Table 2

Overview of evidence on paediatric early warning implementation strategies/interventions

Level of evidenceType of studyInterventionImplementation strategyOutcomesEffectivenessReferences
2- high risk of confounding to bias or high risk of non-causal relationships (n=4)Time series (n=1)
Cohort (n=1)
Before and after (n=2)
MET team (n=1)
Situation awareness intervention (n=1)
Education programme (n=2)
Checklist-based form followed flow of situation awareness algorithm; completed by charge nurse (n=1)
Didactic education session (45 min) and participation in 2 video-recorded mock patient hand-off (n=1)
Multifaceted e-learning package and 3-hour face-to-face low-fidelity simulation package (n=1)
Costs and benefits of operating MET (n=1)
Rate of UNSAFE (unrecognised situation awareness failure events) (n=1)
Paediatric interns patient hand-offs (n=1)
Unplanned admission to PHDU (n=1)
Vital sign documentation (n=1)
Communication and medical review (n=1)
3 clinical deterioration events would offset costs of MET (n=1)
Rate of UNSAFE transfers significantly reduced (n=1)
Significant improvement in paediatric intern hand-offs (n=1)
Reduction in unplanned admission to PHDU (not significant) (n=1)
Significant improvement in vital sign documentation (n=1)
Significant improvement in number of documented communication episodes (n=1)
84 86 92 93
3 non-analytic case review
(n=3)
Chart review (n=2)
Cost analysis exercise (n=1)
Cardiopulmonary resuscitation attempts (n=1)
PEWS scoring system and watchful eye action algorithm (n=1)
CHEWS and escalation of care algorithm (n=1)
Piloted intervention through multiphases (n=2)Cost of CPR (n=1)
Number of days between CPA (n=1)
Unplanned CICU transfers (n=1)
Short-term costs of CPR events more expensive than adults; post PICU admission costs higher than arrest/event cases (n=1)
Increase in number of days between CPA (n=1)
Reduction in unplanned CICU transfers (n=1)
87 88 94
4 expert opinion (n=9)Qualitative study (n=3)
Quality improvement initiative (n=4)
Course evaluation survey (n=1)
Cross-sectional survey (n=1)
PEWS and escalation algorithm (n=1)
RRS/MET programme (n=4)
RRS incl. calling criteria, EWS and MET (n=1)
Foundation changes, eg, ISBAR, midlevel changes, eg, RRT and advanced changes, eg, FARRT (n=1)
Education course (n=1)
Social marketing (n=2)
Multisite and multidisciplinary improvement collaborative (n=2)
Comprehensive paediatric change package (n=1)
Plan-Do-Check-Act (n=1)
Multiphased pilots (n=2)
Roll out cycles/phases across different units (n=3)
Introduced on limited basis then expanded to full 24/7 service roll out (n=2)
Multiprofessional 1 day face-to-face education programme (n=1)
How EWS supports clinician decision-making (n=1)
Achievement and maintenance situation awareness (n=1)
Cardiopulmonary arrest rates/code blue events (n=4)
PICU mortality (n=1)
RRS activations (n=2)
Improvement in patient safety culture (n=1)
Benefits of MET (n=1)
Values/attitudes placed on MET by clinicians (n=1)
Barriers to activating MET (n=2)
Most useful aspects of education course (n=1)
EWS alerts clinicians to concerning vital sign changes; prompts critical thinking about possible deterioration; provides less-experienced nurses with age-based vital sign reference ranges and empowers nurses to escalate care and communicate concerns (n=1)
A number of social, technological and organisational factors were identified as influencing the achievement of situation awareness categorised under the 3 themes of team based care, availability of standardised data, and standardised processes and procedures (n=1)
No reduction, or no significant reduction, in code rates (n=2)
Significant reductions in code blue events and PICU mortality (n=1)
Reduction in CPA organisationally (n=1)
Reduction in RRS activations (n=1)
Patient safety culture scores improved (only statistically significant improvement was seen in “non-punitive response to error” (n=1)
MET benefits included education provided on hospital floors; satisfaction of service users incl. patients, nurses and physicians; empowerment of bedside staff (n=1)
Clinicians valued RRS; enhanced patient safety and improved relationships among clinicians in general care and ICU areas; reported on barriers that shaped decision to activate MET (n=1)
Most useful aspects of education course were, discussion/review of real-life cases; learning to use SBAR which improved communication between clinicians and team working; multiprofessional approach which improved understanding among each professional group when dealing with deterioration cases (n=1)
83 85 89–91 95–97