Safe system framework - 3: Recognising deterioration

Recognising deterioration

The ability to spot physiological deviations before significant changes in care are needed or harm occurs is a fundamental working element and central to the system.


Children, families and carers 

  • Involvement in individualised care decisions
  • Opportunities to contribute to the recognition of the deteriorating child such as: safety netting; being taught what matters with regard to the patient’s condition and empowering families to express concerns (for example-family members being able to activate a system of escalation to senior staff as part of PEW charts)

Clinicians and wider team

  • PEW charts/track and trigger tool including clarity on the frequency of observations, triggers for escalation (chart trigger/staff concerns) and clear protocols for graded response
  • Structured communication for escalation, such as Situation, Background, Assessment and Recommendation tool (SBAR)
  • Systems and processes regarding the assessment and monitoring of patients such as clinical handover, safety briefings, multi-disciplinary rounds and ward rounds
  • Knowledge and practice of the use of situational awareness to improve safety
  • Good clinical pathways for the identification of clinical conditions requiring urgent care such as sepsis

Service or organisation

  • Leadership at all levels to support the responsibilities of the clinicians and wider team in recognising the deteriorating child including evidence/examples of good practice and actions for improvement
  • Knowledge of the use of situational awareness to improve safety in the senior leadership team

Regional, national, networks

  • System wide knowledge and thinking on the gaps, research and debate in this area including support for the publication and recommendations for action when evidence becomes available


ReACT parent films - “If you see something, say something”, these films are created for parents, and for staff supporting and empowering parents and families

Reducing term admissions to neonatal units - a programme working to reduce harm and reduce separation of mother and baby

Standards for assessing, measuring and monitoring vital signs in infants, children and young people (2013, currently being udated for 2016)

Emergency life support guidelines and courses – Paediatric Basic Life Support (BLS)Advanced Paediatric Life Support (APLS),European Paediatric Life Support (EPLS) and Newborn Life Support (NLS)

ReACT resources on Paediatric Early Warning Systems including examples of PEWS charts; NHS Institute, Ireland, Scotland and Northern Ireland; BAPM Newborn Early Warning Trigger and Track (NEWTT)

SAFE resource pack - a toolkit to help develop situation awareness locally, and with examples of clinical escalation and SBAR document - especially see sections on using structured communication and the huddle

Resources to support the prompt recognition of sepsis and the rapid initiation of treatment (including Paediatric Sepsis Six and other UK Sepsis Trust resources)

Peadiatric Care Online (PCO UK) - supports daily clinical practice by providing immediate, accessible information to inform decisions at point of care

MedsIQ - brings together tools and improvement projects that have been developed to address medication errors affecting children and young people

Spotting the Sick Child – an interactive tool to support health professionals in the assessment of the acutely sick child


The Irish Paediatric Early Warning System (PEWS): National Clinical Guideline

A systematic literature review to support the development of a National Clinical Guideline – Paediatric Early Warning System (PEWS). Fianl Report (2014) School of Nursing and Human Sciences, Dublin City University

S Nahdi Pediatric Early Warning System (PEWS) Summary of literature review

‘High Dependency Care for Children – Time to Move on’

Mari Akre, Marsha Finkelstein, Mary Erickson, Meixia Liu, Laurel Vanderbilt and Glenn Billman (2010) Sensitivity of the Pediatric Early Warning Score to Identify Patient Deterioration. Pediatrics 2010;125;e763; originally published online March 22, 2010; DOI: 10.1542/peds.2009-0338

Bonafide CP, Holmes JH, Nadkarni VM, Lin R, Landis JR, Keren R. (2012) Development of a score to predict clinical deterioration in hospitalized children. J Hosp Med. 2012 Apr;7(4):345-9. doi: 10.1002/jhm.971. Epub 2011 Nov 17.

Brady PW & Goldenhar LM (2013) A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. BMJ Quality and Safety. 0:1-9.

Brady PW, Muething S, Kotagal U, Ashby M, Gallagher R, Hall D, Goodfriend M, White C, Bracke TM, DeCastro V, Geiser M, Simon J, Tucker KM, Olivea J, Conway PH, Wheeler DS. (2013) Improving situation awareness to reduce unrecognised clinical deterioration and serious safety events. Pediatrics. 131(1):e298-e308.

Chapman S.M, Grocott M.P.W, Franck L.S. (2010) Systematic review of paediatric alert criteria for identifying hospitalised children at risk of clinical deterioration. Intensive Care Medicine. 36:600-611.

Edwards DE et al (2008) Prospective cohort study to rest the predictability of the Cardiff and Vale Paediatric Early Warning System (C and VPEWS). Archives of Diseases in Childhood. 1–4.

Egdell, P. Finlay, L. Pedley, D. (2008) The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department Emergency Medicine Journal 25:745-749

Harriet Holme, Reena Bhatt, Marita Koumettou, Mark A.S. Griffin and Lucinda C. Winckworth (2013) Retrospective Evaluation of a New Neonatal Trigger Score. Pediatrics 2013;131;e837; originally published online February 18, 2013; DOI: 10.1542/peds.2012-0640

McCabe A, Duncan H, Heward Y. (2009) Paediatric early warning systems: where do we go from here? Paediatr Nurs. 2009 Feb;21(1):14-7.

Mandy Odell, Karin Gerber, Melanie Gager (2010) Call 4 Concern: patient and relative activated critical care outreach. British Journal of Nursing, 2010, Vol 19, No 00

Christopher S Parshuram, James Hutchison and Kristen Middaugh (2009) Development and initial validation of the Bedside Paediatric Early Warning System score. Critical Care 2009, 13:R135 (doi:10.1186/cc7998)

Parahuram, C. (2011) Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children. Critical Care .15(4), pp. 184.

Roberts KE, Bonafide CP, Paine CW, Paciotti B, Tibbetts KM, Keren R, Barg FK, Holmes JH. (2014) Barriers to calling for urgent assistance despite a comprehensive pediatric rapid response system. American Journal of Critical care. 23(3): 223-229.

Roland D, Oliver A, Edwards ED, Mason BW, Powell CVE. (2014) Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years? Archives of Disease in Childhood. 99:26–29.

Roland D. (2013) Paediatric early warning scores: Holy Grail and Achilles’ heel. Postgraduate Medical Journal. 89: 358-365.

Roland D, Madar J, Connolly G. (2010) The Newborn Early Warning (NEW) system: development of an at-risk infant intervention system. Infant. 6(4):116-120.

L Sinitsky and A Reece (2015) Can paediatric early warning systems predict serious clinical deterioration in paediatric inpatients? Arch Dis Child 2016 101: 109-113 doi: 10.1136/archdischild-2015-309304

M Thompson, N Coad, A Harnden, R Mayon-White, R Perera, and D Mant (2009) How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child 2009 94: 888-893 originally published online July 15, 2009

Karen M. Tucker, Tracy L. Brewer, Rachel B. Baker, Brenda Demeritt, and Michael T. Vossmeyer (2009) Prospective Evaluation of a Pediatric Inpatient Early Warning Scoring System JSPN Vol. 14, No. 2, April 2009

Tume L. (2012) The deterioration of children in ward areas in a specialist children’s hospital. Nurs Crit Care. 2007 Jan-Feb;12(1):12-9.