Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme : the PUMA mixed methods study

Allen, D; Lloyd, A; Edwards, D; Hood, K; Huang, C; Hughes, J; Jacob, N; Lacy, D; Moriarty, Y; Oliver, A; Preston, J; Sefton, G; Sinha, I; Skone, R; Strange, H; Taiyari, K; Thomas-Jones, E; Trubey, R; Tume, LN; Powell, C; Roland, D

Abstract

Background: Paediatric mortality rates in the United Kingdom are amongst the highest in Europe. Clinically missed
deterioration is a contributory factor. Evidence to support any single intervention to address this problem is limited,
but a cumulative body of research highlights the need for a systems approach.
Methods: An evidence-based, theoretically informed, paediatric early warning system improvement programme
(PUMA Programme) was developed and implemented in two general hospitals (no onsite Paediatric Intensive Care
Unit) and two tertiary hospitals (with onsite Paediatric Intensive Care Unit) in the United Kingdom. Designed to har‑
ness local expertise to implement contextually appropriate improvement initiatives, the PUMA Programme includes
a propositional model of a paediatric early warning system, system assessment tools, guidance to support improve‑
ment initiatives and structured facilitation and support.
Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative out‑
come was a composite metric (adverse events), representing the number of children monthly that experienced one
of the following: mortality, cardiac arrest, respiratory arrest, unplanned admission to Paediatric Intensive Care Unit, or
unplanned admission to Higher Dependency Unit. System changes were assessed qualitatively through observations
of clinical practice and interviews with staf and parents. A qualitative evaluation of implementation processes was
undertaken.
Results: All sites assessed their paediatric early warning systems and identifed areas for improvement. All made
contextually appropriate system changes, despite implementation challenges. There was a decline in the adverse
event rate trend in three sites; in one site where system wide changes were organisationally supported, the decline
was signifcant (ß= -0.09 (95% CI: −0.15, −0.05); p=<0.001). Changes in trends coincided with implementation of
site-specifc changes

• Journal Article Type: Article
• Acceptance Date: Nov 10, 2021
• Publication Date: Jan 2, 2022
• Deposit Date: Jan 6, 2022
• Publicly Available Date: Jan 6, 2022
• Journal: BMC Health Services Research
• Electronic ISSN: 1472-6963
• Publisher: Springer Verlag
• Volume: 22
• Issue: 1
• Pages: 9
• DOI: https://doi.org/10.1186/s12913-021-07314-2
• Publisher URL: https://doi.org/10.1186/s12913-021-07314-2
• Related Public URLs: https://bmchealthservres.biomedcentral.com/
• Additional Information: Projects : PUMA - Paediatric early warning system (PEWS): Utilisation and Mortality Avoidance.