Table 5

Summary of action evidence

Author	Country	Methodology	Analysis	Search area	Evidence contribution
Adelstein et al 49	Australia	Prospective comparison of rapid response team (RRT) criteria breaches	Statistical	EWS	Day/night differences in activation identified. Nurses may not understand what is required for activation. Staff not investing in calling criteria.
Almblad et al 8	Sweden	Retrospective review of the electronic patient record and a context assessment of the work environment using the Alberta Context Tool	Statistical	Snowball sample	Senior leadership consistently identified as important.
Andrews and Waterman19	UK	Interviews and observations	Grounded theory	EWS	Track and trigger tools (TTT) act as prompts to action. TTT used to overcome challenges in communication and particularly valuable for junior staff. Negative attitude towards calling for help.
Astroth et al 50	USA	Semistructured interviews with nurses	Coding categories were generated from the data, and consensus on final themes was achieved through an iterative process.	EWS	Situation under control—no need to escalate or perceived business of medical staff discouraged staff from RRT activation. Staff encouraged to use their intuition when activating the RRT. Concern about feeling inadequate in front of colleagues a barrier to RRT activation. Inexperienced staff teaming up—led to staff trusting their own judgement. Traditional hierarchies a barrier to RRT activation—nurses more likely to call the attending physician rather than activate the RRT.
Azzopardi et al 20	Australia	Survey	Statistical analysis	PEWS	Score rarely the determining factor in escalation—would not escalate for a patient who looked well but would escalate for a patient they were worried about even if not triggering. Negative attitude towards calling for help—feeling inadequate/perceived business of paediatric intensive care unit had an impact on doctors escalating but not nurses. Senior leadership is important when implementing a MET.
Bavare et al 104	USA	Retrospective observational study of rapid response events	Descriptive statistics	PEWS	All family-activated RRT had appropriate clinical triggers with the most common being uncontrolled pain. More than half of Family-Initiated pediatric rapid response (FIRR) had a vital signs change that should have qualified clinician-RRT activation. Seventy-six per cent FIRRs needed at least one or more interventions. Twenty-seven per cent of family-initiated RRTs needed transfer to intensive care unit compared with 60% transfer rate for clinician RRTs.
Bogert et al 98	USA	Implementation of Condition Help (ConditionH)	Descriptive statistics	Family involvement	Implementation of ConditionH. ConditionH being addressed during daily rounds.
Bonafide et al 21	USA	Semistructured interviews	Grounded theory	PEWS	Disinclination to seek help and concerns about appearing inadequate in front of colleagues. Informal peer support. Senior leadership important.
Braaten22	USA	Document review and interviews using the principles of cognitive work analysis	Inductive and deductive forms of analysis—cognitive work analysis, framework and directed content analysis	EWS	Issues around availability of equipment and staffing. Negative attitude/delays around calling for help with staff needing to justify escalation. Other factors impact on this including the perception that the situation is under control/perceived business of physicians/not wanting to appear inadequate.
Brady et al 88	USA.		Statistical process control charts	Situational awareness	Concerns about resources reported
Brady et al 102	USA	A retrospective cohort study looking at the association between family and clinician activations and transfer to the intensive care unit following a MET call	Quality improvement methods and statistical process control charts were used to assess the rate of family activation of METs.	Family involvement	Direct mechanism for families to activate a MET. Concerns from clinicians about a family-activated MET overburdening the system are unfounded.
Chua et al 36	Singapore	A qualitative survey using critical incident technique	Inductive content analysis	EWS	Staff felt that they had not been educated to an adequate level—training lacking. Negative attitude towards calling for help—fears of appearing inadequate.
Cioffi48	Australia	Unstructured interviews with nurses who had activated the medical emergency team (MET)	Simple code and retrieve	EWS	Reluctance to activate—doubting ability; fears of appearing inadequate; decisions made based on the perceived availability of resources/business of medical staff/time of day all had an impact on decisions to activate the MET. Importance of having staff concern in the MET criterion.
Cioffi51	Australia	Unstructured interviews	Simple code and retrieve	EWS	Importance of having staff concern in a calling criteria. Reluctance to activate—business of ward a factor.
Cioffi et al 42	Australia	Focus groups with clinicians and nurses exploring their responses to abnormal vital signs	Constant comparison	EWS	Availability of equipment an issue/staffing pressures; staff unable to carry out routine monitoring that would enable the detection of abnormal vital signs (AVS)/escalation hampered because of difficulty finding the appropriate senior person. . MET criteria used to confirm or identify deterioration depending on experience. Negative attitude towards asking for help—lack of confidence questioning peers/fear of being reprimanded/feeling the situation was under control.
de Groot et al 62	Netherlands	Retrospective patient review and semistructured interviews with professionals	Descriptive statistics and grounded theory	PEWS	Easily approachable nurses and physicians, as well as good communication, were considered to be vital for timely intervention in cases of clinical deterioration in paediatric patients. Facilitators for the implementation of registration ofpaediatric early warning score included the integration of scores into the electronic patient records.
Dean et al 99	USA	Two-year reflection following implementation of ConditionH	Descriptive statistics	Family involvement	ConditionH criteria for activation. Concern that family-activated RRS could divert attention away from resources. Clinician involvement important. Daily ‘patient rounds’ involving patients and families is useful. Patients and families have access to relevant information and understand the medical information and care plans.
Demmel et al 58	USA	Discussion of the set-up and implementation of a paediatric early warning scoring tool and an associated algorithm	Rapid Plan-Do-Study-Act (PDSA) cycles were implemented using small tests of change.	PEWS	Education package developed around the history and development of paediatric early warning scores along with the rationale for and the goals of the initiative. The scoring process was explained and how it would be integrated into routine nursing assessments; normal vital sign parameters were reviewed. Importance of common information spaces and display of activation criteria throughout the hospital. Senior lead commitment and importance of champions integral for implementation.
Donohue et al 64	UK	Qualitative design with critical incident technique. Semistructured interviews with nurses and the outreach team.	Thematic analysis	EWS	Some resistance to escalation—clinicians preferring to deal with patient problems within their own team. Inexperienced staff teaming up with more experienced staff once patient deterioration was recognised.
Downey et al 74	UK	Narrative review	‘Patterns were identified and translated to themes, which were further refined using an iterative process.’	PEWS	Impact on communication—packaging information. Facilitates communication across hierarchies.
Endacott and Westley39	Australia	Questionnaire, in-depth interviews and observations	Content analysis and constant comparison	EWS	Art of referral important—using the right language and suggesting actions that would be acceptable to the doctor. Availability of equipment a factor. Negative attitude towards calling for help; escalation dependent on perceived capability of medical staff.
Ennis23	Ireland	Description of implementation of paediatric early warning score and subsequent audit (prospective cohort observational study)	Simple descriptive statistics of numbers of children triggering the paediatric early warning score and compliance with escalation protocol	PEWS	Structured education and training programme on the use of Identify-Situation-Background-Assessment-Recommendation (ISBAR) and paediatric early warning score was provided and nurse manager/staff nurse in charge should review any educational requirements in completing the paediatric early warning score particularly for relief staff. Common information spaces important and display of activation criteria throughout the hospital. Usefulness of ISBAR as a communication tool. Senior lead commitment—paediatric early warning score management policy developed/senior staff promote and reinforce use of the tool
Entwistle73	USA	Editorial	N/A	Family involvement	Little evidence/no evaluations of policies or practices that encourage and support family involvement in clinical monitoring. Propose the innovative practice of interdisciplinary rounds where families are invited, and communication is directed to the patient and family.
Gerdik et al 103	USA	Routine data collection for number of RRT calls and the result of these activations and patient/family survey relating to RRT activation	Statistical analysis	Family involvement	Direct mechanism for families to activate the RRT. Barriers to family activation highlighted, specifically professional resistance. Physician and leadership support important to overcome barriers.
Gill et al 97	Australia	Commentary drawing together family-centred care concepts, the National Safety and Quality Healthcare Service (NSQHS) Standardsand the development of family-initiated care in Australia	N/A	PEWS	Family-activated RRTs now increasingly common in Australia. In the first instance, families need to be aware of the policy. Stress the importance of understanding the number and nature of the call. Reports on health professional’s resistance to it. Families need vigilance to escalate care. Need resources in order to negotiate hierarchies and boundaries.
Greenhouse et al 100	USA focus	Discussion about the implementation of ConditionH	Descriptive statistics	Family involvement	Appropriateness of calls is reported rather than why they are made. Note some scepticism and wariness among nurses and physicians.
Hueckel et al 101	USA	Scripted family teaching about RRT activation at the time of patient admission from ConditionH	Descriptive statistics about delivery of educational programme and RRT call-out; survey testing family understanding	Family involvement	Description of Condition Help. Appropriateness of calls is reported rather than why they are made.
James et al 37	UK	Postal survey with healthcare assistants (HCA) using closed and open questions	Descriptive statistics and content analysis of qualitative data	Observations and monitoring	Workload and ward distractions a barrier to activation, such as time spent locating equipment. Disinclination to seek help from senior staff/clinicians.
Jensen et al 46	Denmark	Focus group exploring nurses’ experiences witha paediatric early warning score	Qualitative meaning condensation analysis	PEWS	Paediatric early warning score as a nursing tool and therefore not valued by medic—no universal language because of this; ‘when you call and say that they have a score of 5, then they don't know what 5 means’ (FG2 P1).
Kaul et al 24	USA	Descriptive cross-sectional study; nurse and medical staff survey	Descriptive statistics	PEWS	Noted that the score provides a ‘universal language’ and interdisciplinary communication
Lobos et al 25	Canada	Implementation discussion	Simple descriptive statistics	PEWS	Situation-Background-Assessment-Recommendation (SBAR) helps establish a common language and guide escalated events. Negative attitude towards calling for help—traditional hierarchies a barrier to activation/concerns about communication between primary and responding team. No false alarms and debriefing useful. Importance of champions (using a social marketing approach) to encourage ‘inter-professional collaboration & advisory group to help establish a sense of ownership’. Lack of support from superiors means less likely to escalate.
Mackintosh et al 27	UK	Comparative case study—a rapid response system (RRS) using ethnographic methods including observations, interviews and documentary review	Inductive and deductive coding facilitated by NVivo. Also used theme building and structuring methods from framework analysis while also informed by other theoretical frameworks such as ‘technology-in-practice’.	EWS	Availability of equipment an issue where the TTT was electronic. Gave junior staff licence to escalate care. Additionally, ‘while standardisation of practice clearly has its beneﬁts, it also comes at a cost that these tools attenuate lower level staff’s authority and ability to persuade staff higher up in the organisation of the credibility of their knowledge’ (p 143). Efforts to develop junior staff’s communication and clinical understanding need to acknowledge power dynamics at play. Usefulness of SBAR communication tool as part of the escalation policy as reported by staff (not seen in action). Negative attitude towards escalation—difficulty in summoning a response. Senior lead commitment to patient safety was important. Zero tolerance for cardiac arrest was championed by senior staff. Night-time/out-of-hours pressures identified.
Mackintosh et al 38	UK	Ethnographic perspective; observations, semistructured interviews	Data were inductively and deductively coded and organised thematically.	EWS	Negative attitude towards seeking help. Escalating care outside the parameters marked by a track and trigger tool proved difficult; power struggles identified—junior staff have difficulty persuading more senior staff of the credibility of their knowledge. Difficulties in activation across professional boundaries.
Massey et al 67	Australia	In-depth semistructured interviews	Inductive approach—thematic analysis	EWS	Common information spaces useful. Display of activation criteria throughout hospital. General negative attitude towards calling for help—appearing inadequate in front of others. Importance of leadership support. Peer support—would often consult their colleagues.
McCabe et al 35	UK	Opinion piece about lessons to be learnt from the adult experience of implementing early warning systems	N/A	PEWS	Specific education package needed on how to use an early warning system (EWS) and on basic clinical assessment, guidance and standardisation of observation and monitoring. Advocate situational simulated scenario education and e-learning. Highlight the usefulness of communication tools such as SBAR for establishing roles and responsibilities, engaging them in making an appropriate management plan that can, if necessary, be escalated. Senior lead commitment key—reflected in resources and education—to improve the safety and quality of care of hospitalised patients. Families need to be empowered to request a patient review.
McDonnell et al 26	UK	Single-centre, mixed methods before-and-after study including a survey to measure changes in nurses’ knowledge after implementation of a track and trigger system (T&Ts). Also, qualitative interviews.	Statistical analysis and thematic framework analysis	EWS	Rolling education programme for all nurses on the recognition and response to deteriorating patients and an overview of the T&Ts. Workplace pressures; nurses concerned that they could not always summon a timely response from doctors/night-time pressures also identified. Need for staff concern in T&Ts.
Monaghan28	UK focus	Commentary on the development of the Brighton paediatric early warning score and setting up a paediatric critical care outreach team	Simple descriptive statistics of all activations, actions and outcomes during the first 3 months of implementation	PEWS	Education-based model was developed to assist in recognising deterioration. Temporary staff/workplace pressures impact on staff’s ability to detect deterioration.
Paciotti et al 71	USA	Semistructured interviews with clinicians to explore physicians’ viewpoints on families facilitating the identification of children with a deteriorating condition	Grounded theory and constant comparison	Family involvement	Concerns that resources would be diverted away with an increase in calls—not supported
Pattison and Eastham29	UK	Mixed methods study looking at the impact of a critical care outreach team (CCOT)	Statistical analysis and grounded theory	EWS	Availability of equipment an issue/workload. Negative attitude towards calling for help—situation under control/ward business. Inexperienced staff teaming up/checking with peers before calling the CCOT.
Pearson and Duncan30	UK	Brief review of the evidence base surrounding the paediatric early warning score together with reflections from their own experiences from the Birmingham Children’s Hospital	N/A	PEWS	Team training and education is important increasing confidence in the use of medical language and empowering bedside carers. ‘Although doing observations is fundamental to nursing practice many … have not been taught a structured approach to assessment.’ Advocate a simulated environment. Value of a more structured approach to communication—advocate the use of a shared communication model such as SBAR to communicate findings to superiors. Need for senior commitment—cultural change may be required to ensure management support (reflected in resources and education)/importance of champions.
Salamonson et al 56	Australia	Survey with closed and open questions to examine perceptions of and satisfaction with the MET	Descriptive statistics and content analysis	EWS	Need for more education on deterioration identified. Negative attitude towards asking for help; attitude of MET team a barrier to activation.
Shearer et al 31	Australia	A multimethod study; a point prevalence survey; a prospective audit of all patients experiencing a cardiac arrest, unplanned intensive care unit (ICU) admission or death over an 8-week period. Structured interviews with staff to explore cognitive and sociocultural barriers to activation.	Iterative coding	EWS	Adequate staffing and a lack of beds on critical care leads to a failure to activate the RRS. Score rarely the single determining factor in activation despite the fact that staff recognised patients met activation criteria. Data from the point prevalence study confirm this as only one patient had a serious adverse event. Negative attitude towards calling for help—situation under control; treating team had expertise to treat (particularly when the physiological instability was in the area of expertise of the treating team). Traditional (intraprofessional clinical) hierarchies a barrier to activation.
Sønning et al 41	Norway	Questionnaire of a sample of staff who use a paediatric early warning score	Descriptive statistics	PEWS	Nurses gain self-confidence. More effective communication.
Stewart et al 32	Sweden	Mixed methods. Retrospective review of records and nurse-led focus groups.	Statistical analysis and content analysis	EWS	The RRS was valuable for junior staff escalating care across hierarchical and professional boundaries. Senior lead commitment—culture of support promoted by nursing administrators.
Van Voorhis and Willis 33	USA	Discussion paper highlighting the process of developing a paediatric RRS. The system was evaluated by prospectively collected data recorded on RRS activation forms and existing performance improvement database information.	N/A	PEWS	Display of activation criteria throughout the hospital on lanyards and use of whiteboards useful. Debriefing following activation and a commitment to no false alarms is encouraged. Senior lead commitment—administrative arm of the RRS vital. Uses Condition Help. The appropriateness of calls was facilitated by the ‘no false alarms’ culture.
de Vries et al 86	Netherlands	Semistructured interview	Qualitative content analysis	PEWS	Paediatric early warning score facilitated communication across hierarchies.
Watson et al 45	USA	Mixed methods, retrospective medical record observations and observations of nurse interactions in 1 min blocks	Observation analysis, although this is not described, and statistical analysis	PEWS	Availability of equipment a factor. Score rarely the determining factor in escalation. SBAR.

N/A, not applicable.