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, R; Huang, C; Lugg-Widger, F; 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, LN; Powell, C

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.

Citation

review. BMJ Open, 9(5), e022105. https://doi.org/10.1136/bmjopen-2018-022105

• Journal Article Type: Article
• Acceptance Date: Mar 8, 2019
• Publication Date: May 5, 2019
• Deposit Date: Sep 4, 2019
• Publicly Available Date: Sep 4, 2019
• Journal: BMJ Open
• Publisher: BMJ Publishing Group
• Volume: 9
• Issue: 5
• Pages: e022105
• DOI: https://doi.org/10.1136/bmjopen-2018-022105
• Publisher URL: https://doi.org/10.1136/bmjopen-2018-022105
• Related Public URLs: https://bmjopen.bmj.com/
• Additional Information: Projects : PUMA Study