Introduction

Recognizing the development of critical illness at an early stage and differentiating it from a minor illness can be challenging. A large number of the children admitted to hospital will have signs of a critical illness, but their condition will stabilize and they will be treated and discharged without further decline. Some children, however, will need additional treatment and further monitoring due to signs of deterioration. The National Institute for Health and Clinical Excellence defines deterioration as the worsening of a patient's state or a gradual decline, which places nurses in a unique clinical position to identify signs of deterioration in children and enact an appropriate response.1 Changes in vital parameters and behavior indicating a decline in a patient's condition may be present in the 24 hours prior to an adverse event.2-4 Nurses' bedside observations are therefore essential in identifying signs of clinical deterioration. While attention has been given to the observation of pediatric patients5 and national guidelines focusing on pediatric early warning systems have been published,6 unacknowledged clinical deterioration of hospitalized pediatric patients remains a problem.7,8 In 2008, a review of 89 hospital deaths was conducted, indicating that, in 70% of the cases, some of the factors that led to these deaths could have been avoided. These factors included lack of recognizing and responding to clinical deterioration.2 A 2013 review of 3857 deaths found that 21% could have been prevented.9 This is a problem existing not only within pediatrics. Internationally, nursing care is performed in settings where productivity and efficiency are a focus, and thus constant pressure is a prevailing issue in nursing care.10 This has resulted in elements of fundamental nursing care being left undone. In England, two-third of nurses working in hospitals stated that they do not have time to talk to and comfort their patients.10

Pediatric patients: a challenge

The ability for health care professionals to detect the deterioration of children's conditions is a significant issue, as their physiological response to illness is distinctly different from that of adults.11 In contrast to adults, children have compensatory mechanisms that can mask indicators of deterioration; they can, for example, maintain an almost normal blood pressure despite considerable loss of fluid.12 However, when they can no longer compensate, children can rapidly become critically ill. This is further complicated because pediatric patients are often unable to articulate how or what they are feeling, depending on their age and cognitive ability.12 Due to these factors, pediatric patients are at an increased risk of unrecognized clinical deterioration. Outside intensive care units, 8% to 14% of cardiac arrest incidences involve pediatric patients,13 for which the survival rate is only 15% to 33%, and for those who do survive, the likelihood of a poor neurological outcome is 35%.3 It is important to acknowledge and act on the often discreet signs of acute and critical illness in children. For most children, acute illnesses develop gradually over many hours.3 Since pediatric nurses are around the patient 24 hours a day, their role is essential; they are key players when it comes to identifying patients through structured bedside observations and using their intuition to intervene at an early stage and potentially prevent further decline.14

Pediatric Early Warning Score

The Pediatric Early Warning Score (PEWS) has been identified as a tool to alert staff to children at risk of condition deterioration.15 It is designed to help health care professionals identify signs of critical illness and the onset of deterioration in order to facilitate a prompt response for hospitalized pediatric patients7 and to help determine the clinical condition of pediatric patients. The tool aims to provide health care professionals with an aggregate score based upon physiological parameters, such as respiratory rate, respiratory effort, oxygen saturation, systolic blood pressure, pulse rate and level of consciousness.5 When a child's clinical condition deteriorates, deviation from the normal vital parameters will result in an increased score, which indicates that interventions may be required; corresponding actions and observation levels are also outlined in supportive algorithms and clinical decision support tools.16 The Pediatric Early Warning Score (PEWS) is therefore a systematic assessment of several observations, primarily vital signs.

Recent PEWS reviews have shown that there is no agreement on which PEWS should be implemented or what parameters PEWS should comprise.5,17 The reviews also highlighted that although a wide range of PEWS have been published, the evidence is still limited. Among the scores, there is a large diversity in the components and amount of parameters as well as scoring strategies. All of the scores PEWS identified relied heavily on vital parameters,5,17 whereas others included staff concerns as a parameter.18 However, incorporating staff concerns only as a box to be ticked in PEWS does not incorporate nurses' describing their specific concerns or what worries them about a patient's condition. Qualitative studies have highlighted the need to find a way to add integration of clinical judgment into PEWS.19,20

PEWS and individual clinical assessment

PEWS does not distinguish between diagnosis or individual patient characteristics. Therefore, there is a risk of overlooking children who do not have a normal stress response as well as children who have habitually impaired physiology due to a chronic disease. Children with expected abnormal vital parameters often have unnecessary clinical assessments, which frequently results in an increased workload. Unnecessary clinical assessments have been documented as a reason for not conducting PEWS observations or complying with PEWS protocols.20 Furthermore, PEWS does not allow much room for individual clinical assessment. Studies on adult populations have documented that nurses also often use intuition to recognize patients whose condition is deteriorating.21,22 Benner et al. define intuition as "a judgment without a rationale, a direct apprehension and response without recourse to calculative rationality."23^(p.208) The nurse's role in the care of clinically deteriorating children has been studied in various contexts. Zachariasse et al.24 studied the role of nurses in the first assessment of children in the emergency department and concluded that nurses' clinical impressions on its own were not a predictor of severe illness in pediatric patients, but they did provide additional information on top of the objective predictors. Gawronski et al.14 examined factors influencing the escalation of care for hospitalized children with deteriorating conditions and documented that the staff did rely on their clinical judgment even though they found PEWS to be a useful screening tool in identifying clinical changes.

A PEWS that gives nurses an opportunity to add their clinical assessment can potentially meet some of these challenges mentioned above. In an Individual Pediatric Early Warning Score (I-PEWS), vital parameters are supplemented with clinical assessment by the nursing staff, which enables them to add specific clinical characteristics or signs that trigger their concern.

It is unclear which signs and symptoms trigger nurses' concerns about pediatric patients. Clarifying these signs could potentially help nurses put their intuition into words, and possibly help them take action based on their intuitive feelings and obtain medical support for pediatric patients in an early stage of deterioration. It is also not clear if adding these specific signs as a parameter in PEWS would improve its ability to detect children with conditions that are about to deteriorate.

Studies about adult patients have shown that identifying and adding signs that triggers nurses' concerns about a patient's condition improved patient outcomes when such signs were integrated into an early warning score,21,25 however, this has not been studied in a pediatric population. Studies indicate that nurses' clinical impressions do play an important role in assessing the condition of a pediatric patient.14,24 Systematic and scoping reviews concerning PEWS have focused on its performance and nurses' use of it.5,15,26 Therefore, a scoping review is necessary to explore the literature on this subject, since this has not been previously done.

A preliminary search was conducting in the following databases: PROSPERO, MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, and JBI Database of Systematic Reviews and Implementation Reports. No current or in-progress systematic reviews on the topic were identified.

The objective of this scoping review is to identify and map the signs and symptoms that trigger nurses' concerns about the deteriorating conditions of hospitalized pediatric patients (up to 18 years of age).

This scoping review is the first in a range of studies aiming to improve the performance of PEWS and its acceptability among health care professionals. Along with the present study, a Delphi study is being conducted to identify and describe a classic and anticipated pathological picture of hospitalized children. The results from this scoping review and the results from the Delphi study will be integrated into I-PEWS and will be tested in a prospective, cluster-randomized cross-over project.

Review question

What are the signs and symptoms that trigger nurses' concerns about the deteriorating conditions of hospitalized pediatric patients (up to 18 years of age)?

Inclusion criteria

Participants

This review will consider studies that include registered nurses - regardless of age, sex and duration of their nursing career - who have graduated from a bachelor nursing program and who work in a hospital setting with pediatric patients.

Concept

The concept being studied in this scoping review is the signs and symptoms that trigger nurses' concerns about a pediatric patient's condition when the patient's vital signs are not the cause of worry. This could be a child's unwillingness to interact normally that would evoke the nurse's "gut-feeling" that the child is ill and in need of immediate intervention. This review will consider studies investigating the signs and symptoms triggering nurses' concerns in the process of early recognition (the period during which there are observable features before the seriousness of the condition is recognized) in deteriorating pediatric patients. There will be no limitations in relation to the pediatric patients' clinical condition.

Context

This scoping review will consider studies that include acute hospitals in which nurses provide care for pediatric patients.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This scoping review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion.

Qualitative studies will also be considered, provided that they focus on qualitative data that include, but are not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description and action research. In addition, reviews that meet the inclusion criteria will also be considered. The reference lists of the papers included in the review will be screened for primary articles.

Studies published in English, Norwegian, Swedish and Danish will be included. The specific signs and symptoms triggering nurses to have concerns about a pediatric patient's condition will be translated to English and follow recommendations from reporting qualitative data.27 Studies will not be restricted by date to enable the widest possible evidence to be mapped.

Methods

The proposed scoping review will be conducted in accordance with the JBI methodology.28,29

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE (via PubMed) and CINAHL (via EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, as well as the index terms used to describe the articles, were used to develop a full search strategy for reporting in MEDLINE via PubMed (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source.

Information sources

The databases to be searched are MEDLINE (via PubMed), CINAHL (via EBSCO), Embase (via Ovid), Scopus (via Elsevier) and Swemed (via Karolinska Institutet). The search for unpublished PhD dissertations will be done through ProQuest Dissertations and Theses.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA), and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the web application Rayyan (Qatar Computing Research Institute, Doha, Qatar). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.30

Data extraction

Data extraction will involve two independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, study methods, and key findings relevant to the review objective. A draft charting table is provided (see Appendix II). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements arising between the reviewers will be resolved through discussion or with a third reviewer. The authors of the papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results, which will describe how the results relate to the review's question.

Funding

This study is supported by the Novo Nordic Foundation (NNF180C0052020) and Lundbeckfonden. None of the funding bodies will have any role in the review process.

Acknowledgments

Britt Laugesen, Aalborg University Hospital, and Professor Preben Ulrich Pedersen, Aalborg University for their contributions.

Appendix I: Search strategy

MEDLINE (via PubMed)

(((((nursing[TIAB]) OR nurses[TIAB]) OR nurse[TIAB]) OR "Nursing Staff"[Mesh]) OR "Nursing"[Mesh]) OR "Nurses"[Mesh]

AND

(((((((((((("adolescents"[tiab]) OR "children"[tiab]) OR "child"[tiab]) OR "Infant"[tiab]) OR "Infant"[Mesh]) OR "Child"[Mesh]) OR "Adolescent"[Mesh]) OR "Paediatrics" [tiab]) OR "Pediatrics" [tiab]) OR "Pediatrics"[Mesh]))

AND

((((((((("clinical thinking" [tiab]) OR "clinical judgment" [tiab]) OR "clinical reasoning" [tiab]) OR "situation awareness" [tiab]) OR "Awareness"[Mesh]) OR "Nursing Assessments" [tiab]) OR "Nursing Assessment" [tiab]) OR "Nursing Assessment"[Mesh]) OR ((((((((((((((((((((((((((((((((((((((((((triggers[tiab] OR worrisome[tiab]) OR worried[tiab]) OR worry[tiab]) OR "concerned about a patient"[tiab])) OR (("Changes of concern"[tiab])) OR concerned[tiab]) OR concern[tiab]) OR knowing[tiab]) OR "nursing gaze"[tiab]) OR "clinical gaze"[tiab]) OR "gut feelings"[tiab]) OR "gut feeling"[tiab]) OR cues[tiab]) OR "Cues"[Mesh]) OR "decision making"[tiab]) OR ("Decision Making"[Mesh] AND "Clinical Decision-Making"[Mesh])) OR recognise[tiab]) OR recognize[tiab]) OR "early recognition"[tiab]) OR recognition[tiab]) OR "Recognition (Psychology)"[Mesh]) OR "clinical judgment"[tiab]) OR "clinical judgment"[tiab]) OR judgement[tiab]) OR judgment[tiab]) OR "Judgment"[Mesh]) OR observations[TIAB]) OR observation[tiab]) OR "Observation"[Mesh]) OR nursing assessment[tiab]) OR "Nursing Assessment"[Mesh]) OR "nursing diagnosis"[tiab]) OR "Nursing Diagnosis"[Mesh]) OR intuitiveness[tiab]) OR intuitive[tiab]) OR intuition[tiab]) OR "non analytical reasoning"[tiab]) OR "reflective reasoning"[tiab]) OR reflective thinking[tiab]) OR "Intuition"[Mesh])))

AND

((((((((((((((((((((((((((((((((((((((("paediatric early warning system"[tiab]) OR "pediatric early warning system"[tiab]) OR ("track and trigger"[tiab])) OR "alarm score"[tiab]) OR "pediatric early warning score"[tiab]) OR "paediatric early warning score"[tiab]) OR "early warning score"[tiab]) OR "at risk patient" [tiab]) OR "patients at risk" [tiab]) OR "patient at risk" [tiab]) OR "critical conditions" [tiab]) OR "patient problems" [tiab]) OR "patient problem" [tiab]) OR "critically ill" [tiab]) OR worsening [tiab]) OR "deteriorating patients" [tiab]) OR "deteriorating patient" [tiab]) OR deteriorations [tiab]) OR deterioration [tiab]) OR deteriorated [tiab]) OR deteriorate [tiab]) OR "rapid response systems" [tiab]) OR "rapid response system" [tiab]) OR "emergency assistance" [tiab]) OR "emergency teams" [tiab]) OR "emergency team" [tiab]) OR "outreach team" [tiab]) OR "outreach teams" [tiab]) OR "medical emergency teams" [tiab]) OR "medical emergency team" [tiab]) OR "rapid response teams" [tiab]) OR "rapid response team" [tiab]) OR "hospital rapid response team" [tiab]) OR "Hospital Rapid Response Team"[Mesh]) OR critical illness [tiab]) OR "Critical Illness"[Mesh]) OR emergencies [tiab]) OR "Emergencies"[Mesh])"

Appendix II: Data extraction instrument

References