Table 3

Summary of detection evidence

Author	Country	Methodology	Analysis	Search area	Evidence contribution
Andrews and Waterman19	UK	Interviews and observations	Grounded theory	EWS	Importance of ‘gut feeling’ in detecting deterioration. Vital signs monitoring delegated to junior staff.
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	Staff encouraged to use their intuition when activating the RRT
Azzopardi et al 20	Australia	Survey	Statistical analysis	PEWS	Track 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, Australia	Before-and-after multicentred international controlled trial	Automated vital signs monitoring and early warning score calculated, international study, blinded trial, hospitals retained own early warning score and escalation policy.	Electronic systems	The electronic health record (EHR) provides a prompt to action.
Bonafide et al 21	USA	Semistructured interviews	Grounded theory	PEWS	Vital 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	USA	Prospective feasibility study	Video recording and electronic patient data collected prospectively. Pragmatic observational study of VitalPAC deployment in two large hospitals.	Electronic systems	Alarm fatigue—a barrier to escalation
Bonafide et al 83	USA	Video review and response time outcome	Statistical analysis	PEWS	Alarm fatigue—a barrier to escalation
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	Vital 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	USA	Focus groups ×7—held in groups of participants with similar roles	Constant comparison	Situational awareness	Paediatric early warning score supplementing gut feeling but these were not standardised.
Burns et al 68	USA	Semistructured interviews were used drawing on a descriptive phenomenological methodology.	Iterative thematic analysis	Snowball sample	Importance of professional intuition is reported.
Chua et al 36	Singapore	A qualitative survey using critical incident technique	Inductive content analysis	EWS	Vital 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	Australia	Unstructured interviews with nurses who had activated the medical emergency team (MET)	Simple code and retrieve	EWS	Importance of gut feeling and ‘knowing’ your patient in the detection of deterioration. Importance of having staff concern in the MET criterion.
Cioffi51	Australia	Unstructured interviews	Simple code and retrieve	EWS	Importance of gut feeling and intuition in recognising deterioration. Importance of having staff concern in a calling criteria.
Cioffi et al 42	Australia	Focus groups with clinicians and nurses exploring their responses to abnormal vital signs	Constant comparison	EWS	Intuition 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	USA	Retrospective 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 statistics	Electronic systems	Professional intuition used in conjunction with the Modified Early Warning Score
Davies et al 53	USA	Survey looking at barriers to rapid response system (RRS) activation	Statistical analysis	EWS	Professional intuition used over RRS activation criteria—barrier to activation
de Groot et al 62	Netherlands	Retrospective patient review and semistructured interviews with professionals	Descriptive statistics and grounded theory	PEWS	Importance of professional intuition is reported.
Donohue et al 64	UK	Qualitative design with critical incident technique. Semistructured interviews with nurses and the outreach team.	Thematic analysis	EWS	Importance of gut feeling and intuition in detecting deterioration
Downey et al 74	UK	Narrative review	‘Patterns were identified and translated to themes, which were further refined using an iterative process.’	PEWS	Drive towards automated alerts
Endacott et al 43	UK	Mixed methods case study—semistructured interviews and audit of charts	Qualitative content analysis and descriptive statistics	Observations and monitoring	Gut feeling important—interestingly particularly for nurses whereas doctors sought additional empirical evidence to back up intuition.
Endacott and Westley39	Australia	Questionnaire, in-depth interviews and observations	Content analysis and constant comparison	EWS	Intuition and anticipatory skills important in detecting deterioration
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.
Fagan et al 82	USA	Observational cohort comparison study	Descriptive statistics	Electronic systems	Concerns 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 focus	Opinion piece	N/A	Family involvement	Parents 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	UK	The vital signs (VS) and early warning data for all inpatients for 1 year to investigate patterns of VS observations collected	Statistical	Observations and monitoring	Staffing 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	UK	Semistructured interviews with 17 registered nurses	Constant comparative method informed by grounded theory	Snowball sample	Wider 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	UK	Postal survey with healthcare assistants (HCA) using closed and open questions	Descriptive statistics and content analysis of qualitative data	Observations and monitoring	Factors 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	Denmark	Focus group exploring nurses’ experiences with paediatric early warning scores	Qualitative meaning condensation analysis	PEWS	Sleeping as a part of care identified. Professional intuition. Night-time pressures.
Jones et al 66	Australia	Questionnaire about understandings and barriers to activating a MET	Simple descriptive statistics	EWS	Intuition important when detecting deterioration
Jones et al 77	UK	Electronic capture of physiological data to see if automated clinical alerts increase compliance with an early warning score and improve patient outcomes	Statistical	Electronic systems	Electronic 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	USA	Descriptive cross-sectional study; nurse and medical staff survey	Descriptive statistics	PEWS	Benefits 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	Canada	Implementation report	Simple descriptive statistics	PEWS	Delegation 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 analysis	PEWS	Professional intuition
Mackintosh et al 38	UK	Ethnographic perspective; observations, semistructured interviews	Data were inductively and deductively coded using NVivo V.8 and organised thematically.	EWS	Delegation 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	UK	Comparative case study—an 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	Observations 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	UK	Ethnographic study using observations (>120 hours), semistructured interviews (n=45) and documentary review	Thematic analysis with data analysed iteratively in addition to a more strategic and policy-focused coding framework	EWS	Professional intuition important when detecting deterioration
Massey et al 67	Australia	In-depth semistructured interviews	Inductive approach—thematic analysis	EWS	Importance of intuition or ‘sensing clinical deterioration’
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	T&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	Australia	Prospective, controlled, before-and-after intervention trial	Statistical analysis	PEWS	Specific education package developed around the paediatric early warning score which assists in the recognition of deterioration
Mohammed et al 75	UK	Three 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.	Statistical	Electronic systems	Timeliness of electronic vital signs recording when compared with paper systems
Mohammed Iddrisu et al 57	Australia	To explore nurses’ role in recognising and responding to deteriorating postoperative patients through focus groups	Thematic analysis	Snowball sample	Staff concern in tool criteria useful
Paciotti et al 71	USA	Semistructured interviews with clinicians	Grounded theory and constant comparison	Family involvement	Physicians depend on families to explain a child’s baseline.
Pattison and Eastham29	UK	Mixed methods study looking at the impact of a critical care outreach team (CCOT)	Statistical analysis and grounded theory	EWS	Track 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	Italy	Multicentre survey to identify the attitudes and barriers to MET utilisation	Statistical analysis	EWS	Intuition (physical appearance important) in detecting deterioration
Schmidt et al 78	UK	Retrospective analysis of data collected routinely. Pragmatic observational study of VitalPAC deployment in two large hospitals.	Statistical analyses	Electronic systems	Electronic systems provide prompts for alerts, facilitate better recognition of deterioration and are associated with reduced mortality.
Sefton et al 76	UK	Controlled study of vital signs documentation and paediatric early warning Scorecalculation and a survey of acceptability	Descriptive statistics	PEWS	Errors 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	Australia	A mixed methods study	Iterative coding	EWS	Importance of professional intuition
Sønning et al 41	Norway	Questionnaire of a sample of staff who use a paediatric early warning score	Descriptive statistics	PEWS	Appreciate that a paediatric early warning score encourages a systematic approach to monitoring.
Stevenson and Nilsson85	Sweden	Qualitative; focus groups with 21 registered nurses	Content analysis of interviews	Electronic systems	Verbal reports were favoured over the electronic system.
Stewart et al 32	Sweden	Mixed methods. Retrospective review of records and nurse-led focus groups.	Statistical analysis and content analysis	EWS	Intuition 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	UK	A before-and-after study of an electronic automated advisory VS monitoring and notification system. Elevated scores were relayed to an RRT.	Statistical analysis	Snowball sample	Automated versus monitoring associated with a decrease in mortality
Wager et al 84	USA	Observational study	Descriptive statistics	Electronic systems	Batching 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	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	Information relating to transfer to electronic systems—distance the ‘eyes’ of the nurses from the patient; batching. Intuition.
Wheatley34	UK	Ethnographic approach; participant observation and semistructured interviews	Thematic and content analysis	Observations and monitoring	The 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.