School of Healthcare Sciences, Cardiff University, Room 13.08, Eastgate House, Newport Road, Cardiff, CF24 0AB, UK.
Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK.
BMC Health Serv Res. 2022 Jan 2;22(1):9. doi: 10.1186/s12913-021-07314-2.
Paediatric mortality rates in the United Kingdom are amongst the highest in Europe. Clinically missed deterioration is a contributory factor. Evidence to support any single intervention to address this problem is limited, but a cumulative body of research highlights the need for a systems approach.
An evidence-based, theoretically informed, paediatric early warning system improvement programme (PUMA Programme) was developed and implemented in two general hospitals (no onsite Paediatric Intensive Care Unit) and two tertiary hospitals (with onsite Paediatric Intensive Care Unit) in the United Kingdom. Designed to harness local expertise to implement contextually appropriate improvement initiatives, the PUMA Programme includes a propositional model of a paediatric early warning system, system assessment tools, guidance to support improvement initiatives and structured facilitation and support. Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome was a composite metric (adverse events), representing the number of children monthly that experienced one of the following: mortality, cardiac arrest, respiratory arrest, unplanned admission to Paediatric Intensive Care Unit, or unplanned admission to Higher Dependency Unit. System changes were assessed qualitatively through observations of clinical practice and interviews with staff and parents. A qualitative evaluation of implementation processes was undertaken.
All sites assessed their paediatric early warning systems and identified areas for improvement. All made contextually appropriate system changes, despite implementation challenges. There was a decline in the adverse event rate trend in three sites; in one site where system wide changes were organisationally supported, the decline was significant (ß = -0.09 (95% CI: - 0.15, - 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes.
System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations.
英国的儿科死亡率在欧洲处于较高水平。临床上的病情恶化是一个促成因素。支持解决此问题的任何单一干预措施的证据都很有限，但越来越多的研究表明需要采取系统方法。
在英国的两家综合医院（无现场儿科重症监护病房）和两家三级医院（有现场儿科重症监护病房）中，开发并实施了基于证据、理论指导的儿科早期预警系统改进计划（PUMA 计划）。该计划旨在利用当地专业知识实施切合实际的改进措施，包括儿科早期预警系统的命题模型、系统评估工具、支持改进措施的指南以及结构化的促进和支持。每个医院都使用中断时间序列和定性案例研究进行了评估。主要的定量结果是一个综合指标（不良事件），表示每月有多少儿童经历以下情况之一：死亡、心脏骤停、呼吸骤停、意外入住儿科重症监护病房或意外入住高依赖病房。通过观察临床实践和对工作人员和家长的访谈，对系统变化进行了定性评估。还对实施过程进行了定性评估。
所有医院都对其儿科早期预警系统进行了评估，并确定了改进的领域。尽管实施过程中存在挑战，但所有医院都做出了切合实际的系统更改。在三个地点，不良事件发生率趋势有所下降；在一个得到组织支持的系统范围内做出改变的地点，下降趋势具有统计学意义（ß= -0.09（95%CI：-0.15，-0.05）；p<0.001）。趋势变化与特定地点的变化实施同时发生。
为改善儿科早期预警系统而进行的系统级更改可能会对临床结果产生积极影响，但在儿科实践中，由于患者人群较小且临床结果事件发生率较低，因此需要替代的结果测量指标来支持除大型专业中心以外的研究和质量改进，并且需要对罕见事件进行方法学研究。通过投资开发替代的结果测量指标和方法学，PUMA 等计划可以改善儿科和其他患者人群的死亡率和发病率。
