Elsevier

Resuscitation

Volume 109, December 2016, Pages 87-109
Resuscitation

Review article
Systematic review of paediatric track and trigger systems for hospitalised children

https://doi.org/10.1016/j.resuscitation.2016.07.230Get rights and content

Abstract

Context

Early and accurate recognition of the deteriorating hospitalised child is complex. Paediatric track and trigger systems (PTTS) support clinical decision-making by ‘tracking’ the child’s condition through monitoring of clinical signs and ‘triggering’ a request for an appropriate review when pre-determined criteria are breeched.

Objective

To describe the number and nature of published PTTS and appraise the evidence on their validity, calibration, and effect on important patient outcomes (death, cardiac and/or respiratory arrest, unplanned transfer to intensive/high dependency care, immediate/urgent request for review, rapid response system activation).

Method

GRADE methodology. Papers identified through electronic database and citation searching.

Results

Thirty-three PTTS were identified from 55 studies. There was considerable variety in the number and type of parameters, although all contained one or more vital signs. The evidence to support PTTS implementation was very low and the majority of outcomes did not achieve statistical significance. When PTTS was implemented as part of a rapid response system, the evidence was moderate to low but there was some evidence of a statistically significant improvement in outcome.

Conclusion

There is now some limited evidence for the validity and clinical utility of PTTS scores. The high (and increasing) number of systems is a significant confounder. Further research is needed particularly around the thresholds for the vital signs and the reliability, accuracy and calibration of PTTS in different settings.

Introduction

Effective management of clinical deterioration in hospitalised children is a priority for healthcare professionals, patients and carers alike. Optimal care for a deteriorating child is complex.1 It requires that: signs and symptoms of deterioration are recognised by ward staff; staff are empowered to call for assistance promptly; the assistance is readily available and appropriately skilled; and the interventions arising from this response improve outcomes. The first ‘link’ in this chain is early, accurate recognition of clinical deterioration. This is frequently inadequate.2, 3, 4

A number of tools are available to help staff identify deteriorating children. These ‘early warning systems’ prompt calls for senior assistance with changes in vital signs or other parameters.5 In 2005 21.5% of UK paediatric centres reported using an ‘early warning system’6; this rose to 85% by 2013.7 Many different systems are in use but they appear in two main forms: ‘score’ and ‘trigger’-based systems. Score-based systems assign values to vital signs, and other clinical indicators, representing the extent of deviation from ‘normal.’ These component values are combined to generate an overall score. Higher scores should represent an increased risk of deterioration, prompting review by senior clinicians. Trigger-based systems contain a number of pre-defined thresholds. When one or more thresholds are breeched, this ‘triggers’ a pre-determined response. Unlike score-based systems, trigger-based systems result in a dichotomous ‘all or nothing’ response. This typically means activation of a rapid response system (RRS) (also known as ‘critical care outreach’, ‘rapid response’ or ‘medical emergency’ teams). Although there are differences between these types of tools, they share two common characteristics: the ability to ‘track’ the child’s condition through ongoing monitoring and the facility to ‘trigger’ a request for an appropriate clinical review. Therefore, for the purpose of this review, score and trigger-based systems will be collectively referred to as paediatric track and trigger systems (PTTS).

The ideal PTTS utilises routinely monitored clinical signs, is simple to use and acceptable to users with robust validation in a relevant population.5 As with all clinical prediction tools, there is an important trade-off between sensitivity and specificity. The overall predictive performance of a tool is most commonly summarised by the area under the receiver operator characteristic (AUROC) curve, with values greater than 0.7 regarded as useful. Score-based systems should also have acceptable calibration, and accurately classify children into low, medium and high risk categories.8 As score-based PTTS are generally used with an action/escalation plan, calibration indicates the appropriateness of the response to each PTTS score in light of the degree of risk.

We conducted a systematic review of PTTS performance in 2009 and reported that the evidence on validity, calibration, reliability and utility was weak, and adoption of PTTS into clinical practice could not be recommended (findings summarised in Supplemental data Table A).5 Since this work there has been widespread implementation of PTTS and an increase in the literature describing their predictive performance. This updated systematic review is necessary to reconsider these recommendations.

Section snippets

Objectives

This review was undertaken to examine the key characteristics of PTTS and to appraise the evidence on their validity, calibration and clinical utility.

Methods

Paediatric track and trigger systems were defined to be any system which attempts to identify hospitalised children who are at risk of, or suffering from, critical deterioration through ongoing monitoring of clinical signs. Children in critical care, emergency room and theatres were excluded as they have differing staffing and monitoring strategies.

The review protocol rigorously adhered to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.9 The review was

Search results

The search was conducted on 27th May 2016 (Fig. 1, Supplemental data Table B). Thirty-three PTTS were identified from 55 papers. Different PTTS with the same name were numbered in order of publication to distinguish between them.

Main characteristics of paediatric track and trigger systems

Table 3 summarises the included studies, PTTS characteristics and quality rating. Many systems were minor modifications of previously published systems. Twenty-one were classified as ‘scoring systems’, and 12 as ‘trigger systems’. Fourteen were ‘age-dependent’ and 19

Death—very low evidence

The 2 observational studies29, 41 had small sample sizes and low event rates. The studies demonstrated that death on intensive care following unplanned admission from the ward had a relative risk of 1.28 (95% CI 0.66–2.52), however results were not significant41. Relative risk of unexpected death on the ward could not be calculated as there was only 1 death in the study population29.

Cardiac arrest—very low evidence

Three studies examined cardiac arrest.27, 49, 54 Two studies were severely limited by methodological concerns.49,

Paediatric track and trigger systems as part of a package of intervention

Ten observational studies described the introduction of PTTS as part of instigating a RRS.18, 32, 36, 37, 57, 61, 62, 63, 66, 67 A further study52 in a hospital with an established RRS examined a package of interventions designed to increase situational awareness.

Discussion

PTTS are now an established part of care for children in hospital. Most paediatric centres report using them.7 There is striking diversity in the components, thresholds and efficacy of the systems. The Paediatric Early Warning System Score I59 remains the most complex, with nineteen parameters. By contrast, the Paediatric Early Warning Score I48, 49 and its derivatives42, 51, 55, 58, 60, 64 has far fewer parameters. However, these ‘simpler’ systems are constituted from parameters which have

Conclusion

Although there remains low levels evidence on the effect of PTTS as a single intervention, there is moderate evidence of its impact on mortality and cardiac and respiratory arrests when delivered as a care package. The high (and increasing) number of systems, outcomes and metrics is a significant confounder. Further research is needed on the optimal characteristics, diagnostic accuracy and calibration of PTTS in different settings.

Conflict of interest statement

No conflicts of interest to declare.

Acknowledgements

This study received no direct funding but was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London.

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