Table 4

Summary of early warning system effectiveness study outcomes

OutcomeFirst author, yearInterventionPTTTCountryNumber of centresSpecialist unit?Existing RRT/
MET?
PopulationStudy designStudy duration in monthsEvents before, n (rate)Events after,
n (rate)
Effect size (95% CI)P valueQuality score (max=26)
Implemented a new PTTTImplemented new RRT/
MET
Modified escalation processStaff training/
education
Mortality
Deaths on ward (per 1000 admissions)Tibballs 200513 Melbourne Activation CriteriaAustralia1YNAll inpatientsUncontrolled before-after study (prospective)53
(41 before, 12 after)
13
(0.12)
2
(0.06)
RR=0.45
(0.10 to 1.99)†
0.2910
Hospital-wide deaths (per 100 discharges)Sharek 200717 Paediatric rapid response team (RRT) triggering criteriaUSA1YNAll inpatientsUncontrolled before-after study (prospective)84
(67 before, 17 after)
547
(1.01)
158
(0.83)
RR=0.82
(0.70 to 0.95)
0.007 15
Hospital-wide deaths, excluding neonate ICU and ED (per 1000 discharges)Zenker 200760 RRT activation criteria*USA1YNAll inpatientsUncontrolled before-after study (prospective)34
(23 before, 11 after)
97
(4.30)
52
(4.45)
RR=1.04
(0.74 to 1.45)†
0.5712
Deaths outside ICU (per 1000 non-ICU patient-days)Brilli 200715 Paediatric medical emergency team triggering criteria (a)USA1YNAll inpatientsUncontrolled before-after study (prospective)27
(15 before, 12 after)
9
(0.10)
2
(0.04)
RR=0.39
(0.08 to 1.80)†
0.1314
Ward death rate (per 1000 ward admissions)Hanson 201061 Not described USA1YNAll inpatientsUncontrolled before-after study (retrospective)36
(24 before, 12 after)
13
(1.50)
2
(0.45)
RR=0.30
(0.07 to 1.31)†
0.0718
Total hospital deaths (per 1000 admissions)Tibballs 200962 Melbourne Activation CriteriaAustralia1YNAll inpatientsUncontrolled before-after study (prospective)89
(41 before, 48 after)
459
(4.38)
398
(2.87)
RR=0.65
(0.57 to 0.75)
<0.000115
Deaths on ward (per 1000 admissions)Tibballs 200962 Melbourne Activation CriteriaAustralia1YNAll inpatientsUncontrolled before-after study (prospective)89
(41 before, 48 after)
13
(0.12)
6
(0.04)
RR=0.35
(0.13 to 0.92)
0.03 15
All-cause hospital mortality (per 1000 admissions)Kotsakis 201163 Modified Melbourne Activation CriteriaCanada4YNAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
553
(9.97)
540
(9.65)
RR=0.97 (0.83 to 1.12)0.6518
All-cause hospital mortality (per 1000 discharges)Parshuram 201864 Bedside PEWSBelgium, Ireland, The Netherlands, England, Italy, Canada, New Zealand21YNAll inpatientsCluster randomised trial (prospective)18
(6 pre,
12 post)
Con:
61
(1.31)
Con:
147
(1.56)
OR=1.01
(0.61 to 1.69)
0.9623
Int:
52
(1.95)
Int:
97
(1.93)
Hospital mortality (per 1000 admissions)Kutty 201873 NRUSA38YNAll inpatientsInterrupted time series (retrospective)180
(60 before, 120 after)
N/AN/AOR=0.94
(0.93 to 0.95)
0.9820
PICU mortality
PICU mortality after PICU admission from ward (per PICU admission)Anwar-al-Haque, 201018 Paediatric RRT triggering criteria (b)Pakistan1YNAll inpatientsUncontrolled before-after study (retrospective)18
(9 before, 9 after)
23
(51.11)
5
(15.63)
RR=0.31
(0.13 to 0.72)†
0.0076
PICU mortality after PICU readmission within 48 hours of discharge (per 1000 admissions)Kotsakis 201163 Modified Melbourne Activation CriteriaCanada4YNAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
16
(0.29)
7
(0.13)
RR=0.43
(0.17 to 0.99)
<0.0518
PICU mortality after urgent PICU admission from ward (per 1000 admissions)Kotsakis 201163 Modified Melbourne Activation CriteriaCanada4YNAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
70
(1.3)
61
(1.1)
RR=0.90
(0.70 to 1.00)
0.2518
Death prior to discharge (per unplanned PICU transfer)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
51
(6.3)
56
(6.5)
RR=1.03
(0.72 to 1.49)†
0.9923
PICU mortality (per PICU admission)Duns 201466 Between the Flags (BTS) tool*Australia1YYAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
30
(8.57)
20
(5.49)
RR=0.64
(0.37 to 1.11)†
0.147
Death in PICU (per 1000 patient-days)Agulnik 201767 Children’s Hospital Cardiac Early Warning Score (C-CHEWS)Guatemala1YNOncology unitUncontrolled before-after study (retrospective)24
(12 before, 12 after)
21
(1.25)
22
(1.10)
RR=0.89
(0.49 to 1.61)†
0.7619
Death in PICU (per emergency PICU admission)Sefton 201568 Modified Bristol PEWT (a)UK1YNAll PICU admissionsControlled before-after study (retrospective)24
(12 before, 12 after)
17
(10.8)
14
(8.4)
RR=0.78
(0.40 to 1.53)†
0.4716
Deaths in PICU (per unplanned PICU admission)Kolovos 201869 RRT activation criteria*USA1YNAll unplanned PICU admissionsUncontrolled before-after study (retrospective)78
(42 before, 36 after)
54†
(4.9)
40†
(3.8)
RR=0.77
(0.52 to 1.15)†
0.20†12
PICU mortality (per 1000 discharges)Parshuram 201864 Bedside PEWSBelgium, Ireland, The Netherlands, England, Italy, Canada, New Zealand21YNAll inpatientsCluster randomised trial (prospective)18
(6 pre,
12 post)
Con:
34
(0.73)
Con:
91
(0.96)
OR=0.95
(0.48 to 1.86)
0.8823
Int:
33
(1.24)
Int:
56
(1.12)
Cardiac arrest
Cardiac arrests on ward (per 1000 admissions)Tibballs 200513 Melbourne Activation CriteriaAustralia1YNAll inpatientsUncontrolled before-after study (prospective)53
(41 before, 12 after)
20
(0.19)
4
(0.11)
RR=0.58
(0.20 to 1.70)
0.3310
Cardiopulmonary arrests (per 1000 non-ICU patient-days)Brilli 200715 Paediatric medical emergency team triggering criteria (a)USA1YNAll inpatientsUncontrolled before-after study (prospective)27
(15 before, 12 after)
7
(0.08)
2
(0.04)
RR=0.50
(0.10 to 2.42)†
0.1114
Ward cardiac arrest rate (per 1000 ward admissions)Hanson 201061 Not described USA1YNAll inpatientsUncontrolled before-after study (retrospective)36
(24 before, 12 after)
11
(1.27)
2
(0.45)
RR=0.35
(0.08 to 1.58)†
0.1318
Ward cardiopulmonary arrests (per 1000 patient-days)Hunt 200816 Paediatric medical emergency team triggering criteriaUSA1YNAll inpatientsUncontrolled before-after study (prospective)24
(12 before, 12 after)
5
(0.10)
5
(0.10)
RR=0.98
(0.22 to 4.24)
0.9717
Preventable cardiac arrests (per 1000 admissions)Tibballs 200962 Melbourne Activation CriteriaAustralia1YNAll inpatientsUncontrolled before-after study (prospective)89
(41 before, 48 after)
17
(0.16)
10
(0.07)
RR=0.45
(0.20 to 0.97)
0.04 15
Unexpected cardiac arrests (per 1000 admissions)Tibballs 200962 Melbourne Activation CriteriaAustralia1YNAll inpatientsUncontrolled before-after study (prospective)89
(41 before, 48 after)
20
(0.19)
24
(0.17)
RR=0.91
(0.50 to 1.64)
0.7515
Actual cardiopulmonary arrests (per 1000 ward admissions)Kotsakis 201163 Modified Melbourne Activation CriteriaCanada4YNAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
69
(1.9)
66
(1.8)
RR=0.95 (0.76 to 1.96)0.6818
Near cardiopulmonary arrests (per 1000 admissions)Kotsakis 201163 Modified Melbourne Activation CriteriaCanada4YNAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
123
(3.4)
67
(1.9)
RR=0.54
(0.52 to 0.57)
<0.00118
Cardiac arrests on ward (per 1000 non-ICU patient-days)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
6†
(0.03)
2†
(0.01)
RR=0.36
(0.07 to 1.78)†
0.2123
Cardiac arrests (per 1000 patient-days)Parshuram 201864 Bedside PEWSBelgium, Ireland, The Netherlands, England, Italy, Canada, New Zealand21YNAll inpatientsCluster randomised trial (prospective)18
(six pre,
12 post)
Con:
18
(0.11)
Con:
32
(0.10)
RR=1.02
(0.65 to 1.62)
0.9223
Int:
15
(0.12)
Int:
27
(0.11)
Respiratory arrest
Ward respiratory arrests (per 1000 patient-days)Hunt 200816 Paediatric medical emergency team triggering criteriaUSA1YNAll inpatientsUncontrolled before-after study (prospective)24
(12 before, 12 after)
11
(0.23)
3
(0.06)
RR=0.27
(0.07 to 0.95)
0.04 17
Cardiac or respiratory arrest
Cardiac or respiratory arrest (per 1000 discharges)Zenker 200760 RRT activation criteria*USA1YNAll inpatientsUncontrolled before-after study (prospective)34
(23 before, 11 after)
180
(7.98)
60
(5.13)
RR=0.64
(0.48 to 0.86)†
0.1912
Code calls (per 1000 non-ICU patient-days)Brilli 200715 Paediatric medical emergency team triggering criteria (a)USA1YNAll inpatientsUncontrolled before-after study (prospective)27
(15 before, 12 after)
25
(0.27)
6
(0.11)
RR=0.42
(0.17 to 1.03)†
0.06†14
Code calls (per 1000 non-ICU patient-days)Sharek 200717 Paediatric RRT triggering criteriaUSA1YNAll inpatientsUncontrolled before-after study (prospective)84
(67 before, 17 after)
53
(0.52)
5
(0.15)
RR=0.29
(0.10 to 0.65)
0.008 15
Code calls (per 1000 admissions)Anwar-al-Haque 201018 Paediatric RRT triggering criteria (b)Pakistan1YNAll inpatientsUncontrolled before-after study (retrospective)18
(9 before, 9 after)
26
(5.25)
12
(2.73)
RR=0.52
(0.26 to 1.03)
0.066
Calls for urgent review/assistance
Urgent calls to respiratory therapist (per 1000 patient-days)Parshuram 201170 Bedside PEWSCanada1NNAll inpatientsUncontrolled before-after study (prospective)8
(3 before, 5 after)
8
(9.5)
8
(3.4)
RR=0.36
(0.13 to 0.95)†
0.0423
Urgent calls to paediatrician (per 1000 patient-days)Parshuram 201170 Bedside PEWSCanada1NNAll inpatientsUncontrolled before-after study (prospective)8
(3 before, 5 after)
19
(22.6)
12
(5.1)
RR=0.23
(0.11 to 0.46)†
<0.000123
Code blue calls on the ward (per 1000 admissions)Kotsakis 201163 Modified Melbourne Activation CriteriaCanada4YNAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
210
(3.75)
150
(2.70)
RR=0.71
(0.61 to 0.83)
<0.000118
Urgent calls to outreach team (per 1000 admissions)Duns 201466 Between the Flags tool*Australia1YYAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
1058
(39.5)
2120
(76.0)
RR=1.92
(1.79 to 2.07)†
0.02 7
RRT calls (per 1000 patient-days)Panesar 201471 Modified Brighton PEWS (e)USA1YYAll inpatientsUncontrolled before-after study (retrospective)42
(18 before, 24 after)
44
(3.14)
69
(4.23)
RR=1.35
(0.92 to 1.96)†
0.1115
RRT calls (per 1000 patient days)Douglas 201672 Modified Brighton PEWS (b)USA1YYAll inpatientsUncontrolled before-after study (retrospective)24
(12 before, 12 after)
194
(6.17)
292
(9.80)
RR=1.59
(1.33 to 1.90)†
<0.00112
Code calls (per 1000 patient days)Douglas 201672 Modified Brighton PEWS (b)USA1YYAll inpatientsUncontrolled before-after study (retrospective)24
(12 before, 12 after)
31
(0.98)
20
(0.67)
RR=0.68
(0.39 to 1.19)†
0.2112
PICU transfers
Transfers from ward to other specialist units (per 1000 patient-days)Parshuram 201170 Bedside PEWSCanada1NNAll inpatientsUncontrolled before-after study (prospective)8
(3 before, 5 after)
5
(5.9)
19
(8.1)
RR=1.37
(0.51 to 3.63)†
0.54†23
Clinical deterioration events on ward prior to transfer to specialist unit (per 1000 patient-days)Parshuram 201170 Bedside PEWSCanada1NNAll inpatientsUncontrolled before-after study (prospective)8
(3 before, 5 after)
2
(2.4)
1
(0.43)
RR=0.18
(0.02 to 1.97)†
0.16†23
PICU transfers (per 1000 admissions)Duns 201466 Between the Flags tool*Australia1YYAll inpatientsUncontrolled before-after study (prospective)48
(24 before, 24 after)
350
(13.1)
364
(13.1)
RR=1.00
(0.86 to 1.16)†
0.987
Unplanned PICU transfers from ward (per 1000 non-ICU patient-days)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
874
(4.54)
936
(5.25)
IRR=0.73
(0.46 to 1.14)
0.1623
Unplanned transfers to PICU from ward (per 1000 patient-days)Agulnik 201767 Children’s Hospital Cardiac Early Warning ScoreGuatemala1YNOncology unitUncontrolled before-after study (retrospective)24
(12 before, 12 after)
157
(9.3)
130
(6.5)
RR=0.70
(0.56 to 0.88)†
0.003 19
Urgent PICU admissions (per 1000 patient-days)Parshuram 201864 Bedside PEWSBelgium, Ireland, The Netherlands, England, Italy, Canada, New Zealand21YNAll inpatientsCluster randomised trial (prospective)18
(6 pre,
12 post)
Con:
652
(4.01)
Con:
1178
(3.83)
RR=0.95
(0.82 to 1.09)
0.4523
Int:
469
(3.62)
Int:
828
(3.29)
PICU outcomes
Critical deterioration events after PICU transfer (per 1000 non-ICU patient-days)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
260†
(1.35)
282†
(1.58)
IRR=0.38
(0.20 to 0.75)
0.01 23
Mechanical ventilation within 1 hour of unplanned PICU transfer (per unplanned transfer to PICU)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
45
(5.1)
42
(4.5)
RR=0.87
(0.58 to 1.31)†
0.5123
Mechanical ventilation within 12 hours of unplanned PICU transfer (per unplanned transfer to PICU)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
112
(12.8)
103
(11.0)
IRR=0.17
(0.07 to 0.44)
<0.001 23
Vasopressors within 1 hour of unplanned PICU transfer (per unplanned transfer to PICU)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
41
(4.7)
16
(1.7)
RR=0.36
(0.21 to 0.64)†
<0.001 23
Vasopressors within 12 hours of unplanned PICU transfer (per unplanned transfer to PICU)Bonafide 201465 Bedside PEWSUSA1YNAll inpatientsInterrupted time series study (prospective)59
(32 before, 27 after)
71
(8.1)
57
(6.1)
IRR=0.20
(0.06 to 0.62)
0.006 23
Invasive ventilation in PICU (per emergency PICU admission)Sefton 201568 Modified Bristol PEWT (a)UK1YNAll PICU admissionsControlled before-after study (retrospective)24
(12 before, 12 after)
118
(75.2)
104
(62.7)
RR=0.83
(0.72 to 0.97)†
0.002 16
Inotropes in PICU (per emergency PICU admission)Sefton 201568 Modified Bristol PEWT (a)UK1YNAll PICU admissionsControlled before-after study (retrospective)24
(12 before, 12 after)
50
(31.8)
40
(24.1)
RR=0.76
(0.53 to 1.08)†
0.1216
Intubation within 24 hours of PICU admission (per 1000 patient-days)Agulnik 201767 Children’s Hospital Cardiac Early Warning ScoreGuatemala1YNOncology unitUncontrolled before-after study (retrospective)24
(12 before, 12 after)
11
(0.65)
18
(0.90)
RR=1.38
(0.65 to 2.92)†
0.4619
Vasopressors within 24 hours of PICU admission (per 1000 patient-days)Agulnik 201767 Children’s Hospital Cardiac Early Warning ScoreGuatemala1YNOncology unitUncontrolled before-after study (retrospective)24
(12 before, 12 after)
29
(1.72)
37
(1.86)
RR=1.08
(0.66 to 1.75)†
0.6019
Mechanical ventilation during PICU admission (per PICU admission)Kolovos 201869 RRT activation criteria*USA1YNAll unplanned PICU admissionsUncontrolled before-after study (retrospective)78
(42 before, 36 after)
285
(25.98)
233
(22.09)
RR=0.85
(0.73 to 0.99)†
0.0312
Intubation within 1 hour of PICU admission (per PICU admission)Kolovos 201869 RRT activation criteria*USA1YNAll unplanned PICU admissionsUncontrolled before-after study (retrospective)78
(42 before, 36 after)
49
(4.47)
88
(8.34)
RR=1.87
(1.33 to 2.62)
0.0003 12
Significant clinical deterioration events (per 1000 patient-days)Parshuram 201864 Bedside PEWSBelgium, Ireland, The Netherlands, England, Italy, Canada, New Zealand21YNAll inpatientsCluster randomised trial (prospective)18
(6 pre,
12 post)
Con:
144
(0.89)
Con:
259
(0.84)
RR=0.77
(0.61 to 0.97)
0.03 23
Int:
80
(0.62)
Int:
127
(0.50)
  • P values in bold denote statistical significance (<0.05).

  • A critical deterioration event is defined as transfer to the ICU followed by non-invasive or invasive mechanical ventilation or vasopressor infusion within 12 hours.65

  • *Indicates a PTTT not described or validated in the published literature.

  • †Data calculated by research team, based on data presented in the journal article. All data calculated via https://www.medcalc.org.

  • Con, control group; ED, emergency department; ICU, intensive care unit; Int, intervention group; IRR, incident risk ratio; MET, medical emergency team; N/A, not available; PICU, paediatric intensive care unit; PTTT, paediatric track and trigger tool; RR, relative risk; RRT, rapid response team.