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Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review
  1. Rob Trubey1,
  2. Chao Huang2,
  3. Fiona V Lugg-Widger1,
  4. Kerenza Hood1,
  5. Davina Allen3,
  6. Dawn Edwards4,
  7. David Lacy5,
  8. Amy Lloyd1,
  9. Mala Mann6,
  10. Brendan Mason7,
  11. Alison Oliver8,
  12. Damian Roland9,10,
  13. Gerri Sefton11,
  14. Richard Skone8,
  15. Emma Thomas-Jones1,
  16. Lyvonne N Tume12,
  17. Colin Powell13,14
  1. 1 Centre for Trials Research, Cardiff University, Cardiff, UK
  2. 2 Hull York Medical School, University of Hull, Hull, UK
  3. 3 School of Healthcare Sciences, Cardiff University, Cardiff, UK
  4. 4 Department of Paediatrics, Morriston Hospital, Swansea, UK
  5. 5 Wirral University Teaching Hospital, Wirral, UK
  6. 6 University Library Services, Cardiff University, Cardiff, UK
  7. 7 Public Health Wales, Cardiff, UK
  8. 8 Department of Paediatric Intensive Care, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
  9. 9 SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
  10. 10 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary, Leicester, UK
  11. 11 Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
  12. 12 Faculty of Health and Applied Sciences (HAS), University of the West of England Bristol, Bristol, UK
  13. 13 Department of Pediatric Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
  14. 14 Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
  1. Correspondence to Dr Rob Trubey; trubeyrj{at}


Objective To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.

Design Systematic review.

Data sources British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.

Eligibility criteria We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0–18 years), where adverse outcome metrics were reported. Several study designs were considered.

Data extraction and synthesis Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.

Results 36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.

Conclusion There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.

PROSPERO registration number CRD42015015326

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

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  • Contributors RT: screening and review of papers, contribution to design of work, preparation of manuscript; CH: screening and review of papers, contribution to concept and design of work, review of manuscript; FVL-W: contribution to design of work, screening and review of papers, review of manuscript; KH: contribution to concept and design of work, screening and review of papers, review of manuscript; CP, DR, BM, AO, DE, RS, GS, DL, LNT, DA, AL, ET-J: contribution to concept and design of work, screening and review of papers, review of manuscript; MM: information specialist, review of manuscript.

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

  • Competing interests None declared.

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

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

  • Patient consent for publication Not required.

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