Table 4

Summary of planning evidence

Evidence contribution
Abraham et al 91 USAPre/postprospective studyThe quality and completeness of the handoff note—both tools—was assessed by a multiprofessional round.Structured handoverValue of a checklist tool for handover
Brady and Goldenhar63 USA.Focus groups ×7—held in groups of participants with similar rolesConstant comparisonSituational awarenessHuddle useful to proactively identify and plan for risk.
Structure to support handover important.
Brady et al 88 USAStatistical process control chartsSituational awarenessHuddles led by a watchstander charge nurse. When risk is identified the team discussed this and developed a plan to mitigate risk.
Claussen et al 65 USARetrospective review of calls to the rapid response team (RRT) and cardiac arrest calls to evaluate impact of evidence-based guidelinesDescriptive statisticsElectronic systemsThe huddle was seen as useful and was called as a patient’s status was changing to ‘red’ so that all team members were informed.
Davies et al 53 USASurvey looking at barriers to rapid response system (RRS) activationStatistical analysisEWSActivation criteria displayed around the hospital
Demmel et al 58 USADiscussion of the set-up and implementation of a paediatric early warning scoring tool and an associated algorithmRapid
Plan-Do-Study-Act (PDSA) cycles were implemented using small tests of change. The data from the PDSA cycles were continuously collected, analysed and reviewed with the multidisciplinary staff and planning team and used to give ongoing direction to the implementation plan.
PEWSImportance of common information spaces and display of activation criteria throughout the hospital
Donahue et al 92 USAFocus group evaluation of a training programme which was developed to teach paraprofessionals Situation-Background-Assessment-Recommendation (SBAR) communication toolNot clearStructured handoverValue of a structured approach to handover.
Adaptation of the SBAR tool for handover.
Ennis23 IrelandDescription 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 protocolPEWSCommon information spaces important and display of activation criteria throughout the hospital.
Usefulness of ISBAR as a communication tool.
Goldenhar et al 87 USASemistructured interviews and focus groups to develop a deeper understanding of a newly implemented huddle systemConstant comparisonSituational awarenessImportance of the huddle—empowerment and sense of community; facilitated greater and better information sharing.
Each huddle participant was asked to systematically report on patients in their units who they thought would deteriorate in the near future and to label them as ‘watchers’, asking senior nurses and physician leads to coach charge nurses on how to integrate their perceptions into an informal severity of illness assessment (comprehension) and training the clinicians on how to use the information to facilitate prediction and planning for at-risk patients (projection).
Mackintosh et al 47 UKEthnographic
two-stage process of lightly structured observations followed by a more focused period of data generation to test and elaborate the outcomes from stage 1
Initial thematic analysis and search for negative casesSituational awarenessFor teams with a strong level of situation awareness (SA), key supports were all used in a balanced and supportive manner to gather and disseminate information which served to promote a culture of shared ownership and a proactive model of workload management, with temporary disruptions to the model easily accommodated.
Whiteboard—when used effectively was a vital means for supporting SA. It provides teams with a snapshot of a constantly changing workload, the team’s activity levels and resource availability. Workload at times compromised its effectiveness. And irrespective of workloads, location and local traditions had a bearing on its use and usefulness.
Whiteboards need to be in a visible location.
Importantly, the interplay between these key supports for SA will vary depending on the context; the same supports used differently will naturally produce different outcomes.
Handover took many forms: structured and informal; profession specific and interprofessional; participatory or a one-way transmission of information. The effectiveness of SA was dependent on the form that handover took—who was present, contributions made, information relayed. SA was more likely to be compromised when key people were absent.
Senior staff coordinator important for SA and became compromised if they were largely focused on providing patient care.
Mackintosh et al 27 UKComparative case study—an RRS using ethnographic methods including observations, interviews and documentary reviewInductive 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’.EWSAvailability of equipment was an issue where the track and trigger tool (TTT) was electronic.
Electronic systems helped HCAs and nursing staff to share understandings, planning and manage their workload.
Massey et al 67 AustraliaIn-depth semistructured interviewsInductive approach—thematic analysisEWSCommon information spaces useful. Display of activation criteria throughout hospital.
McCrory et al 54 USAProspective, preinterventional and postinterventional study to evaluate the educational intervention of teaching ABC-SBAR (airway, breathing, circulation followed by situation,background, assessment, and recommendation)Two blinded reviewers assessed 52 video-recorded handoffs for inclusion, order and elapsed time to essential handoff information using a scoring tool.Structured handoverInformation sharing for handovers is of variable quality.
A more structured approach will improve information sharing and therefore situational awareness—‘without a structured hand-off tool, paediatric interns overemphasise background information and leave the reason for the call delayed’.
Adaptation of the SBAR tool to include ABC—usefulness of this.
Mullan et al 93 USADescriptive observational studyChecklists were evaluated for rates of use, completion and identification of potential safety events.Situational awarenessThe value of more structured approach to information sharing and situational awareness.
Uses a checklist handover system for physicians. Checklist items focused on the status of the patient, ED providers and hospital resources. A ‘Read-Do’ format was designed.
Parker et al 89 USAManual review of all eligible patient recordsDescriptive statisticsPEWSExample of a bundle around the ‘watcher’ category with five components that needed to be completed within 2 hours of a patient being designated as such.
Pearson and Duncan30 UKBrief review of the evidence base surrounding paediatric early warning scoresN/APEWSValue of a more structured approach to communication—advocate the use of a shared communication model, such as SBAR, to communicate findings to superiors.
Pezzolesi e t al 90 UKDelphi study for tool developmentDescriptive statistics.
Handovers were analysed and rated according to a measure of essential skills.
Situational awarenessInformation on handover—can be of variable quality.
Most handover tools are adaptations of SBAR) communication tool.
Important to remember that handover facilitates teamwork and this hinges on communicative forms that extend beyond the information transfer that is typically the focus of structured handover tools.
Randhawa et al 55 USADescription of the implementation process with cardiopulmonary arrest (CPA) statistics before and after implementationOnce a cycle from the implementation has been completed this is evaluated and then another cycle begins.PEWSWhiteboards placed in a central location displayed scores of all patients so that staff could quickly assess which patients were at high risk for deterioration.
Activation criteria displayed throughout the hospital.
Stewart et al 32 SwedenMixed methods. Retrospective review of records and nurse-led focus groups.Statistical analysis and content analysisEWSHuddle—the score was used during the daily bed ‘huddle’ with the nursing administrators to evaluate current unit acuity, determine staffing need and prepare for any transfers.
Van Voorhis and Willis33 USADiscussion paper highlighting the process of developing a paediatric RRSN/APEWSDisplay of activation criteria throughout the hospital on lanyards and use of whiteboards useful
de Vries et al 86 NetherlandsSemistructured interviewQualitative content analysisPEWSPaediatric early warning score/TTT is used to support situational awareness. Use of a score enables clinicians to have a 'bird’s-eye' view over admitted patients.
Wager et al 84 USAObservational study.
Explored the timeliness and quality of vital signs data entered by three different recording methods.
Descriptive statisticsElectronic systemsBatching of patient data whereby the care provider handwrites the patient’s vital signs and uploads it to the computer at a later time is common, especially as the computers are often busy.
Watson et al 45 USAMixed methods, retrospective medical record observations and observations of nurse interactionsObservation analysis, although this is not described, and statistical analysisPEWSAvailability of equipment is a factor.
Weiss et al 94 CanadaA randomised controlled trial in an academic paediatric intensive care unit (PICU) of 20 handover eventsDifferences between intervention and control groups were assessed using the Mann-Whitney test and multivariate linear regression.Structured handoverValue of a more structured approach to support information sharing—a cognitive aid to facilitate handover that prompted residents to transmit this information. The handover aid was not linked to hospital information systems—so this had to be completed by hand before handover.
Handover is an opportunity for learning and professional socialisation.
Wong e t al 95 UKDescription of user-focused design process for use of electronic monitoring and numbers of observations taken using the system. Acceptability questionnaire.Descriptive statistics on the number of observations recorded using the SEND system and the number of active usersElectronic systemsDevelopment of a flexible electronic system which enabled staff to have an overview of patients—reflections on disconnection
  • ED, emergency department; EWS, early warning system; HCA, healthcare assistant; N/A, not applicable.