iera
rchi
cal a
nd p
rofe
ssio
nal b
ound
arie
s.S
enio
r le
ad c
omm
itmen
t—cu
lture
of s
upp
ort
pro
mot
ed
by
nurs
ing
adm
inis
trat
ors.
Tab
le 5
C
ontin
ued
Con
tinue
d
on April 20, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2018-028796 on 14 N
ovember 2019. D
ownloaded from
32 Jacob N, et al. BMJ Open 2019;9:e028796. doi:10.1136/bmjopen-2018-028796
Open access
Aut
hor
Co
untr
yM
etho
do
log
yA
naly
sis
Sea
rch
area
Evi
den
ce c
ont
rib
utio
n
Van
Voor
his
and
Will
is 33
US
AD
iscu
ssio
n p
aper
hi
ghlig
htin
g th
e p
roce
ss o
f d
evel
opin
g a
pae
dia
tric
RR
S.
The
syst
em w
as
eval
uate
d b
y p
rosp
ectiv
ely
colle
cted
dat
a re
cord
ed o
n R
RS
ac
tivat
ion
form
s an
d e
xist
ing
per
form
ance
im
pro
vem
ent
dat
abas
e in
form
atio
n.
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
.D
ebrie
fing
follo
win
g ac
tivat
ion
and
a c
omm
itmen
t to
no
fals
e al
arm
s is
enc
oura
ged
.S
enio
r le
ad c
omm
itmen
t—ad
min
istr
ativ
e ar
m o
f the
R
RS
vita
l.U
ses
Con
diti
on H
elp
. The
ap
pro
pria
tene
ss o
f cal
ls w
as
faci
litat
ed b
y th
e ‘n
o fa
lse
alar
ms’
cul
ture
.
de
Vrie
s et
al86
Net
herla
nds
Sem
istr
uctu
red
in
terv
iew
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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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