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Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme: the PUMA mixed methods study

Allen, Davina ORCID:, Lloyd, Amy ORCID:, Edwards, Dawn, Hood, Kerenza ORCID:, Huang, Chao, Hughes, Jacqueline, Jacob, Nina, Lacy, David, Moriarty, Yvonne ORCID:, Oliver, Alison, Preston, Jennifer, Sefton, Gerri, Sinha, Ian, Skone, Richard, Strange, Heather ORCID:, Taiyari, Khadijeh, Thomas-Jones, Emma, Trubey, Rob, Tume, Lyvonne, Powell, Colin and Roland, Damian 2022. Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme: the PUMA mixed methods study. BMC Health Services Research 22 (1) , 9. 10.1186/s12913-021-07314-2

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Background 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. Methods 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. Results 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. Conclusions 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.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Healthcare Sciences
Centre for Trials Research (CNTRR)
Additional Information: This article is licensed under a Creative Commons Attribution 4.0 International License
Publisher: BioMed Central
ISSN: 1472-6963
Date of First Compliant Deposit: 12 January 2022
Date of Acceptance: 10 November 2021
Last Modified: 11 Oct 2023 19:54

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