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BMJ Open. 2019 May 5;9(5):e022105. doi: 10.1136/bmjopen-2018-022105.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review.

Author information

1
Centre for Trials Research, Cardiff University, Cardiff, UK.
2
Hull York Medical School, University of Hull, Hull, UK.
3
School of Healthcare Sciences, Cardiff University, Cardiff, UK.
4
Department of Paediatrics, Morriston Hospital, Swansea, UK.
5
Wirral University Teaching Hospital, Wirral, UK.
6
University Library Services, Cardiff University, Cardiff, UK.
7
Public Health Wales, Cardiff, UK.
8
Department of Paediatric Intensive Care, Noah's Ark Children's Hospital for Wales, Cardiff, UK.
9
SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK.
10
Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK.
11
Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
12
Faculty of Health and Applied Sciences (HAS), University of the West of England Bristol, Bristol, UK.
13
Department of Pediatric Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar.
14
Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.

Abstract

OBJECTIVE:

To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.

DESIGN:

Systematic review.

DATA SOURCES:

British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.

ELIGIBILITY CRITERIA:

We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered.

DATA EXTRACTION AND SYNTHESIS:

Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.

RESULTS:

36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.

CONCLUSION:

There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.

PROSPERO REGISTRATION NUMBER:

CRD42015015326.

KEYWORDS:

PEWS; children; clinical deterioration; early warning scores; systematic review; track and trigger scores

Conflict of interest statement

Competing interests: None declared.

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