Implementation of a paediatric early warning system as a complex health technology intervention

Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals

Background

Paediatric early warning systems (PEWS) are a means of tracking physiological state and alerting healthcare professionals about signs of deterioration, triggering a clinical review and/or escalation of care of children. A proactive end-to-end deterioration solution (the DETECT surveillance system) with an embedded e-PEWS that included sepsis screening was introduced across a tertiary children’s hospital. One component of the implementation programme was a sub-study to determine an understanding of the DETECT e-PEWS in terms of its clinical utility and its acceptability.

Aim

This study aimed to examine how parents and health professionals view and engage with the DETECT e-PEWS apps, with a particular focus on its clinical utility and its acceptability.

Method

A prospective, closed (tick box or sliding scale) and open (text based) question, e-survey of parents (n = 137) and health professionals (n = 151) with experience of DETECT e-PEWS. Data were collected between February 2020 and February 2021.

Results

Quantitative data were analysed using descriptive and inferential statistics and qualitative data with generic thematic analysis. Overall, both clinical utility and acceptability (across seven constructs) were high across both stakeholder groups although some challenges to utility (e.g., sensitivity of triggers within specific patient populations) and acceptability (e.g., burden related to having to carry extra technology) were identified.

Conclusion

Despite the multifaceted nature of the intervention and the complexity of implementation across a hospital, the system demonstrated clinical utility and acceptability across two key groups of stakeholders: parents and health professionals.

Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis

Aim

We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS?

Methods

We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias.

Results

Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies.

Conclusions

Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems.

PROSPERO registration: CRD42021269579.

Health professionals' initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

Background

Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability.

Methods

A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts.

Results

Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits.

Conclusions

Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03411-1.

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (the DETECT study): A qualitative interview study

BACKGROUND

Failure to recognize and respond to clinical deterioration in a timely and effective manner is an urgent safety concern, driving the need for early identification systems to be embedded in the care of children in hospital. Pediatric early warning systems (PEWS) or PEW scores alert health professionals (HPs) to signs of deterioration, trigger a review and escalate care as needed. PEW scoring allows HPs to record a child's vital signs and other key data including parent concern.

AIM

This study aimed to explore the experiences and perceptions of parents about the acceptability of a newly implemented electronic surveillance system (the DETECT surveillance system), and factors that influenced acceptability and their awareness around signs of clinical deterioration and raising concern.

METHODS

Descriptive, qualitative semi-structured telephone interviews were undertaken with parents of children who had experienced a critical deterioration event (CDE) (n = 19) and parents of those who had not experienced a CDE (non-CDE parents) (n = 17). Data were collected between February 2020 and February 2021.

RESULTS

Qualitative data were analyzed using generic thematic analysis. Analysis revealed an overarching theme of trust as a key factor that underpinned all aspects of children's vital signs being recorded and monitored. The main themes reflect three domains of parents' trust: trust in themselves, trust in the HPs, and trust in the technology.

CONCLUSION

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (The DETECT system) were positive; they found it acceptable and welcomed the use of new technology to support the care of their child.