TY - JOUR
T1 - Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme
T2 - the PUMA mixed methods study
AU - Allen, Davina
AU - Lloyd, Amy
AU - Edwards, Dawn
AU - Hood, Kerenza
AU - Huang, Chao
AU - Hughes, Jacqueline
AU - Jacob, Nina
AU - Lacy, David
AU - Moriarty, Yvonne
AU - Oliver, Alison
AU - Preston, Jennifer
AU - Sefton, Gerri
AU - Sinha, Ian
AU - Skone, Richard
AU - Strange, Heather
AU - Taiyari, Khadijeh
AU - Thomas-Jones, Emma
AU - Trubey, Rob
AU - Tume, Lyvonne
AU - Powell, Colin
AU - Roland, Damian
N1 - Funding Information:
We would like to thank and acknowledge the input from Debra Smith (Research Associate, October 2015–February 2017), who contributed to the systematic reviews, pre-implementation ethnographic data collection and preliminary data summaries; Marie-Jet Bekker, Fiona Lugg-Widger and Mala Mann for their contribution to the systematic reviews; Aimee Grant, (Research Associate, Qualitative methods, 3/2016-9/2017) conducted pre-implementation and process evaluation ethnographic data collection, contributed to pre-implementation case study analysis; James Bunn, Enitan Carrol and Brendon Mason for their clinical contribution to the study design; Lena Meister, Rhys Thomas, Laura Tilly and Vicky Winters for their contribution as study administrators; Vincent Poile for the development of the study database; and Catherine Lisles for proofreading the final report. Mike Robling acted as a critical reader of an earlier draft of the paper. We would like to thank the Study Steering Committee members for their continued support: Professor Gordon Taylor (chairperson, University of Exeter), Professor Ann Greenhough (King’s College London), Dr. Jennifer McGaughtey (Queen’s University Belfast), Dr. Roger Paslow (University of Leeds), Dr. Gale Pearson (Birmingham University Hospital) and Ms. Jayne Wheway (NHS England). We also wish to thank the providers of nursing/clinical studies officer and administrative support in all sites. These include staff at the Health and Care Research Wales Workforce and the local NIHR Clinical Research Networks.
Funding Information:
Kerenza Hood declares membership of the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) General Committee (2016–present), the NIHR Research Professors Committee (2019–present), the NIHR Clinical Trials Unit Standing Advisory Committee (2014–18) and the NIHR HTA Funding Committee Policy Group (2017–present). Gerri Sefton declares grants from the NIHR Invention for Innovation (i4i) programme for the Dynamic Electronic Tracking and Escalation to reduce Critical care Transfers (DETECT) study outside the submitted work. Lyvonne Tume declares being a member and vice chairperson of the NIHR HTA Topic Identification Panel (Panel C) (2016–January 2020), a member of the NIHR HTA Prioritisation Committee C (2016–19) and a member of the HTA Prioritisation Committee C Methods Group (2016–19). Damian Roland declares being clinical lead for the NHS England/Royal College of Paediatrics and Child Health National Paediatric Early Warning System programme (2018–present).
Publisher Copyright:
© 2021, The Author(s).
PY - 2022/1/2
Y1 - 2022/1/2
N2 - 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 harness 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 improvement initiatives and structured facilitation and support. Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome 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 staff and parents. A qualitative evaluation of implementation processes was undertaken. Results: All sites assessed their paediatric early warning systems and identified 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 significant (ß = -0.09 (95% CI: − 0.15, − 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes. Conclusions: System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations.
AB - 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 harness 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 improvement initiatives and structured facilitation and support. Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome 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 staff and parents. A qualitative evaluation of implementation processes was undertaken. Results: All sites assessed their paediatric early warning systems and identified 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 significant (ß = -0.09 (95% CI: − 0.15, − 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes. Conclusions: System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations.
KW - Healthcare improvement
KW - Paediatric early warning systems
KW - Quality improvement
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U2 - 10.1186/s12913-021-07314-2
DO - 10.1186/s12913-021-07314-2
M3 - Article (journal)
C2 - 34974841
AN - SCOPUS:85122139253
SN - 1472-6963
VL - 22
JO - BMC Health Services Research
JF - BMC Health Services Research
IS - 1
M1 - 9
ER -