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

Trubey, Rob; Huang, Chao; Lugg-Widger, Fiona V; Hood, Kerenza; Allen, Davina; Edwards, Dawn; Lacy, David; Lloyd, Amy; Mann, Mala; Mason, Brendan; Oliver, Alison; Roland, Damian; Sefton, Gerri; Skone, Richard; Thomas-Jones, Emma; Tume, Lyvonne N; Powell, Colin

Abstract

© 2019 Author(s) (or their employer(s)). Re-use permitted under CC BY. Published by BMJ. 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.

Citation

Trubey, R., Huang, C., Lugg-Widger, F. V., Hood, K., Allen, D., Edwards, D., Lacy, D., Lloyd, A., Mann, M., Mason, B., Oliver, A., Roland, D., Sefton, G., Skone, R., Thomas-Jones, E., Tume, L. N., & Powell, C. (2019). 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. BMJ open, 9(5), Article e022105. https://doi.org/10.1136/bmjopen-2018-022105

• Journal Article Type: Review
• Acceptance Date: Mar 8, 2019
• Online Publication Date: May 5, 2019
• Publication Date: 2019-05
• Deposit Date: Jul 30, 2019
• Publicly Available Date: Jul 30, 2019
• Journal: BMJ Open
• Print ISSN: 2044-6055
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 9
• Issue: 5
• Article Number: e022105
• DOI: https://doi.org/10.1136/bmjopen-2018-022105
• Keywords: General Medicine
• Public URL: https://hull-repository.worktribe.com/output/2019778
• Publisher URL: https://bmjopen.bmj.com/content/9/5/e022105
• Additional Information: Copyright information: © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.; This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
• Contract Date: Jul 30, 2019