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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, Rob; Huang, Chao; Lugg-Widger, Fiona V.; Hood, Kerenza; Allen, Davina; Edwards, Dawn; Lacy, David; Lloyd, Amy; Mann, Mala; Mason, Brendan; Oliver, Alison; Roland, Damian; Sefton, Gerri; Skone, Richard; Thomas-Jones, Emma; Tume, Lyvonne N.; Powell, Colin


Rob Trubey

Chao Huang

Fiona V. Lugg-Widger

Kerenza Hood

Davina Allen

Dawn Edwards

David Lacy

Amy Lloyd

Mala Mann

Brendan Mason

Alison Oliver

Damian Roland

Gerri Sefton

Richard Skone

Emma Thomas-Jones

Lyvonne N. Tume

Colin Powell


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.


Trubey, R., Huang, C., Lugg-Widger, F. V., Hood, K., Allen, D., Edwards, D., …Powell, C. (2019). 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. BMJ Open, 9(5),

Journal Article Type Article
Acceptance Date Mar 8, 2019
Online Publication Date May 5, 2019
Publication Date May 5, 2019
Deposit Date May 7, 2019
Publicly Available Date May 7, 2019
Journal BMJ Open
Electronic ISSN 2044-6055
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Volume 9
Issue 5
Keywords paediatric early warning, track and trigger tools, score, systematic review
Public URL


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