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Qualitative study exploring factors influencing escalation of care of deteriorating children in a children’s hospital
  1. Orsola Gawronski1,2,
  2. Christopher Parshuram3,
  3. Corrado Cecchetti4,
  4. Emanuela Tiozzo1,
  5. Marta Luisa Ciofi degli Atti5,
  6. Immacolata Dall’Oglio1,2,
  7. Gianna Scarselletta6,
  8. Caterina Offidani7,
  9. Massimiliano Raponi7,
  10. Jos M Latour8
  1. 1 Continuing Education and Nursing Research Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
  2. 2 Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
  3. 3 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
  4. 4 Department of Critical Care Medicine, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
  5. 5 Clinical Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
  6. 6 Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
  7. 7 Medical Directorate, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
  8. 8 School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
  1. Correspondence to Orsola Gawronski; orsola.gawronski{at}


Background System-level interventions including rapid response teams and paediatric early warning scores have been designed to support escalation of care and prevent severe adverse events in hospital wards. Barriers and facilitators to escalation of care have been rarely explored in paediatric settings.

Aim This study explores the experiences of parents and healthcare professionals of in-hospital paediatric clinical deterioration events to identify factors associated with escalation of care.

Methods Across 2 hospital sites, 6 focus groups with 32 participants were conducted with parents (n=9) and healthcare professionals (n=23) who had cared for or witnessed a clinical deterioration event of a child. Transcripts of audio recording were analysed for emergent themes using a constant comparative approach.

Findings Four themes and 19 subthemes were identified: (1) impact of staff competencies and skills, including personal judgement of clinical efficacy (self-efficacy), differences in staff training and their impact on perceived nursing credibility; (2) impact of relationships in care focusing on communication and teamwork; (3) processes identifying and responding to clinical deterioration, such as patient assessment practices, tools to support the identification of patients at risk and the role of the rapid response team; and (4) influences of organisational factors on escalation of care, such as staffing, patient pathways and continuity of care.

Conclusions Findings emphasise the considerable influence of social processes such as teamwork, communication, models of staff organisation and staff education. Further studies are needed to better understand how modification of these factors can be used to improve patient safety.

  • pediatrics
  • parents
  • physicians
  • nurses
  • critical illness
  • qualitative research
  • hospital rapid response team

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors OG was involved in the conception and the design of the study, collected all data, contributed to the analysis and interpretation of the data, and led the writing of this paper. JML and CP were involved in the conception and the design of the study, supervised data collection, and contributed to the analysis of the data and the drafting of the paper. GS was involved in data collection and analysis. CC, MLCdA, IDO and CO were involved in the study conception, design and drafting of the paper. ET and MR are the guarantors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CP is the named inventor of the BedsidePEWS and has shares in a decision support company of which the BedsidePEWS is a product.

  • Patient consent Not required.

  • Ethics approval The hospital’s ethics committee (Bambino Gesù Children’s Hospital Ethics Review Board, 915_OPBG_2015) approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Qualitative data are held on the hospital’s computers, in password-protected folders. Unpublished data are available upon request to the corresponding author.

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