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Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review
  1. Veronica Lambert1,
  2. Anne Matthews1,
  3. Rachel MacDonell2,
  4. John Fitzsimons3
  1. 1School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
  2. 2HSE Clinical Programmes, Office of Nursing & Midwifery Services Directorate, Health Service Executive
  3. 3Our Lady of Lourdes Hospital Drogheda & Quality Improvement Division Health Service Executive
  1. Correspondence to Dr Veronica Lambert; veronica.lambert{at}


Objective To systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children.

Method The electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised.

Results From a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration.

Conclusions Despite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.

  • PEWS
  • Paediatric early warning system
  • clinical deterioration
  • children
  • systematic review

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors VL was the lead investigator for the original and revised review. VL and AM designed the review protocol, developed and ran the updated search searches, selected and appraised the papers, extracted data and drafted the initial manuscript. RM and JF commented on the protocol, searches, evidence appraisal and revised the manuscript for important intellectual content. All authors approved the final manuscript.

  • Funding This work was supported by the Irish Department of Health and overseen by the National Clinical Effectiveness Committee and Health Service Executive PEWS Guideline Development Group.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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