S.A.F.E 4: Recognising deterioration


Once we know how to communicate effectively, we need to recognise and respond to the deteriorating child in a timely way. This section outlines ways we can achieve this effectively, including tools to support recognition and learning.

Identifying deterioration early

It is often difficult to detect deterioration early, particularly in sepsis. Therefore, we need to change the way we look at children to see if we can increase our awareness of potential deterioration.

Five risk factors are associated with preventing deterioration, as detailed in studies from Cincinnati Children's Hospital and Medical Centre (Brady et al,. Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events. Pediatrics, 2013. 131; e298-e308).

  • Family concerns should always be taken seriously, even if vital signs are normal.
  • High-risk therapies raise the risk and make the child a potential candidate for deterioration.
  • Presence of an elevated early warning score is a marker, though it is not always present.
  • Watcher/clinician gut feeling is where any member of staff senses that the child is not right.
  • Concerns about communication with the patient, parent or their family are discussed (eg they speak a different language to you and your team).

PEWS Development

Figure 1: Developing PEWS with PDSA Cycles

The presentation gives a brief overview of some of the main components used in recognising and responding to deterioration and can be used as an introduction. However, most information is included with the suggested tools.

Presentation 4 - Identifying Deterioration Early (PPT, 593KB)

Tools and worked examples

The main tool for recognising and responding to deterioration in children is a Paediatric Early Warning Score or System.

There is a variety in use across the country, but two examples have been selected below. In addition, there is a list of the PEWS each S.A.F.E site is using. There are also tools for reviewing cases of unrecognised deterioration and specific causes of deterioration which will help you provide learning to your team.

Tool 1: Paediatric Early Warning Scores and systems (PEWS)

There is no perfect PEWS. The key is to have good observations and to use one consistently, bearing in mind that PEWS are designed to be sensitive but may lack specificity.

The score is part of a system incorporating all of the above. If one recognises the limitations of the PEWS then its value increases as part of a system. Nurses need to be trained in standardised observations and doctors in responding to the PEWS.

The NHS Insititute for Innovation and Improvement (NHS III) described PEWS as follows:

"Early warning scores are generated by combining the scores from a selection of routine observations of patients eg pulse, respiratory rate, respiratory distress, conscious level. Different observations are selected for children and adults due to their naturally different physiological responses. If a child's clinical condition is deteriorating the 'score' for the observations will (usually) increase and so a higher or increasing score gives an early indication that intervention may be required. Early intervention can 'fix' problems and can avoid the need to transfer a child to a higher level of care and thus avoid or reduce harm."


Tool 2: RECALL tool

The RECALL (Rapid Evaluation of Cardio-respiratory Arrests with Lessons for Learning) tool was developed at Great Ormond Street Hospital to allow real-time analysis of deterioration by asking a number of key questions after a child deteriorates. This allows the clinical team to mitigate and change processes to prevent the next deterioration. (Runnacles et al., RECALL (Rapid Evaluation of Cardio-Respiratory Arrests with Lessons For Learning): Developing a Tool to Learn from Paediatric Arrests. Arch Dis Child 2013;98:A56 doi:10.1136/archdischild-2013-304107.131)

Part 1 allows for the evaluation of deterioration. This considers the assessment of the patient in the previous 24 hours and the escalation in response to the deterioration, clinical reviews and interventions, with any lessons for learning identified.

RECALL Form - Part 1 (GOSH) (MS Word, 43KB)

Part 2 provides an opportunity for the clinical lead to review the deterioration and gather any additional information. Based on this, a decision is made to either accept the report with changes, or to gather further information. 

RECALL Form - Part 2 (GOSH) (MS Word, 31KB)

Here are posters from two S.A.F.E sites who have implemented RECALL as part of their local project.

University College Hospital RECALL Poster (PDF, 531KB)

Royal Free RECALL Poster (PDF, 327KB)

Tool 3: Re-ACT

NHS England has prepared resources, including a number of short videos, that address key areas which need to be considered in developing a programme to decrease unexpected deterioration.

Re-ACT (Responding to Ailing Children Tool) covers the following broad themes:

  • parent/carer engagement
  • health care professional education
  • systems improvement
  • score and system design
  • reducing term admissions to neonatal units.


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