Journal Article

Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

Mann, Mala, Tume, Lyvonne N, Sefton, Gerri, Powell, Colin, Allen, Davina, Trubey, Robert, Jacob, Nina, Hood, Kerenza, Moriarty, Yvonne, Lloyd, Amy, Roland, Damian

2019

Overview

ObjectiveTo identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.MethodsA hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.ResultsDetecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.ConclusionsThere is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.PROSPERO registration numberCRD42015015326.

• Publisher: British Medical Journal Publishing Group,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Child / children / Clinical Deterioration / early warning scores / Evidence-Based Medicine / Exegesis & hermeneutics / Health Status Indicators / Hospitals, Pediatric / Humans / Inpatient care / Intensive Care Units, Pediatric / Literature reviews / Monitoring, Physiologic / Paediatrics / Patient assessment / Pediatric nursing / Pediatrics / Pediatrics - methods / PEWS / Severity of Illness Index / Systematic review / track and trigger scores / Vital signs