Table 3

Summary of detection evidence

Evidence contribution
Andrews and Waterman19 UKInterviews and observationsGrounded theoryEWSImportance of ‘gut feeling’ in detecting deterioration.
Vital signs monitoring delegated to junior staff.
Astroth et al 50 USASemistructured interviews with nursesCoding categories were generated from the data, and consensus on final themes was achieved through an iterative process.EWSStaff encouraged to use their intuition when activating the RRT
Azzopardi et al 20 AustraliaSurveyStatistical analysisPEWSTrack and trigger tools used to confirm or identify deterioration depending on experience. Useful for junior staff.
Vital signs monitoring delegated to junior staff.
Bellomo et al 79 International: USA, Sweden, UK, Netherlands, AustraliaBefore-and-after multicentred international controlled trialAutomated vital signs monitoring and early warning score calculated, international study, blinded trial, hospitals retained own early warning score and escalation policy.Electronic systemsThe electronic health record (EHR) provides a prompt to action.
Bonafide et al 21 USASemistructured interviewsGrounded theoryPEWSVital signs monitoring delegated to junior workers who may not have the knowledge to interpret results. Track and trigger tools used to confirm or identify deterioration depending on experience and particularly useful for junior staff.
Professional intuition important for senior staff to detect deterioration.
Bonafide et al 81 USAProspective feasibility studyVideo recording and electronic patient data collected prospectively. Pragmatic observational study of VitalPAC deployment in two large hospitals.Electronic systemsAlarm fatigue—a barrier to escalation
Bonafide et al 83 USAVideo review and response time outcomeStatistical analysisPEWSAlarm fatigue—a barrier to escalation
Braaten22 USADocument review and interviews using the principles of cognitive work analysisInductive and deductive forms of analysis—cognitive work analysis, framework and directed content analysisEWSVital signs monitoring delegated to junior workers who may not have the knowledge to interpret results.
Track and trigger tools used to confirm or identify deterioration depending on experience. Professional intuition important for more senior staff/when clinical change is abrupt.
Issues around availability of equipment and staffing.
Brady and Goldenhar63 USAFocus groups ×7—held in groups of participants with similar rolesConstant comparisonSituational awarenessPaediatric early warning score supplementing gut feeling but these were not standardised.
Burns et al 68 USASemistructured interviews were used drawing on a descriptive phenomenological methodology.Iterative thematic analysisSnowball sampleImportance of professional intuition is reported.
Chua et al 36 SingaporeA qualitative survey using critical incident techniqueInductive content analysisEWSVital signs monitoring is the responsibility of nurses. The regularity of this activity can lead to it being viewed as a mundane activity.
Importance of ‘gut feeling’ and intuition in detection of deterioration.
Cioffi48 AustraliaUnstructured interviews with nurses who had activated the medical emergency team (MET)Simple code and retrieveEWSImportance of gut feeling and ‘knowing’ your patient in the detection of deterioration.
Importance of having staff concern in the MET criterion.
Cioffi51 AustraliaUnstructured interviewsSimple code and retrieveEWSImportance of gut feeling and intuition in recognising deterioration.
Importance of having staff concern in a calling criteria.
Cioffi et al 42 AustraliaFocus groups with clinicians and nurses exploring their responses to abnormal vital signsConstant comparisonEWSIntuition important, particularly for more senior staff to detect AVS. Knowing your patient reported as key; knowledge and experience seen as essential.
Claussen et al 65 USARetrospective review of calls to the rapid response team (RRT) and cardiac arrest calls to evaluate impact of evidence-based guidelines (preintervention).Modified Early Warning Score and huddle implemented. EHR available throughout to compare pre and post.Descriptive statisticsElectronic systemsProfessional intuition used in conjunction with the Modified Early Warning Score
Davies et al 53 USASurvey looking at barriers to rapid response system (RRS) activationStatistical analysisEWSProfessional intuition used over RRS activation criteria—barrier to activation
de Groot et al 62 NetherlandsRetrospective patient review and semistructured interviews with professionalsDescriptive statistics and grounded theoryPEWSImportance of professional intuition is reported.
Donohue et al 64 UKQualitative design with critical incident technique.
Semistructured interviews with nurses and the outreach team.
Thematic analysisEWSImportance of gut feeling and intuition in detecting deterioration
Downey et al 74 UKNarrative review‘Patterns were identified and translated to themes, which were further refined using an iterative process.’PEWSDrive towards automated alerts
Endacott et al 43 UKMixed methods case study—semistructured interviews and audit of chartsQualitative content analysis and descriptive statisticsObservations and monitoringGut feeling important—interestingly particularly for nurses whereas doctors sought additional empirical evidence to back up intuition.
Endacott and Westley39 AustraliaQuestionnaire, in-depth interviews and observationsContent analysis and constant comparisonEWSIntuition and anticipatory skills important in detecting deterioration
Entwistle73 USAEditorialN/AFamily involvementLittle 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.
Fagan et al 82 USAObservational cohort comparison studyDescriptive statisticsElectronic systemsConcerns about overburdening staff with automated alerts.
When considering the patient’s baseline, nursing staff are expected to notify the patient’s care provider immediately responsible for the patient when the vital signs meet or exceed the clinical trigger.
Graedon and Graedon72 USA focusOpinion pieceN/AFamily involvementParents to explain child’s baseline.
Need to have detailed information about signs and symptoms that they should look for that would require alerting the medical team.
Propose the need for structured inclusion of family concern during ward rounds (safety walkrounds).
Hands et al 44 UKThe vital signs (VS) and early warning data for all inpatients for 1 year to investigate patterns of VS observations collectedStatisticalObservations and monitoringStaffing levels and availability of equipment impede the collection of vital signs and early warning data.
Night-time factors also play a role with a decrease in observations noted.
Hope et al 61 UKSemistructured interviews with 17 registered nursesConstant comparative method informed by grounded theorySnowball sampleWider context of night-time care considered; there is some indication that staff are making a choice and prioritising sleep over monitoring.
James et al 37 UKPostal survey with healthcare assistants (HCA) using closed and open questionsDescriptive statistics and content analysis of qualitative dataObservations and monitoringFactors other than the score used to detect deterioration—intuition/patient’s own descriptions.
Vital signs monitoring delegated to junior staff who may not have the skills to interpret results; many HCAs did not ‘fully understand this neurological assessment and it is implications for the acutely unwell patient thus resulting in the risk of an inaccurate Early warning score’ (p 552).
Jensen et al 46 DenmarkFocus group exploring nurses’ experiences with paediatric early warning scoresQualitative meaning condensation analysisPEWSSleeping as a part of care identified.
Professional intuition.
Night-time pressures.
Jones et al 66 AustraliaQuestionnaire about understandings and barriers to activating a METSimple descriptive statisticsEWSIntuition important when detecting deterioration
Jones et al 77 UKElectronic capture of physiological data to see if automated clinical alerts increase compliance with an early warning score and improve patient outcomesStatisticalElectronic systemsElectronic systems can provide prompts or alerts for monitoring vital signs.
This system demonstrated significant improvement in clinician attendance to patients who are acutely ill with an early warning score of 3 and above.
Kaul et al 24 USADescriptive cross-sectional study; nurse and medical staff surveyDescriptive statisticsPEWSBenefits of Bedside PEWS—nurses more likely to identify early signs of deterioration and a greater ability to escalate care. Delegation to junior staff justified.
Lobos e t al 25 CanadaImplementation reportSimple descriptive statisticsPEWSDelegation to junior staff.
Education package developed around the RRS with a variety of informal lectures and interactive sessions; ‘lunch and learns’, ‘education coffee carts’ and simulation programmes for instance.
Lydon et al 40 30 semistructured interviews based on the theory of planned behaviour were conducted.
Questionnaire with Likert scale developed from the interview data.
Deductive content analysisPEWSProfessional intuition
Mackintosh et al 38 UKEthnographic perspective; observations, semistructured interviewsData were inductively and deductively coded using NVivo V.8 and organised thematically.EWSDelegation of routine observation and vital signs monitoring to junior staff.
Professional intuition important; ‘knowing the patient’ important for detecting subtle changes in a patient’s condition.
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’.EWSObservations and monitoring delegated to junior staff/HCAs and nurses—early warning system (EWS) legitimised delegation of these tasks.
Importance of pattern recognition and intuition.
The TTTs used to confirm or identify deterioration and are particularly useful for junior staff.
Mackintosh et al 52 UKEthnographic study using observations (>120 hours), semistructured interviews (n=45) and documentary reviewThematic analysis with data analysed iteratively in addition to a more strategic and policy-focused coding frameworkEWSProfessional intuition important when detecting deterioration
Massey et al 67 AustraliaIn-depth semistructured interviewsInductive approach—thematic analysisEWSImportance of intuition or ‘sensing clinical deterioration’
McDonnell et al 26 UKSingle-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 analysisEWST&Ts used to confirm or identify deterioration depending on the experience of the user. Specific objective information was seen as helping the response arm prioritise work
Importance of professional intuition or ‘gut feeling’ in detecting deterioration.
Need for staff concern in T&Ts.
McKay et al 59 AustraliaProspective, controlled, before-and-after intervention trialStatistical analysisPEWSSpecific education package developed around the
paediatric early warning score which assists in the recognition of deterioration
Mohammed et al 75 UKThree phases; the first two were based in a classroom and asked nurses to calculate an early warning score from vignettes using pen and paper followed by a handheld computer. The third phase followed the previous approach but was based on the ward after nurses had been using the device for 4 weeks.StatisticalElectronic systemsTimeliness of electronic vital signs recording when compared with paper systems
Mohammed Iddrisu et al 57 AustraliaTo explore nurses’ role in recognising and responding to deteriorating postoperative patients through focus groupsThematic analysisSnowball sampleStaff concern in tool criteria useful
Paciotti et al 71 USASemistructured interviews with cliniciansGrounded theory and constant comparisonFamily involvementPhysicians depend on families to explain a child’s baseline.
Pattison and Eastham29 UKMixed methods study looking at the impact of a critical care outreach team (CCOT)Statistical analysis and grounded theoryEWSTrack and trigger tool is used to either confirm or identify deterioration depending on the experience of the user.
‘Gut feeling’/intuition important—patient appearance often an important sign in detecting deterioration.
Radeschi et al 60 ItalyMulticentre survey to identify the attitudes and barriers to MET utilisationStatistical analysisEWSIntuition (physical appearance important) in detecting deterioration
Schmidt et al 78 UKRetrospective analysis of data collected routinely. Pragmatic observational study of VitalPAC deployment in two large hospitals.Statistical analysesElectronic systemsElectronic systems provide prompts for alerts, facilitate better recognition of deterioration and are associated with reduced mortality.
Sefton et al 76 UKControlled study of vital signs documentation and paediatric early warning Scorecalculation and a survey of acceptabilityDescriptive statisticsPEWSErrors in paper-based documentation were found; incorrect age-specific chart used; inaccurate documentation of values and plotting of trends; incorrect score calculation. In comparison, the error rate using the electronic score was low.
Shearer et al 31 AustraliaA mixed methods studyIterative codingEWSImportance of professional intuition
Sønning et al 41 NorwayQuestionnaire of a sample of staff who use a paediatric early warning scoreDescriptive statisticsPEWSAppreciate that a paediatric early warning score encourages a systematic approach to monitoring.
Stevenson and Nilsson85 SwedenQualitative; focus groups with 21 registered nursesContent analysis of interviewsElectronic systemsVerbal reports were favoured over the electronic system.
Stewart et al 32 SwedenMixed methods. Retrospective review of records and nurse-led focus groups.Statistical analysis and content analysisEWSIntuition still plays a part—the ‘score’ was rarely the single determining factor in activation but rather prompted nurses to gather additional information.
Subbe et al 80 UKA before-and-after study of an electronic automated advisory VS monitoring and notification system. Elevated scores were relayed to an RRT.Statistical analysisSnowball sampleAutomated versus monitoring associated with a decrease in mortality
Wager et al 84 USAObservational studyDescriptive 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. Individual tablet PCs seem to eliminate this from occurring.
Watson et al 45 USAMixed methods, retrospective medical record observations and observations of nurse interactions in 1 min blocksObservation analysis, although this is not described, and statistical analysisPEWSInformation relating to transfer to electronic systems—distance the ‘eyes’ of the nurses from the patient; batching.
Wheatley34 UKEthnographic approach; participant observation and semistructured interviewsThematic and content analysisObservations and monitoringThe regularity of vital signs monitoring may also lead to it becoming viewed as mundane practice that can be delegated to healthcare assistants.
Workplace pressure/equipment failures affect quality of observations.
  • AVS, abnormal vital signs; N/A, not applicable; TTT, track and trigger tool.