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Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development
  1. Nina Jacob1,
  2. Yvonne Moriarty1,
  3. Amy Lloyd1,
  4. Mala Mann2,
  5. Lyvonne N Tume3,
  6. Gerri Sefton4,
  7. Colin Powell5,6,
  8. Damian Roland7,8,
  9. Robert Trubey1,
  10. Kerenza Hood1,
  11. Davina Allen9
  1. 1 Centre for Trials Research, Cardiff University, Cardiff, UK
  2. 2 University Library Services, Cardiff University, Cardiff, UK
  3. 3 Faculty of Health and Applied Sciences (HAS), University of the West of England Bristol, Bristol, UK
  4. 4 Alder Hey Children's NHS Foundation Trust, Liverpool, UK
  5. 5 Department of Pediatric Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
  6. 6 Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
  7. 7 Emergency Department, Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK
  8. 8 SAPPHIRE Group, University of Leicester Department of Health Sciences, Leicester, UK
  9. 9 School of Healthcare Sciences, Cardiff University, Cardiff, UK
  1. Correspondence to Dr Nina Jacob; Jacobn{at}


Objective 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.

  • PEWS
  • track and trigger scores
  • early warning scores
  • clinical deterioration
  • children
  • systematic review

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:

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  • 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.

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