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Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence

Barriers and facilitators related to the implementation of a physiological track and trigger... Abstract Purpose To identify the barriers to, and facilitators of, the implementation of physiological track and trigger systems (PTTSs), perceived by healthcare workers, through a systematic review of the extant qualitative literature. Data sources Searches were performed in PUBMED, CINAHL, PsycInfo, Embase and Web of Science. The reference lists of included studies were also screened. Study selection The electronic searches yielded 2727 papers. After removing duplicates, and further screening, a total of 10 papers were determined to meet the inclusion criteria and were reviewed. Data extraction A deductive content analysis approach was taken to organizing and analysing the data. A framework consisting of two overarching dimensions (‘User-related changes required to implement PTTSs effectively’ and ‘Factors that affect user-related changes’), 5 themes (staff perceptions of PTTSs and patient safety, workflow adjustment, PTTS, implementation process and local context) and 14 sub themes was used to classify the barriers and facilitators to the implementation of PTTSs. Results of data synthesis Successful implementation of a PTTS must address the social context in which it is to be implemented by ensuring that the users believe that the system is effective and benefits patient care. The users must feel invested in the PTTS and its use must be supported by training to ensure that all healthcare workers, senior and junior, understand their role in using the system. Conclusion PTTSs can improve patient safety and quality of care. However, there is a need for a robust implementation strategy or the benefits of PTTSs will not be realized. systematic review, critical illness, early warning system, early warning score, qualitative methods Introduction The incidence of in-patient hospital deaths has been estimated to be 9.5 patients per 1000 admissions [1]. Many of these deaths are not without prior warning signs of patient deterioration. This deterioration is often preceded by identifiable, negative changes in physiological parameters [2–6] in the hours preceding serious adverse events such as cardiac arrest, intensive care admission and death [4, 6–8]. Physiological track and trigger systems (PTTSs) are increasingly being used as an aid to help healthcare workers identify deteriorating patients so that immediate, appropriate intervention can occur [9]. PTTSs utilize simple algorithms into which data pertaining to key vital signs (e.g. heart rate) are inputted [10]. A single composite score is generated and can be used by the medical team to determine the stability of the patient’s condition and to inform decisions regarding any changes in care [11, 12]. The implementation of PTTSs has been widely recommended to ensure that patient deterioration is recognized and addressed [12]. There is also emerging evidence that the information provided by PTTSs can improve the ability to detect clinical deterioration [13]. PTTSs have been found to help reduce intensive care unit (ICU) admissions after emergency surgical procedures [14], and to be predictive of sudden adverse events (SAEs) [7]. PTTSs are used in an increasingly diverse range of medical settings such as paediatrics [12, 15], surgery wards [16] and obstetrics [17]. However, despite the potential for PTTSs to have a positive impact on patient safety and quality of care [18], compliance with these systems has been found to be poor [11, 19, 20]. Non-compliance with PTTSs includes failure to record vital signs [21], or to take appropriate actions based upon the score [11, 20, 22]. These issues have been linked to problems with implementation, particularly in terms of the adequacy of the training on using the PTTSs [20, 22]. System-specific issues have also emerged which may limit the universal implementation of PTTSs such as limited utility with particular patient populations (e.g. chronic obstructive pulmonary disease (COPD); palliative care patients [23]), and human factors issues such as staff attitudes, poor communication of deterioration or confidence in the PTTS [24]. Given that the potential of PTTSs to improve patient care and prevent SAEs, healthcare workers’ lack of compliance with the implementation of these systems is concerning. This creates a need to identify and address the factors that are contributing to inappropriate, or non-, use of these systems. The aim of this systematic review is to examine, and synthesize, the qualitative research that has been carried out with healthcare workers that reports barriers to, and facilitators of, the implementation of PTTSs. Healthcare workers have a unique insight into the functioning of interventions or systems in situ. Their knowledge regarding barriers and facilitators to effective and appropriate implementation of PTTSs may inform future research in this area or specific changes required to these systems. Methods Search strategy Comprehensive searches were performed using PubMed, CINAHL, PsycInfo, Embase and Web of Science, in August 2016. A sample search strategy for this systematic review is presented in Supplementary Material 1. The searches used a combination of ‘early warning’ OR ‘track and trigger’ with a series of terms relating to healthcare workers and healthcare institutions. Year of publication was not restricted within the searches. All titles and abstracts returned during searches were screened to identify potentially relevant articles. Where an article appeared relevant, the full-text was viewed and a decision regarding its inclusion or exclusion was made. Finally, the reference lists of all included papers were examined to identify other potentially suitable studies for inclusion. Inclusion criteria Studies were required to present qualitative data concerning the perspectives and experiences of healthcare workers regarding the implementation of a PTTS within a hospital setting, be written in English, and be published in a peer-reviewed journal. Consistent with guidance from the Cochrane Qualitative Research Methods Group [25], we restricted the qualitative studies included to: empirical studies with a clear description of the sampling strategy, the data collection procedures and the type of data analysis used. Exclusion criteria Excluded studies were editorials, reviews and papers that were not based on actual experiences related to the implementation of PTTSs, quantitative-only studies or studies published in a language other than English. Studies were excluded if were we unable to determine the sampling strategy, data collection tool or how the data was analysed. Data extraction Data were extracted from each study on the following variables: author, year of publication, location of study, sample size, population (e.g. doctors, nurses), name of PTTS, qualitative data collection methods, summary of results and conclusion. Data extraction was performed independently by two researchers (F.C. and C.W.). There was agreement of 94.4% on the data extracted by the two raters. Areas of disagreement were resolved through discussion between the two raters. Content analysis Content analysis was carried out by F.C., P.O.C., S.L. and C.W. A deductive content analysis approach was taken to organizing and analysing the data [26]. This approach was used because we were using the dimensions, themes and sub themes identified by Bergs et al. [27], as part of their analysis of barriers and facilitators to the implementation of surgical safety checklists, as an initial framework for organizing the key findings. The findings from the papers included in the review were extracted (see Supplementary Material 2). Two dimensions were used to classify the data: ‘User-related changes required to implement PTTSs effectively’ and ‘Factors that affect user-related changes’. The first dimension is concerned with ensuring that the PTSS is being used as intended. This dimension is focused on changes that need to be made at the team level in order to get doctors and nurses to actually use the PTTS. The themes identified in this dimension are concerned with the attitudes and perceptions of staff to the PTTS, as well as organizational level considerations. The main themes and sub themes for this dimension are shown in Fig. 1. Figure 1 Open in new tabDownload slide Dimensions, themes and sub themes for classification. Figure 1 Open in new tabDownload slide Dimensions, themes and sub themes for classification. The second dimension is concerned with the barriers to, or facilitators of, the user-related changes required to successfully implement a PTTS. The main themes and sub themes for this dimension are also shown in Fig. 1. Although the key findings were consistent with the themes identified by Bergs et al. [27], it was necessary to make some changes at the sub theme level in order to ensure fit with the data collated from the PTTS papers. These changes to the Bergs et al. [27] framework were made through discussion and consensus. Graneheim and Lundman have previously emphasized the value of dialogue among coders in order to produce agreement on the way in which qualitative data should be coded [28]. Based upon the revised framework, each of the papers was discussed among the four researchers, and consensus reached about the relevant themes and sub themes on the basis of the data provided within each paper. The classifications are provided in Supplementary Material 2. Quality assessment The methodological quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs [QATSDD;[29]]. The QATSDD is a validated tool for assessing study quality [30, 31] and scores on this measure can range between 0 and 48, with higher scores indicative of stronger methodological rigour. To apply the instrument to the assessment of a qualitative study raters must appraise the study’s: theoretical framework; presentation of aims/objectives; description of the research setting, consideration of sample size in terms of analysis; representativeness of sample; description of data collection procedures; explanation of measurement tool selection; description of the recruitment process; the correspondence between the research question and the format and content of the data collection; correspondence between the research question and data analysis methodology; explanation of analytical method chosen; determination of the reliability of the analysis procedures; contribution of users to study design; and acknowledgment of study’s strengths and weaknesses. The methodological quality of the included papers was assessed by two reviewers (F.C. and C.W.). Any inconsistencies in scoring were reviewed and resolved through discussion. Results Search strategy The search strategy yielded 2727 papers. Following the removal of duplicates, and further screening, a total of 35 papers were considered potentially suitable for inclusion (see Fig. 2) and their full-text was examined. After full-text review, 10 studies were deemed to meet the inclusion criteria. Two of the included studies were mixed-methods. Figure 2 Open in new tabDownload slide PRISMA flow diagram. Figure 2 Open in new tabDownload slide PRISMA flow diagram. Quality score In these 10 studies, QATSDD scores ranged from 35.9 to 69.2% of the total possible score (M = 20.4, SD = 5.0). The studies performed best on the QATSDD subscale ‘description of procedures for data collection’, with a mean score of 2.7 (SD = 0.7) out of a possible total of three. The reviewed studies performed poorly on the subscales ‘good justification for analytic method selected’ (M = 0.7, SD = 1.2) and ‘evidence of user involvement in design’ (M = 0.3, SD = 0.7). Synthesis of findings Of the 10 included studies, 5 were carried out in the UK, 2 in Ireland and 1 each in the USA, Australia and Norway. Four of the studies only included a single type of healthcare worker (e.g. nurses), with the remainder having representation from more than one group of healthcare workers. The mean number of participants included was 47.1 (SD 64.5; range 6–218). The studies included an assessment of six different PTTSs: the Modified Early Warning Score (MEWS; n = 3), the Irish National Early Warning Score (NEWS; n = 2), the Early Warning Score (EWS; n = 1), the observation and response chart (n = 1), the Patient at Risk (PAR; n = 1) chart and the Modified Obstetrics Early Warning Score (MEOWS; n = 1) For more details, see Supplementary Material 2. As shown in Fig. 1, the data were classified under two dimensions: ‘User-related changes required to implement PTTSs effectively’ and ‘Factors that affect user-related changes’. Dimension 1: User-related changes required to implement PTTSs effectively The themes, sub themes and descriptive examples from the included papers are shown in Table 1. A more detailed outline of the included studies and the corresponding themes identified are provided in Supplementary Material 2. Table 1 Themes, sub themes and descriptive example for the ‘User-related changes required to implement PTTS effectively’ dimension Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Table 1 Themes, sub themes and descriptive example for the ‘User-related changes required to implement PTTS effectively’ dimension Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Theme 1.1: Staff perception of the PTTS and patient safety Some staff praised the system for alerting nurses and physicians to concerning vital sign changes [36, 37], and helping staff to quickly identify deteriorating patients [22, 32]. However, there was a perceived negative impact of PTTSs on clinical judgement [22, 32, 38]. PTTSs were seen as improving the medical response to deterioration [22, 33, 34]. This increased patient intervention was commonly thought to result in alarm fatigue and the potential for false alarms [22, 32, 39]. The additional documentation was perceived to increase workload without substantive benefit [22, 34, 38]. A recommended solution was to streamline the documentation [32]. Theme 1.2: Workflow adjustments Integrating a PTTS into existing healthcare structures required a change in staff workflow [33, 35]. This may include the re-alignment of staff schedules [38] or streamlining of hospital protocols [32]. Rapid response to deterioration often depended on immediate availability of doctors. This lack of response is particularly challenging when senior medical team members were busy [22, 35, 39]. The lack of doctor availability was sometimes reported by nurses to lead to a delay in patients receiving the appropriate treatment [33]. However, the system was successful in increasing nurses’ and junior medical staff members’ initiative to take charge of a situation rather than waiting for a more senior doctor to arrive and diagnose the patient before starting treatment [33, 35]. Dimension 2: Factors that affect user-related changes The themes, sub themes and descriptive examples from included papers are shown in Table 2. A more detailed outline of the included studies and the themes identified within each are provided in Supplementary Material 2. Table 2 Themes, sub themes and exemplar citation for the ‘Factors that affect user-related changes’ dimension Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Table 2 Themes, sub themes and exemplar citation for the ‘Factors that affect user-related changes’ dimension Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Theme 2: PTTS The support of key multidisciplinary stakeholders is necessary for the success of the system [41]. There is a common perception that PTTS scores are devised without proper stakeholder involvement [38]. As such, the users of the PTTS can feel little psychological ownership of the system, which negatively impacts their likelihood of using it [38]. However, where staff perceived benefits in using the system, the level of psychological ownership is higher than when this is not the case, especially among less senior medical staff and nurses [22, 32]. Theme 2.3: Implementation Process When training on using the PTTSs was implemented effectively, nursing staff reported a greater ability to read the chart and recognize deterioration [33]. However, senior doctors may be unaware of their expected role in the use of the PTTSs [39]. In addition, it appeared that staff in some studies did not feel training was adequate [38, 39]. Specific issues identified that could be remediated through training were the awareness of senior doctors to adjust parameters when required for certain conditions [33, 39], and the lack of strict guidelines for how the system should be used [35]. Nurses have lauded the improved inter-professional communication and greater prioritization for patients at risk of immediate deterioration that is afforded by the implementation of a PTTS [22, 35, 40]. However, there can be a disjunction between doctors and nurses’ perception of how to utilize the system. Nurses see the system as a method to get doctors to come and examine a particular patient [32, 34, 39]. Although junior doctors also appear to approach PTTSs as a prioritization tool to assess the severity of deterioration, they have more of a focus on the specific scores that are used to derive the overall score-despite the score not having been designed for this purpose [22, 40]. Theme 2.4: Local context The introduction of a PTTS was well received in contexts where staff could seamlessly incorporate the system into their existing work patterns [32, 34, 37]. However, a common finding was that the level of understanding of the PTTS was not consistent across different professional groups [22, 32, 34–36, 39]. It was reported that delays in response times were a result of doctors’ lack of awareness of their specific role when implementing PTTSs [32, 39]. Discussion A consistent finding in articles on quality improvement in healthcare is that change is difficult to achieve, and can be challenging to sustain [41]. PTTSs have been identified as an effective intervention for identifying deteriorating patients [42] and a means of reducing the occurrence of SAEs [43]. However, in spite of the potential for improving patient safety and quality of care, issues relating to compliance with PTTS protocols have been identified [32]. When introducing a behavioural-based safety intervention, such as a PTTS, it is important that consideration is given to the socio-technological system. These systems approach to complex organizational work design recognizes the interaction between people and technology [44]. This systems approach recognizes that changes in an organization require the consideration of a range of factors interacting at different levels (e.g. individual healthcare providers, teams, organization, economic and political context [44]). The findings from this systematic review have demonstrated that there is a need to consider both how the system fits within the current workflow, and the implementation process itself. The findings from our systematic review are in broad agreement with many of the factors that were identified as being detrimental to the implementation of the World Health Organization (WHO) surgical checklist identified in the Bergs et al.’s systematic review [27]. For example, workflow, psychological ownership and training were common issues with both safety interventions. This finding is unsurprising as the implementation of any new patient safety intervention is a complicated process that requires a consideration of how the proposed safety improvement integrates within a complex socio-technological system. Simply imposing a safety intervention is unlikely to be effective if the implementation process has not been carefully considered [35, 39]. The papers included in our review suggest that PTTS can increase the frequency of ‘false positives’, workload and need for intervention [22, 32, 39]. In order to be useful, PTTSs must balance specificity and sensitivity. Therefore, the precision of the thresholds included may be crucial [45]. Too many ‘false positives’ may discourage staff from engaging with the PTTS. Therefore, it is perhaps unsurprising that compliance with PTTSs has been found to be poor [38]. This lack of compliance may be exacerbated by the lack of willingness of senior doctors to modify the parameters [39]. The belief that PTTSs have a negative effect on clinical judgement is also a common criticism levelled at these systems [22, 32, 38]. PTTSs should act as decision support tools that reinforce clinical decision-making as opposed to replacing it. A mechanism that has been suggested for encouraging nurses to use their clinical judgement in assessing patients may be to alter PTTSs such that nurses’ perceptions of changes in patients’ conditions could contribute to the overall score [46]. It is noteworthy that the importance of support for senior leadership was not explicitly mentioned in the majority of the papers included in this review. However, it was common that senior medical team members were unaware of their role in the PTTS process [22, 33, 35]. Although support from leadership was infrequently mentioned, it is arguably implicit in terms of being required to address issues of workflow, aligning the system with existing guidelines and supporting education and training. There is a growing literature demonstrating that sustainable interventions require active and supportive leadership, an infrastructure to support the intervention, training, involvement of key internal and external stakeholders, multidisciplinary collaboration, support for local adaptation and rewards for innovation and change [47]. A supportive leadership has been identified as an important factor in the successful implementation of any safety system [48]. Future research Based upon the review, it is possible to identify a number of areas for future research. First, the quality of the papers included in the review was variable. Researchers should ensure rigour in both data collection and analysis in future qualitative assessments of PTTSs. Second, future research should ensure that the opinions of all of the groups that are involved in the use of a PTTS are represented. The majority of included papers focus on one particular group of healthcare professionals, and even when doctors were included they tended to be smaller in number than nurses or midwives. Although most of the included studies did not include detail about the seniority of the participants, only one study [36] specifically reported the inclusion of senior physicians. Therefore, it is likely that the opinions of this particular group were under-represented. Finally, in addition to the issue of representativeness, researchers should ensure that there are sufficient numbers of participants to reach data saturation. To illustrate, three of the included studies had seven or less participants. It is difficult to provide an exact number of when data saturation is achieved. This depends upon the methodological and epistemological perspective of the researcher [49]. However, it seems unlikely that a sample of <10 respondents from one professional group of healthcare providers is going to provide a complete overview of every perspective to the use of a PTTS. Limitations There are a number of limitations to this systematic review. First, although we aimed to reduce reviewer bias by having two authors conduct the data extraction independently, the published conclusions are only representative of the reviewers’ interpretations of data presented within the included papers. Second, we adapted Bergs et al. [27] thematic structure to analyse our data. It is possible that the adoption of another structure to analyse the content of our data may have yielded different outcomes. Third, there was variability between the type of PTTS, and the domain of healthcare in which the PTTS was applied. As such, arguably, caution should be taken in drawing general conclusions due to these differences. Nevertheless, there are considerable similarities between these PTTSs, and they share a common purpose of identifying acutely unwell patients. This is reflected in the homogeneity of the themes found across the papers. Finally, we only reviewed qualitative data in this systematic review, which can lead to general criticism of qualitative research concerning researcher bias and generalization [50]. Conclusion PTTSs are complex socio-technological interventions that require consideration at the level of the individual, team, hospital and policy [47]. It is essential that future research explores modifications or strategies that may allow for the better functioning of PTTSs and assesses the effect on patient outcomes. Implementing a new safety system is more than just eliminating barriers [27]. Successful implementation of a PTTS must address the social context in which the PTTS is to be implemented. Consideration must also be given to how the system is integrated with current work practices, and how to foster support from the end users. The absence of an effective implementation strategy will mean that the potential benefits for patient safety and quality of care of PTTSs will not be realized. Supplementary material Supplementary material is available at International Journal for Quality in Health Care online. Funding This research was partially supported by funding from the National Doctor Training and Planning, Health Services Executive, Republic of Ireland. References 1 Mitchell IA , McKay H, Van Leuvan C et al. . A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients . Resuscitation 2010 ; 81 : 658 – 66 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Kause J , Smith G, Prytherch D et al. . A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study . Resuscitation 2004 ; 62 : 275 – 82 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Hillman KM , Bristow PJ, Chey T et al. . Duration of life-threatening antecedents prior to intensive care admission . Intensive Care Med 2002 ; 28 : 1629 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Hogan H , Healey F, Neale G et al. . Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study . BMJ Qual Saf 2012 ; 21 : 737 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Findlay GP , Shotton H, Kelly K et al. . Time to Intervene?: A Review of Patients who Underwent Cardiopulmonary Resuscitation as a Result of an in-hospital Cardiorespiratory Arrest. www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf (10 April 2017 , date last accessed). 6 Cei M , Bartolomei C, Mumoli N. In‐hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score: a prospective study . Int J Clin Pract 2009 ; 63 : 591 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 7 De Meester K , Das T, Hellemans K et al. . Impact of a standardized nurse observation protocol including MEWS after intensive care unit discharge . Resuscitation 2013 ; 84 : 184 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Paterson R , MacLeod DC, Thetford D et al. . Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit . Clin Med 2006 ; 6 : 281 – 4 . Google Scholar Crossref Search ADS WorldCat 9 Subbe CP , Kruger M, Rutherford P et al. . Validation of a modified Early Warning Score in medical admissions . QJM 2001 ; 94 : 521 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Morgan RJ , Williams F, Wright MM. An early warning score for the early detection of patients with impending illness . Clin Intensive Care 1997 ; 8 : 100 . OpenURL Placeholder Text WorldCat 11 Ludikhuize J , de Jonge E, Goossens A. Measuring adherence among nurses one year after training in applying the Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments . Resuscitation 2011 ; 82 : 1428 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Smith GB , Prytherch DR, Meredith P et al. . The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death . Resuscitation 2013 ; 84 : 465 – 70 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Fullerton JN , Price CL, Silvey NE et al. . Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment? Resuscitation 2012 ; 83 : 557 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Peris A , Zagli G, Maccarrone N et al. . The use of Modified Early Warning Score may help anesthesists in postoperative level of care selection in emergency abdominal surgery . Minerva Anestesiol 2012 ; 78 : 1034 – 8 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 15 Adshead N , Thomson R. Use of a paediatric early warning system in emergency departments: implementing an early warning system to identify deterioration can help adult-trained nurses accurately assess children’s needs and interventions, say Nicola Adshead and Raynie Thomson . Emerg Nurs 2009 ; 17 : 22 – 5 . Google Scholar Crossref Search ADS WorldCat 16 Subbe CP , Williams E, Fligelstone L et al. . Does earlier detection of critically ill patients on surgical wards lead to better outcomes? Ann R Coll Surg Engl 2005 ; 87 : 226 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Bick DE , Sandall J, Furuta M et al. . A national cross sectional survey of heads of midwifery services of uptake, benefits and barriers to use of obstetric early warning systems (EWS) by midwives . Midwifery 2014 ; 30 : 1140 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Health Service Executive (HSE) . Training Manual for the Compass© Education Programme Incorporating the National Early Warning Score (for Non-Pregnant Adult Patients). Available from: http://www.hse.ie/eng/about/Who/clinical/natclinprog/acutemedicineprogramme/earlywarningscore/trainingmanual6.pdf (10 April 2017 , date last accessed). 19 Hands C , Reid E, Meredith P et al. . Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol . BMJ Qual Saf 2013 ; 22 : 719 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Niegsch M , Fabritius ML, Anhøj J. Imperfect implementation of an early warning scoring system in a Danish teaching hospital: a cross-sectional study . PLoS ONE 2013 ; 8 : e70068 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Fuhrmann L , Østergaard D, Lippert A et al. . A multi-professional full-scale simulation course in the recognition and management of deteriorating hospital patients . Resuscitation 2009 ; 80 : 669 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Lydon S , Byrne D, Offiah G et al. . A mixed-methods investigation of health professionals’ perceptions of a physiological track and trigger system . BMJ Qual Saf 2016 ; 25 : 688 – 69 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Prytherch DR , Smith GB, Schmidt PE et al. . ViEWS—towards a national early warning score for detecting adult inpatient deterioration . Resuscitation 2010 ; 31 : 932 – 7 . Google Scholar Crossref Search ADS WorldCat 24 Le Lagadec MD , Dwyer T. Scoping review: the use of early warning systems for the identification of in-hospital patients at risk of deterioration . Aust Crit Care 2016 . doi.org/10.1016/j.aucc.2016.10.003 . OpenURL Placeholder Text WorldCat 25 Hannes K . Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K et al. (eds). Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions, Version 1. Cochrane Collaboration Qualitative Methods Group, 2011 . cqrmg.cochrane.org/supplemental-handbook-guidance. (10 April 2017, date last accessed). Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 26 Elo S , Kyngäs H. The qualitative content analysis process . J Adv Nurs 2008 ; 62 : 107 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Bergs J , Lambrechts F, Simons P et al. . Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence . BMJ Qual Saf 2015 ; 24 : 776 – 86 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Graneheim UH , Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . Nurs Educ Today 2004 ; 24 : 105 – 12 . Google Scholar Crossref Search ADS WorldCat 29 Sirriyeh R , Lawton R, Gardner P et al. . Reviewing studies with diverse designs: the development and evaluation of a new tool . J Eval Clin Pract 2012 ; 18 : 746 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 30 Blackwell JE , Alammar HA, Weighall AR et al. . A systematic review of cognitive function and psychosocial well-being in school-age children with narcolepsy . Sleep Med Rev 2016 . dx.doi.org/10.1016/j.smrv.2016.07.003 . OpenURL Placeholder Text WorldCat 31 Augestad LB , Jiang L. Physical activity, physical fitness, and body composition among children and young adults with visual impairments: a systematic review . Br J Vis Impair 2015 ; 33 : 167 – 82 . Google Scholar Crossref Search ADS WorldCat 32 Elliott D , Allen E, Perry L et al. . Clinical user experiences of observation and response charts: focus group findings of using a new format chart incorporating a track and trigger system . BMJ Qual Saf 2015 ; 24 : 65 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 33 McDonnell A , Tod A, Bray K et al. . A before and after study assessing the impact of a new model for recognizing and responding to early signs of deterioration in an acute hospital . J Adv Nurs 2013 ; 69 : 41 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Cherry PG , Jones CP. Attitudes of nursing staff towards a Modified Early Warning System . Br J Nurs 2015 ; 24 : 812 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Donohue LA , Endacott R. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards . Intensive Crit Care Nurs 2010 ; 26 : 10 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Bonafide CP , Roberts KE, Weirich CM et al. . Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety . J Hosp Med 2013 ; 8 : 248 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Stafseth SK , Grønbeck S, Lien T et al. . The experiences of nurses implementing the Modified Early Warning Score and a 24-hour on-call Mobile Intensive Care Nurse: an exploratory study . Intensive Crit Care Nurs 2016 ; 34 : 33 – 41 . Google Scholar Crossref Search ADS WorldCat 38 Martin RL . Midwives’ experiences of using a modified early obstetric warning score (MEOWS): a grounded theory study . Evid Based Midwifery 2015 ; 13 : 59 – 65 . OpenURL Placeholder Text WorldCat 39 Fox A , Elliott N. Early warning scores: a sign of deterioration in patients and systems: Adrian Fox and Naomi Elliott report on nurses’ experience of using the tool and the problems they encountered . Nurs Manag 2015 ; 22 : 26 – 31 . Google Scholar Crossref Search ADS WorldCat 40 Andrews T , Waterman H. Packaging: a grounded theory of how to report physiological deterioration effectively . J Adv Nurs 2005 ; 52 : 473 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat 41 Grol RP , Bosch MC, Hulscher ME et al. . Planning and studying improvement in patient care: the use of theoretical perspectives . Milbank Q 2007 ; 85 : 93 – 138 . Google Scholar Crossref Search ADS PubMed WorldCat 42 Alam N , Hobbelink EL, Van Tienhoven AJ et al. . The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review . Resuscitation 2014 ; 85 : 587 – 94 . Google Scholar Crossref Search ADS PubMed WorldCat 43 Hillman KM , Bristow PJ, Chey T et al. . Antecedents to hospital deaths . Int Med J 2001 ; 31 : 343 – 8 . Google Scholar Crossref Search ADS WorldCat 44 Flin R , Winter J, Sarac C et al. . Report for Methods and Measures Working Group of WHO Patient Safety. Cakil Sarac MR. Human Factors in Patient Safety: Review of Topics and Tools . Geneva : World Health Organization , 2009 : 05 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 45 Chapman SM , Wray J, Oulton K et al. . ‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems . Arch Dis Child 2017 ; 102 : 487 – 95 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Kyriacos U , Jelsma J, Jordan S. Monitoring vital signs using early warning scoring systems: a review of the literature . J Nurs Manag 2011 ; 19 : 311 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 47 Pronovost PJ , Watson SR, Goeschel CA et al. . Sustaining reductions in central line–associated bloodstream infections in Michigan intensive care units: a10-year analysis . Am J Med Qual 2016 ; 31 : 197 – 202 . Google Scholar Crossref Search ADS PubMed WorldCat 48 Catchpole K , Russ S. The problem with checklists . BMJ Qual Saf 2015 . doi:10.1136/bmjqs-2015-004431 . OpenURL Placeholder Text WorldCat 49 Baker SE , Edwards R. How Many Qualitative Interviews is Enough?: Expert Voices and Early Career Reflections on Sampling and Cases in Qualitative Research . Southampton : National Centre for Research Methods , 2012 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 50 Britten N , Fisher B. Qualitative research and general practice . Br J Gen Pract 1993 ; 43 : 270 – 1 . Google Scholar PubMed OpenURL Placeholder Text WorldCat © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence

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Oxford University Press
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© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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10.1093/intqhc/mzx148
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Abstract

Abstract Purpose To identify the barriers to, and facilitators of, the implementation of physiological track and trigger systems (PTTSs), perceived by healthcare workers, through a systematic review of the extant qualitative literature. Data sources Searches were performed in PUBMED, CINAHL, PsycInfo, Embase and Web of Science. The reference lists of included studies were also screened. Study selection The electronic searches yielded 2727 papers. After removing duplicates, and further screening, a total of 10 papers were determined to meet the inclusion criteria and were reviewed. Data extraction A deductive content analysis approach was taken to organizing and analysing the data. A framework consisting of two overarching dimensions (‘User-related changes required to implement PTTSs effectively’ and ‘Factors that affect user-related changes’), 5 themes (staff perceptions of PTTSs and patient safety, workflow adjustment, PTTS, implementation process and local context) and 14 sub themes was used to classify the barriers and facilitators to the implementation of PTTSs. Results of data synthesis Successful implementation of a PTTS must address the social context in which it is to be implemented by ensuring that the users believe that the system is effective and benefits patient care. The users must feel invested in the PTTS and its use must be supported by training to ensure that all healthcare workers, senior and junior, understand their role in using the system. Conclusion PTTSs can improve patient safety and quality of care. However, there is a need for a robust implementation strategy or the benefits of PTTSs will not be realized. systematic review, critical illness, early warning system, early warning score, qualitative methods Introduction The incidence of in-patient hospital deaths has been estimated to be 9.5 patients per 1000 admissions [1]. Many of these deaths are not without prior warning signs of patient deterioration. This deterioration is often preceded by identifiable, negative changes in physiological parameters [2–6] in the hours preceding serious adverse events such as cardiac arrest, intensive care admission and death [4, 6–8]. Physiological track and trigger systems (PTTSs) are increasingly being used as an aid to help healthcare workers identify deteriorating patients so that immediate, appropriate intervention can occur [9]. PTTSs utilize simple algorithms into which data pertaining to key vital signs (e.g. heart rate) are inputted [10]. A single composite score is generated and can be used by the medical team to determine the stability of the patient’s condition and to inform decisions regarding any changes in care [11, 12]. The implementation of PTTSs has been widely recommended to ensure that patient deterioration is recognized and addressed [12]. There is also emerging evidence that the information provided by PTTSs can improve the ability to detect clinical deterioration [13]. PTTSs have been found to help reduce intensive care unit (ICU) admissions after emergency surgical procedures [14], and to be predictive of sudden adverse events (SAEs) [7]. PTTSs are used in an increasingly diverse range of medical settings such as paediatrics [12, 15], surgery wards [16] and obstetrics [17]. However, despite the potential for PTTSs to have a positive impact on patient safety and quality of care [18], compliance with these systems has been found to be poor [11, 19, 20]. Non-compliance with PTTSs includes failure to record vital signs [21], or to take appropriate actions based upon the score [11, 20, 22]. These issues have been linked to problems with implementation, particularly in terms of the adequacy of the training on using the PTTSs [20, 22]. System-specific issues have also emerged which may limit the universal implementation of PTTSs such as limited utility with particular patient populations (e.g. chronic obstructive pulmonary disease (COPD); palliative care patients [23]), and human factors issues such as staff attitudes, poor communication of deterioration or confidence in the PTTS [24]. Given that the potential of PTTSs to improve patient care and prevent SAEs, healthcare workers’ lack of compliance with the implementation of these systems is concerning. This creates a need to identify and address the factors that are contributing to inappropriate, or non-, use of these systems. The aim of this systematic review is to examine, and synthesize, the qualitative research that has been carried out with healthcare workers that reports barriers to, and facilitators of, the implementation of PTTSs. Healthcare workers have a unique insight into the functioning of interventions or systems in situ. Their knowledge regarding barriers and facilitators to effective and appropriate implementation of PTTSs may inform future research in this area or specific changes required to these systems. Methods Search strategy Comprehensive searches were performed using PubMed, CINAHL, PsycInfo, Embase and Web of Science, in August 2016. A sample search strategy for this systematic review is presented in Supplementary Material 1. The searches used a combination of ‘early warning’ OR ‘track and trigger’ with a series of terms relating to healthcare workers and healthcare institutions. Year of publication was not restricted within the searches. All titles and abstracts returned during searches were screened to identify potentially relevant articles. Where an article appeared relevant, the full-text was viewed and a decision regarding its inclusion or exclusion was made. Finally, the reference lists of all included papers were examined to identify other potentially suitable studies for inclusion. Inclusion criteria Studies were required to present qualitative data concerning the perspectives and experiences of healthcare workers regarding the implementation of a PTTS within a hospital setting, be written in English, and be published in a peer-reviewed journal. Consistent with guidance from the Cochrane Qualitative Research Methods Group [25], we restricted the qualitative studies included to: empirical studies with a clear description of the sampling strategy, the data collection procedures and the type of data analysis used. Exclusion criteria Excluded studies were editorials, reviews and papers that were not based on actual experiences related to the implementation of PTTSs, quantitative-only studies or studies published in a language other than English. Studies were excluded if were we unable to determine the sampling strategy, data collection tool or how the data was analysed. Data extraction Data were extracted from each study on the following variables: author, year of publication, location of study, sample size, population (e.g. doctors, nurses), name of PTTS, qualitative data collection methods, summary of results and conclusion. Data extraction was performed independently by two researchers (F.C. and C.W.). There was agreement of 94.4% on the data extracted by the two raters. Areas of disagreement were resolved through discussion between the two raters. Content analysis Content analysis was carried out by F.C., P.O.C., S.L. and C.W. A deductive content analysis approach was taken to organizing and analysing the data [26]. This approach was used because we were using the dimensions, themes and sub themes identified by Bergs et al. [27], as part of their analysis of barriers and facilitators to the implementation of surgical safety checklists, as an initial framework for organizing the key findings. The findings from the papers included in the review were extracted (see Supplementary Material 2). Two dimensions were used to classify the data: ‘User-related changes required to implement PTTSs effectively’ and ‘Factors that affect user-related changes’. The first dimension is concerned with ensuring that the PTSS is being used as intended. This dimension is focused on changes that need to be made at the team level in order to get doctors and nurses to actually use the PTTS. The themes identified in this dimension are concerned with the attitudes and perceptions of staff to the PTTS, as well as organizational level considerations. The main themes and sub themes for this dimension are shown in Fig. 1. Figure 1 Open in new tabDownload slide Dimensions, themes and sub themes for classification. Figure 1 Open in new tabDownload slide Dimensions, themes and sub themes for classification. The second dimension is concerned with the barriers to, or facilitators of, the user-related changes required to successfully implement a PTTS. The main themes and sub themes for this dimension are also shown in Fig. 1. Although the key findings were consistent with the themes identified by Bergs et al. [27], it was necessary to make some changes at the sub theme level in order to ensure fit with the data collated from the PTTS papers. These changes to the Bergs et al. [27] framework were made through discussion and consensus. Graneheim and Lundman have previously emphasized the value of dialogue among coders in order to produce agreement on the way in which qualitative data should be coded [28]. Based upon the revised framework, each of the papers was discussed among the four researchers, and consensus reached about the relevant themes and sub themes on the basis of the data provided within each paper. The classifications are provided in Supplementary Material 2. Quality assessment The methodological quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs [QATSDD;[29]]. The QATSDD is a validated tool for assessing study quality [30, 31] and scores on this measure can range between 0 and 48, with higher scores indicative of stronger methodological rigour. To apply the instrument to the assessment of a qualitative study raters must appraise the study’s: theoretical framework; presentation of aims/objectives; description of the research setting, consideration of sample size in terms of analysis; representativeness of sample; description of data collection procedures; explanation of measurement tool selection; description of the recruitment process; the correspondence between the research question and the format and content of the data collection; correspondence between the research question and data analysis methodology; explanation of analytical method chosen; determination of the reliability of the analysis procedures; contribution of users to study design; and acknowledgment of study’s strengths and weaknesses. The methodological quality of the included papers was assessed by two reviewers (F.C. and C.W.). Any inconsistencies in scoring were reviewed and resolved through discussion. Results Search strategy The search strategy yielded 2727 papers. Following the removal of duplicates, and further screening, a total of 35 papers were considered potentially suitable for inclusion (see Fig. 2) and their full-text was examined. After full-text review, 10 studies were deemed to meet the inclusion criteria. Two of the included studies were mixed-methods. Figure 2 Open in new tabDownload slide PRISMA flow diagram. Figure 2 Open in new tabDownload slide PRISMA flow diagram. Quality score In these 10 studies, QATSDD scores ranged from 35.9 to 69.2% of the total possible score (M = 20.4, SD = 5.0). The studies performed best on the QATSDD subscale ‘description of procedures for data collection’, with a mean score of 2.7 (SD = 0.7) out of a possible total of three. The reviewed studies performed poorly on the subscales ‘good justification for analytic method selected’ (M = 0.7, SD = 1.2) and ‘evidence of user involvement in design’ (M = 0.3, SD = 0.7). Synthesis of findings Of the 10 included studies, 5 were carried out in the UK, 2 in Ireland and 1 each in the USA, Australia and Norway. Four of the studies only included a single type of healthcare worker (e.g. nurses), with the remainder having representation from more than one group of healthcare workers. The mean number of participants included was 47.1 (SD 64.5; range 6–218). The studies included an assessment of six different PTTSs: the Modified Early Warning Score (MEWS; n = 3), the Irish National Early Warning Score (NEWS; n = 2), the Early Warning Score (EWS; n = 1), the observation and response chart (n = 1), the Patient at Risk (PAR; n = 1) chart and the Modified Obstetrics Early Warning Score (MEOWS; n = 1) For more details, see Supplementary Material 2. As shown in Fig. 1, the data were classified under two dimensions: ‘User-related changes required to implement PTTSs effectively’ and ‘Factors that affect user-related changes’. Dimension 1: User-related changes required to implement PTTSs effectively The themes, sub themes and descriptive examples from the included papers are shown in Table 1. A more detailed outline of the included studies and the corresponding themes identified are provided in Supplementary Material 2. Table 1 Themes, sub themes and descriptive example for the ‘User-related changes required to implement PTTS effectively’ dimension Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Table 1 Themes, sub themes and descriptive example for the ‘User-related changes required to implement PTTS effectively’ dimension Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Theme . Sub theme . Descriptive example from included studies . Staff perception of the PTTS and patient safety Perception of tool’s utility The PTTS score was useful for providing concrete evidence to back up clinical judgement (Elliott et al. [32]). ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ (McDonnell et al. [33]) Clinical judgement The PTTS was useful in building confidence in recognizing and communicating deterioration, especially for newly qualified and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts’ (Elliott et al. [32]). However, there was the view that the tool was an example of de-skilling and erasing clinical judgement (Elliott et al. [32]). ‘We should be educating junior staff to look for more than just teaching them to use colours’ (McDonnell et al. [33]) Increased intervention The PTTS was successful at improving the nurses’ understanding of the need to emphasize importance of doctor review. ‘You can see the score is getting higher and shove it in front of them and they [the doctors have] got to look at it, haven’t they?’ (Cherry & Jones [34]) Perceived importance The PTTS was beneficial during handovers for junior doctors, and provided a rationale for contacting more senior doctors. ‘It gives you a clear cut reason to contact someone more senior… they’ll ask you why you called them and if the [score] is high that can be the reason’ (Lydon et al. [22]) Workflow adjustments Aligning workflow of team members The mandatory involvement of senior staff may cause a time delay in the treatment of patients, especially among surgical teams where senior medical staff are working in outpatient clinics or the operating theatre. ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can’t always get them’ (Donohue & Endacott [35]) Increased activity for uncertain benefit The system appeared to increase the potential for false alarms and alarm fatigue. ‘NEWS [the PTTS] has increased the number of interventions on patients including possibly unnecessary interventions’ (Lydon et al. [22]) Theme 1.1: Staff perception of the PTTS and patient safety Some staff praised the system for alerting nurses and physicians to concerning vital sign changes [36, 37], and helping staff to quickly identify deteriorating patients [22, 32]. However, there was a perceived negative impact of PTTSs on clinical judgement [22, 32, 38]. PTTSs were seen as improving the medical response to deterioration [22, 33, 34]. This increased patient intervention was commonly thought to result in alarm fatigue and the potential for false alarms [22, 32, 39]. The additional documentation was perceived to increase workload without substantive benefit [22, 34, 38]. A recommended solution was to streamline the documentation [32]. Theme 1.2: Workflow adjustments Integrating a PTTS into existing healthcare structures required a change in staff workflow [33, 35]. This may include the re-alignment of staff schedules [38] or streamlining of hospital protocols [32]. Rapid response to deterioration often depended on immediate availability of doctors. This lack of response is particularly challenging when senior medical team members were busy [22, 35, 39]. The lack of doctor availability was sometimes reported by nurses to lead to a delay in patients receiving the appropriate treatment [33]. However, the system was successful in increasing nurses’ and junior medical staff members’ initiative to take charge of a situation rather than waiting for a more senior doctor to arrive and diagnose the patient before starting treatment [33, 35]. Dimension 2: Factors that affect user-related changes The themes, sub themes and descriptive examples from included papers are shown in Table 2. A more detailed outline of the included studies and the themes identified within each are provided in Supplementary Material 2. Table 2 Themes, sub themes and exemplar citation for the ‘Factors that affect user-related changes’ dimension Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Table 2 Themes, sub themes and exemplar citation for the ‘Factors that affect user-related changes’ dimension Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Theme . Sub theme . Descriptive example from included studies . PTTS Execution process did not merge with existing guidelines Senior nurses’ concerns centred on the lack of flexibility of the PTTS for patients with pre-existing chronic diseases where the PTTS did not recognize that abnormal vitals were to be expected (Elliott et al. [32]). ‘Someone with COPD is not going to have a respiratory rate of 12 to 16, it’s going to be more elevated generally, but that is normal for them’ (McDonnell et al. [33]) Psychological ownership Strict escalation procedures were found to be empowering for less experienced staff. ‘[It] certainly gives you a bit more bravery to pick up the phone’ (Elliott et al. [32]) Implementation Process Education and training Some doctors were unaware of the significance of scores observed, their role within the system, or of the corresponding escalation procedures. The participants attributed these problems to a lack of training (Fox & Elliott [39]). ‘[The PTTS] put the responsibility on the nurse to call for help. However the doctors don’t write acceptable parameters at the back of the sheet. So we have to keep calling every time the patient triggers’ (Fox & Elliott [39]) Reluctance to modify parameters Doctors were reluctant to modify parameters for patients with chronic conditions. This caused patients to trigger the PTTS in the absence of clinical deterioration, which resulted in over-reporting and false positives (Lydon et al. [22]; Elliott et al. [32]). ‘The nurse in charge would be constantly reviewing twenty-eight patients and that’s all they would do all shift, because at some time, each patient would fall into the orange section for some reason’ (Fox & Elliott [39]) Lack of strict guidelines There appeared to be frequent misunderstandings between care teams. ‘…The responsibility and ultimate charge rests with the team [surgical or medical] looking after them and I feel very much I am brought in to help give some advice, to offer support but not take charge’ (Donohue & Endacott [35]) Local Context Communication and language The PTTS empowers nurses to take action to protect their deteriorating patients. You see, with the early warning system you have got more ammunition, haven’t you…It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can’t argue with a score of 5 or 6. They’ll just come’ (Andrews & Waterman [40]) Improving credibility of referral The score packages a multitude of changes in vital signs together to improve the credibility of a patient referral: ‘There’s a certain level at which you need to report things, whereas sometimes I think without the scoring system you could be reporting lots of little things all the time and always being told that it’s nothing to worry about’ (Andrews & Waterman [40]) Organizational context One criticism of nurses’ implementation of the system was the suggestion by medical staff that nursing staff viewed the PTTS as a way of offloading responsibility (Bergs et al. [27]).‘Some nurses see [the PTTS] as something where they ring you and then wash their hands- They’ve rung someone, anyone, so their job is now done’ (Bergs et al. [27]). Nurses criticized medical staff for failing to adequately fulfil the duties required of them by the chart: doctors commonly failed to complete the section of the chart documenting previously recorded changes: ‘…getting the doctor to fill in the modification…a nightmare’ (Elliott et al. [32]) Theme 2: PTTS The support of key multidisciplinary stakeholders is necessary for the success of the system [41]. There is a common perception that PTTS scores are devised without proper stakeholder involvement [38]. As such, the users of the PTTS can feel little psychological ownership of the system, which negatively impacts their likelihood of using it [38]. However, where staff perceived benefits in using the system, the level of psychological ownership is higher than when this is not the case, especially among less senior medical staff and nurses [22, 32]. Theme 2.3: Implementation Process When training on using the PTTSs was implemented effectively, nursing staff reported a greater ability to read the chart and recognize deterioration [33]. However, senior doctors may be unaware of their expected role in the use of the PTTSs [39]. In addition, it appeared that staff in some studies did not feel training was adequate [38, 39]. Specific issues identified that could be remediated through training were the awareness of senior doctors to adjust parameters when required for certain conditions [33, 39], and the lack of strict guidelines for how the system should be used [35]. Nurses have lauded the improved inter-professional communication and greater prioritization for patients at risk of immediate deterioration that is afforded by the implementation of a PTTS [22, 35, 40]. However, there can be a disjunction between doctors and nurses’ perception of how to utilize the system. Nurses see the system as a method to get doctors to come and examine a particular patient [32, 34, 39]. Although junior doctors also appear to approach PTTSs as a prioritization tool to assess the severity of deterioration, they have more of a focus on the specific scores that are used to derive the overall score-despite the score not having been designed for this purpose [22, 40]. Theme 2.4: Local context The introduction of a PTTS was well received in contexts where staff could seamlessly incorporate the system into their existing work patterns [32, 34, 37]. However, a common finding was that the level of understanding of the PTTS was not consistent across different professional groups [22, 32, 34–36, 39]. It was reported that delays in response times were a result of doctors’ lack of awareness of their specific role when implementing PTTSs [32, 39]. Discussion A consistent finding in articles on quality improvement in healthcare is that change is difficult to achieve, and can be challenging to sustain [41]. PTTSs have been identified as an effective intervention for identifying deteriorating patients [42] and a means of reducing the occurrence of SAEs [43]. However, in spite of the potential for improving patient safety and quality of care, issues relating to compliance with PTTS protocols have been identified [32]. When introducing a behavioural-based safety intervention, such as a PTTS, it is important that consideration is given to the socio-technological system. These systems approach to complex organizational work design recognizes the interaction between people and technology [44]. This systems approach recognizes that changes in an organization require the consideration of a range of factors interacting at different levels (e.g. individual healthcare providers, teams, organization, economic and political context [44]). The findings from this systematic review have demonstrated that there is a need to consider both how the system fits within the current workflow, and the implementation process itself. The findings from our systematic review are in broad agreement with many of the factors that were identified as being detrimental to the implementation of the World Health Organization (WHO) surgical checklist identified in the Bergs et al.’s systematic review [27]. For example, workflow, psychological ownership and training were common issues with both safety interventions. This finding is unsurprising as the implementation of any new patient safety intervention is a complicated process that requires a consideration of how the proposed safety improvement integrates within a complex socio-technological system. Simply imposing a safety intervention is unlikely to be effective if the implementation process has not been carefully considered [35, 39]. The papers included in our review suggest that PTTS can increase the frequency of ‘false positives’, workload and need for intervention [22, 32, 39]. In order to be useful, PTTSs must balance specificity and sensitivity. Therefore, the precision of the thresholds included may be crucial [45]. Too many ‘false positives’ may discourage staff from engaging with the PTTS. Therefore, it is perhaps unsurprising that compliance with PTTSs has been found to be poor [38]. This lack of compliance may be exacerbated by the lack of willingness of senior doctors to modify the parameters [39]. The belief that PTTSs have a negative effect on clinical judgement is also a common criticism levelled at these systems [22, 32, 38]. PTTSs should act as decision support tools that reinforce clinical decision-making as opposed to replacing it. A mechanism that has been suggested for encouraging nurses to use their clinical judgement in assessing patients may be to alter PTTSs such that nurses’ perceptions of changes in patients’ conditions could contribute to the overall score [46]. It is noteworthy that the importance of support for senior leadership was not explicitly mentioned in the majority of the papers included in this review. However, it was common that senior medical team members were unaware of their role in the PTTS process [22, 33, 35]. Although support from leadership was infrequently mentioned, it is arguably implicit in terms of being required to address issues of workflow, aligning the system with existing guidelines and supporting education and training. There is a growing literature demonstrating that sustainable interventions require active and supportive leadership, an infrastructure to support the intervention, training, involvement of key internal and external stakeholders, multidisciplinary collaboration, support for local adaptation and rewards for innovation and change [47]. A supportive leadership has been identified as an important factor in the successful implementation of any safety system [48]. Future research Based upon the review, it is possible to identify a number of areas for future research. First, the quality of the papers included in the review was variable. Researchers should ensure rigour in both data collection and analysis in future qualitative assessments of PTTSs. Second, future research should ensure that the opinions of all of the groups that are involved in the use of a PTTS are represented. The majority of included papers focus on one particular group of healthcare professionals, and even when doctors were included they tended to be smaller in number than nurses or midwives. Although most of the included studies did not include detail about the seniority of the participants, only one study [36] specifically reported the inclusion of senior physicians. Therefore, it is likely that the opinions of this particular group were under-represented. Finally, in addition to the issue of representativeness, researchers should ensure that there are sufficient numbers of participants to reach data saturation. To illustrate, three of the included studies had seven or less participants. It is difficult to provide an exact number of when data saturation is achieved. This depends upon the methodological and epistemological perspective of the researcher [49]. However, it seems unlikely that a sample of <10 respondents from one professional group of healthcare providers is going to provide a complete overview of every perspective to the use of a PTTS. Limitations There are a number of limitations to this systematic review. First, although we aimed to reduce reviewer bias by having two authors conduct the data extraction independently, the published conclusions are only representative of the reviewers’ interpretations of data presented within the included papers. Second, we adapted Bergs et al. [27] thematic structure to analyse our data. It is possible that the adoption of another structure to analyse the content of our data may have yielded different outcomes. Third, there was variability between the type of PTTS, and the domain of healthcare in which the PTTS was applied. As such, arguably, caution should be taken in drawing general conclusions due to these differences. Nevertheless, there are considerable similarities between these PTTSs, and they share a common purpose of identifying acutely unwell patients. This is reflected in the homogeneity of the themes found across the papers. Finally, we only reviewed qualitative data in this systematic review, which can lead to general criticism of qualitative research concerning researcher bias and generalization [50]. Conclusion PTTSs are complex socio-technological interventions that require consideration at the level of the individual, team, hospital and policy [47]. It is essential that future research explores modifications or strategies that may allow for the better functioning of PTTSs and assesses the effect on patient outcomes. Implementing a new safety system is more than just eliminating barriers [27]. Successful implementation of a PTTS must address the social context in which the PTTS is to be implemented. Consideration must also be given to how the system is integrated with current work practices, and how to foster support from the end users. The absence of an effective implementation strategy will mean that the potential benefits for patient safety and quality of care of PTTSs will not be realized. Supplementary material Supplementary material is available at International Journal for Quality in Health Care online. Funding This research was partially supported by funding from the National Doctor Training and Planning, Health Services Executive, Republic of Ireland. References 1 Mitchell IA , McKay H, Van Leuvan C et al. . A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients . Resuscitation 2010 ; 81 : 658 – 66 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Kause J , Smith G, Prytherch D et al. . A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study . Resuscitation 2004 ; 62 : 275 – 82 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Hillman KM , Bristow PJ, Chey T et al. . Duration of life-threatening antecedents prior to intensive care admission . Intensive Care Med 2002 ; 28 : 1629 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Hogan H , Healey F, Neale G et al. . Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study . BMJ Qual Saf 2012 ; 21 : 737 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Findlay GP , Shotton H, Kelly K et al. . Time to Intervene?: A Review of Patients who Underwent Cardiopulmonary Resuscitation as a Result of an in-hospital Cardiorespiratory Arrest. www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf (10 April 2017 , date last accessed). 6 Cei M , Bartolomei C, Mumoli N. In‐hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score: a prospective study . Int J Clin Pract 2009 ; 63 : 591 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 7 De Meester K , Das T, Hellemans K et al. . Impact of a standardized nurse observation protocol including MEWS after intensive care unit discharge . Resuscitation 2013 ; 84 : 184 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Paterson R , MacLeod DC, Thetford D et al. . Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit . Clin Med 2006 ; 6 : 281 – 4 . Google Scholar Crossref Search ADS WorldCat 9 Subbe CP , Kruger M, Rutherford P et al. . Validation of a modified Early Warning Score in medical admissions . QJM 2001 ; 94 : 521 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Morgan RJ , Williams F, Wright MM. An early warning score for the early detection of patients with impending illness . Clin Intensive Care 1997 ; 8 : 100 . OpenURL Placeholder Text WorldCat 11 Ludikhuize J , de Jonge E, Goossens A. Measuring adherence among nurses one year after training in applying the Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments . Resuscitation 2011 ; 82 : 1428 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Smith GB , Prytherch DR, Meredith P et al. . The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death . Resuscitation 2013 ; 84 : 465 – 70 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Fullerton JN , Price CL, Silvey NE et al. . Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment? Resuscitation 2012 ; 83 : 557 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Peris A , Zagli G, Maccarrone N et al. . The use of Modified Early Warning Score may help anesthesists in postoperative level of care selection in emergency abdominal surgery . Minerva Anestesiol 2012 ; 78 : 1034 – 8 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 15 Adshead N , Thomson R. Use of a paediatric early warning system in emergency departments: implementing an early warning system to identify deterioration can help adult-trained nurses accurately assess children’s needs and interventions, say Nicola Adshead and Raynie Thomson . Emerg Nurs 2009 ; 17 : 22 – 5 . Google Scholar Crossref Search ADS WorldCat 16 Subbe CP , Williams E, Fligelstone L et al. . Does earlier detection of critically ill patients on surgical wards lead to better outcomes? Ann R Coll Surg Engl 2005 ; 87 : 226 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Bick DE , Sandall J, Furuta M et al. . A national cross sectional survey of heads of midwifery services of uptake, benefits and barriers to use of obstetric early warning systems (EWS) by midwives . Midwifery 2014 ; 30 : 1140 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Health Service Executive (HSE) . Training Manual for the Compass© Education Programme Incorporating the National Early Warning Score (for Non-Pregnant Adult Patients). Available from: http://www.hse.ie/eng/about/Who/clinical/natclinprog/acutemedicineprogramme/earlywarningscore/trainingmanual6.pdf (10 April 2017 , date last accessed). 19 Hands C , Reid E, Meredith P et al. . Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol . BMJ Qual Saf 2013 ; 22 : 719 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Niegsch M , Fabritius ML, Anhøj J. Imperfect implementation of an early warning scoring system in a Danish teaching hospital: a cross-sectional study . PLoS ONE 2013 ; 8 : e70068 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Fuhrmann L , Østergaard D, Lippert A et al. . A multi-professional full-scale simulation course in the recognition and management of deteriorating hospital patients . Resuscitation 2009 ; 80 : 669 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Lydon S , Byrne D, Offiah G et al. . A mixed-methods investigation of health professionals’ perceptions of a physiological track and trigger system . BMJ Qual Saf 2016 ; 25 : 688 – 69 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Prytherch DR , Smith GB, Schmidt PE et al. . ViEWS—towards a national early warning score for detecting adult inpatient deterioration . Resuscitation 2010 ; 31 : 932 – 7 . Google Scholar Crossref Search ADS WorldCat 24 Le Lagadec MD , Dwyer T. Scoping review: the use of early warning systems for the identification of in-hospital patients at risk of deterioration . Aust Crit Care 2016 . doi.org/10.1016/j.aucc.2016.10.003 . OpenURL Placeholder Text WorldCat 25 Hannes K . Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K et al. (eds). Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions, Version 1. Cochrane Collaboration Qualitative Methods Group, 2011 . cqrmg.cochrane.org/supplemental-handbook-guidance. (10 April 2017, date last accessed). Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 26 Elo S , Kyngäs H. The qualitative content analysis process . J Adv Nurs 2008 ; 62 : 107 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Bergs J , Lambrechts F, Simons P et al. . Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence . BMJ Qual Saf 2015 ; 24 : 776 – 86 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Graneheim UH , Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . Nurs Educ Today 2004 ; 24 : 105 – 12 . Google Scholar Crossref Search ADS WorldCat 29 Sirriyeh R , Lawton R, Gardner P et al. . Reviewing studies with diverse designs: the development and evaluation of a new tool . J Eval Clin Pract 2012 ; 18 : 746 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 30 Blackwell JE , Alammar HA, Weighall AR et al. . A systematic review of cognitive function and psychosocial well-being in school-age children with narcolepsy . Sleep Med Rev 2016 . dx.doi.org/10.1016/j.smrv.2016.07.003 . OpenURL Placeholder Text WorldCat 31 Augestad LB , Jiang L. Physical activity, physical fitness, and body composition among children and young adults with visual impairments: a systematic review . Br J Vis Impair 2015 ; 33 : 167 – 82 . Google Scholar Crossref Search ADS WorldCat 32 Elliott D , Allen E, Perry L et al. . Clinical user experiences of observation and response charts: focus group findings of using a new format chart incorporating a track and trigger system . BMJ Qual Saf 2015 ; 24 : 65 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 33 McDonnell A , Tod A, Bray K et al. . A before and after study assessing the impact of a new model for recognizing and responding to early signs of deterioration in an acute hospital . J Adv Nurs 2013 ; 69 : 41 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Cherry PG , Jones CP. Attitudes of nursing staff towards a Modified Early Warning System . Br J Nurs 2015 ; 24 : 812 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Donohue LA , Endacott R. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards . Intensive Crit Care Nurs 2010 ; 26 : 10 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Bonafide CP , Roberts KE, Weirich CM et al. . Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety . J Hosp Med 2013 ; 8 : 248 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Stafseth SK , Grønbeck S, Lien T et al. . The experiences of nurses implementing the Modified Early Warning Score and a 24-hour on-call Mobile Intensive Care Nurse: an exploratory study . Intensive Crit Care Nurs 2016 ; 34 : 33 – 41 . Google Scholar Crossref Search ADS WorldCat 38 Martin RL . Midwives’ experiences of using a modified early obstetric warning score (MEOWS): a grounded theory study . Evid Based Midwifery 2015 ; 13 : 59 – 65 . OpenURL Placeholder Text WorldCat 39 Fox A , Elliott N. Early warning scores: a sign of deterioration in patients and systems: Adrian Fox and Naomi Elliott report on nurses’ experience of using the tool and the problems they encountered . Nurs Manag 2015 ; 22 : 26 – 31 . Google Scholar Crossref Search ADS WorldCat 40 Andrews T , Waterman H. Packaging: a grounded theory of how to report physiological deterioration effectively . J Adv Nurs 2005 ; 52 : 473 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat 41 Grol RP , Bosch MC, Hulscher ME et al. . Planning and studying improvement in patient care: the use of theoretical perspectives . Milbank Q 2007 ; 85 : 93 – 138 . Google Scholar Crossref Search ADS PubMed WorldCat 42 Alam N , Hobbelink EL, Van Tienhoven AJ et al. . The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review . Resuscitation 2014 ; 85 : 587 – 94 . Google Scholar Crossref Search ADS PubMed WorldCat 43 Hillman KM , Bristow PJ, Chey T et al. . Antecedents to hospital deaths . Int Med J 2001 ; 31 : 343 – 8 . Google Scholar Crossref Search ADS WorldCat 44 Flin R , Winter J, Sarac C et al. . Report for Methods and Measures Working Group of WHO Patient Safety. Cakil Sarac MR. Human Factors in Patient Safety: Review of Topics and Tools . Geneva : World Health Organization , 2009 : 05 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 45 Chapman SM , Wray J, Oulton K et al. . ‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems . Arch Dis Child 2017 ; 102 : 487 – 95 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Kyriacos U , Jelsma J, Jordan S. Monitoring vital signs using early warning scoring systems: a review of the literature . J Nurs Manag 2011 ; 19 : 311 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 47 Pronovost PJ , Watson SR, Goeschel CA et al. . Sustaining reductions in central line–associated bloodstream infections in Michigan intensive care units: a10-year analysis . Am J Med Qual 2016 ; 31 : 197 – 202 . Google Scholar Crossref Search ADS PubMed WorldCat 48 Catchpole K , Russ S. The problem with checklists . BMJ Qual Saf 2015 . doi:10.1136/bmjqs-2015-004431 . OpenURL Placeholder Text WorldCat 49 Baker SE , Edwards R. How Many Qualitative Interviews is Enough?: Expert Voices and Early Career Reflections on Sampling and Cases in Qualitative Research . Southampton : National Centre for Research Methods , 2012 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 50 Britten N , Fisher B. Qualitative research and general practice . Br J Gen Pract 1993 ; 43 : 270 – 1 . Google Scholar PubMed OpenURL Placeholder Text WorldCat © The Author 2017. 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International Journal for Quality in Health CareOxford University Press

Published: Dec 1, 2017

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