Paediatric out-of-hospital clinical deterioration: a mixed-methods scoping review protocol

Abstract

Introduction

In pre-hospital settings, identifying a deteriorating child can be challenging, especially considering that the proportion of paediatric patients with acute illnesses is lower compared with adults. This challenge is exacerbated in pre-hospital settings, where information might be scarce. Physiological alterations indicating changes in a patient’s condition can be detected hours preceding a cardiac arrest. Therefore, maintaining continuous monitoring of the patient’s clinical condition is crucial to detecting any physiological changes promptly, facilitating early identification of critical illness. This scoping review aims to assess the extent, range and nature of published research related to recognising paediatric out-of-hospital clinical deterioration by pre-hospital staff.

Methods and analysis

This scoping review is registered with the Open Science Framework. The review will follow the Joanna Briggs Institute’s (JBI) methodology for scoping reviews. A systematic search of relevant databases (MEDLINE, EMBASE, Web of Science, CINAHL and Scopus) will be conducted. In this scoping review, all types of study designs including quantitative and qualitative studies will be considered. The inclusion is limited to English-language studies published between January 1990 and March 2024. Two independent reviewers (AG and SS) will conduct a thorough screening of titles and abstracts against the pre-defined inclusion criteria for the review. For the selected citations, the full texts will undergo detailed assessment by the two reviewers, ensuring alignment with the inclusion criteria. A quality assessment of the included studies will be done using the Mixed Methods Appraisal Tool. The findings will be presented using diagrams or tables, supplemented by narrative summaries following the JBI guidelines.

Ethics and dissemination

Ethical approval is not required. The findings will be disseminated through publication in a peer-reviewed journal and presentation at conferences and/or seminars.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Pre-hospital settings pose challenges for identifying deteriorating children, who represent a smaller sample of EMS patients compared to adults.

• Specialised knowledge and skills are required for paediatric pre-hospital care, and clinical assessments in emergencies can be particularly stressful and difficult.

• The existing studies exhibit significant heterogeneity in methodology and outcome reporting.

WHAT THIS STUDY ADDS

• This scoping review will be the first to comprehensively focus on the recognition of critically ill paediatric patients in pre-hospital settings.

• It will provide a state-of-the-art overview of the evidence base, including definitions, outcome measures, challenges, and methods related to this topic.

• The review aims to identify the gaps in current research and outline the necessary investigations to improve the recognition and response to paediatric clinical deterioration by ambulance clinicians.

• A scoping review can effectively map, summarise, and present the diverse information available.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings will highlight areas where further research is needed, guiding future studies and funding priorities.

• The insights gained can inform policy decisions aimed at enhancing pre-hospital care for critically ill paediatric patients.

Introduction

Acute paediatric critical illness is defined as ‘a severe condition involving problems with the airway, breathing, circulation or acute deterioration of consciousness¹ ’. Children in hospital settings who die or deteriorate unexpectedly often exhibit noticeable symptoms before the severity of their condition is noticed.² Failure by clinicians to recognise a deteriorating patient often results in adverse events, necessitates escalated care, prolongs hospital stays and sometimes leads to fatalities.³ Moreover, previous research conducted in both adults and children has shown that physiological alterations indicating changes in patient condition can be detected hours preceding a cardiac arrest.4,7 Therefore, maintaining continuous monitoring of the patient’s clinical condition is crucial to detecting any physiological changes promptly, facilitating early identification of critical illness.⁸

On the other hand, in pre-hospital settings, identifying patients at risk of deterioration requiring urgent intervention during acute illness can pose challenges. Especially that the paediatric population comprises around 5–13% of all patients managed primarily by the Emergency Medical Services (EMS) staff,^{9 10} representing a significant but relatively smaller portion of patients attended by EMS personnel when compared with adults. Providing pre-hospital care to children necessitates specialised knowledge and interpersonal skills that differ from those required for managing adult patients.¹¹ Moreover, in emergencies, the clinical examination of children with complicated diseases or severe injuries can be stressful and difficult for medical professionals who are not used to treating children regularly.^{12 13}

Paediatric acute and life-threatening illnesses are uncommon,14,16 but when they do occur, they typically progress rapidly and cause unexpected clinical deterioration. Consequently, early identification of high-risk patients is essential for facilitating early intervention and prompt transportation to appropriate care settings. Over the years, many studies have investigated different assessment methods to identify sick or deteriorating children. This involved several methods, ranging from advanced algorithms to more conventional decision-making based on monitoring Vital Signs (VS). To date, VS monitoring is considered the cornerstone for decision-making in pre-hospital settings. In addition, Paediatric Early Warning Scores (PEWS) were established to identify the hospitalised child’s early deterioration.¹⁷ Other studies have focused on PEWS utilisation in the Emergency Department (ED) and examined if this may be used to predict outcomes, including the requirement for hospital admission and serious illnesses.^{18 19}

The importance of this review lies on the fact that identifying an unwell child can be challenging, especially considering that the proportion of paediatric patients with acute illnesses is lower compared with adults in a pre-hospital environment. This challenge is exacerbated in pre-hospital settings, where information might be scarce. Exploring the predictors, barriers and facilitators to identify Paediatric Out-of-Hospital (POOH) clinical deterioration in the pre-hospital settings can lead to improved early detection and timely interventions, ultimately resulting in better patient outcomes and more effective management of paediatric emergencies in prehospital environments. Finally, this scoping review will be the first to focus on recognising paediatric clinical deterioration in pre-hospital settings. It aims to map the current literature, identify research gaps and guide future investigations.

Aim and objectives

This scoping review aims to explore, assess and describe the existing literature about the predictors, barriers and facilitators to identify POOH clinical deterioration. The specific study objectives are to define POOH clinical deterioration, assess the impact of current recognition methods on patient care and outcomes, identify common outcome measures used in clinically deteriorating children in pre-hospital assessment, evaluate the validity and reliability of current detection methods and identify barriers and facilitators to effective recognition and response by pre-hospital staff.

Methodology and methods

Scoping review design

The planned scoping review will adhere to the Joanna Briggs Institute (JBI) methodology designed for conducting scoping reviews²⁰ and builds on previous guidance developed by Arksey and O’Malley²¹ and Levac et al.²² Studies investigating paediatric clinical deterioration in the pre-hospital settings exhibit heterogeneity in methodology and outcome reporting. Consequently, a scoping review was deemed more appropriate for mapping, summarising and presenting this finding. This methodology will offer recommendations for future research by elucidating methodological approaches and identifying gaps in current knowledge. The review will follow the population/participants, concept, context (PCC) framework endorsed by JBI, which is shown in figure 1 and demonstrates its alignment with the research objective, questions and eligibility criteria.

Figure 1. Population/participants, concept, context framework, showcasing the correlation between research objective, questions and eligibility criteria.

The JBI framework (Peters et al., 2020) recommends organising the review process into nine stages:

1. Defining and aligning the review objectives and questions.

2. Developing and aligning the inclusion criteria with the objective and questions.

3. Describing the planned approach to evidence searching, selection, extraction and charting.

4. Searching for the evidence.

5. Selecting the evidence.

6. Extracting the evidence.

7. Charting the evidence.

8. Summarising the evidence in relation to the objectives and questions.

9. Consultation of information scientists, librarians and/or experts (throughout).

Review registration

This review protocol has been registered with Open Science Framework²³

Review team

This review team is composed of multidisciplinary expert clinicians and academics in the field of paediatric emergency medicine (DR), paediatric pre-hospital care (GW, AG, SS), and adult emergency medicine (TC).

Eligibility criteria

Participants

This scoping review will cover studies that included newborns, neonates, infants or children under 18 years old as categorised in table 1. The focus will be on paediatric patients who have been managed by ambulance staff, specifically studies involving various levels of paramedics or Emergency Medical Technicians (EMTs), rather than nurses or physicians only. Our goal is to examine the role of EMS staff in identifying critically ill children while acknowledging that different countries may use different titles for EMS personnel. Therefore, studies that included a mixed team such as paramedics and nurses/doctors will be included and highlighted in the text to illustrate the varied levels of practice and education. However, studies that only included nurses or physicians in a non-EMS capacity without the involvement of paramedics or EMTs would also be excluded, as their scope of practice and training differs significantly from that of EMS staff. Moreover, studies that focused on paediatric patients who were on cardiac or respiratory arrests on ambulance arrival or included adult patients ≥18 years old will be excluded.

Table 1. Age subgroups defined by the Resuscitation Council UK guidelines³⁰.

Age group	Definition
Newborn	Just after birth
Neonate	Under 1 month
Infant	Under 1 year
Child	Between 1 year and 18 years of age

Concept

This review will investigate studies exploring the concept of acute paediatric critical illness, which is defined as ‘any infants, children, or adolescents facing illnesses, injuries, or post-operative states that increase the likelihood of or result in acute physiological instability, characterised by abnormal physiological indicators or dysfunction/failure of vital organs. Furthermore, it includes patients necessitating clinical assistance, such as regular monitoring or time-sensitive interventions, to prevent further deterioration or death’²⁴. Consequently, studies focusing on concepts related to patient deterioration, severity of illness, mortality, concerning avoidable or preventable hospital admissions or patients' need for a higher level of care will also be included. POOH clinical deterioration may be associated with failure to recognise and respond. Therefore, studies focusing on these concepts will be considered. Moreover, studies implementing and validating different tools for early detection or recognition will be considered as well.

Context

Studies that investigated clinical deterioration in the pre-hospital setting whether ground or air EMS will be included. There will be no specific aetiology of the clinical deterioration, so studies that included trauma or medical patients will be included in the review. Studies that were conducted during interfacility transfers ‘carried out by ambulance clinicians’ and simulation studies will be included. Studies that were conducted in the Emergency Department (ED), Intensive Care Units (ICUs), hospital wards or battlefield/ military studies will be excluded.

Search strategy

In this scoping review, the search strategy was developed with the assistance of an academic librarian. First, two electronic databases, MEDLINE and EMBASE, were searched to identify relevant studies and a full search strategy based on the index terms and keywords used to describe the articles. Table 2 presents each keyword that will be used alongside its synonyms. To validate the adequacy of the selected keywords, the opinions and recommendations of two field experts were sought to guarantee that the search strategy encompassed a broad spectrum of terms related to the research question. The scoping review will involve searching five major databases: MEDLINE, EMBASE, Web of Science, CINAHL and Scopus.

Table 2. Search keywords.

Keywords
Participant	Child, preschool, paediatric, adolescent, infant, newborn, youth.
Concept	Ambulance, air ambulance, Emergency Medical Services, pre-hospital, out of hospital, paramedic, HEMS, EMS
Context	Clinical deterioration, patient deterioration, Early Warning Score, early warning sign, early warning system, EWS, trigger score, track and trigger system, paediatric early warning score, paediatric early warning score system, PEWS, recognition, identification, pre-alert, critical illness, critically ill, risk score.

EMSemergency medical servicesEWSearly warning scoresHEMSHelicopter Emergency Medical ServicesPEWSpaediatric early warning scores

Studies that were published in the English language only will be included. Studies published from 1 January 1990 to 15 March 2024 will be included. Additionally, sources of unpublished studies and grey literature will be explored, which will include theses or dissertations and conference abstracts. This comprehensive approach aims to capture a broad spectrum of evidence, ensuring a thorough exploration of both published and unpublished studies related to the topic. In this scoping review, all types of study designs including quantitative and qualitative studies will be considered. Finally, every source of evidence that is included in the reference list will be checked and further search using the ‘related articles’ feature²⁵ will be done to collect additional research fitting the inclusion criteria.

Study/source of evidence selection

After the initial search, all identified citations will be compiled and uploaded into Covidence systematic review software²⁶ to remove duplicates and facilitate organisation and tracking of the screening process. Subsequently, two independent reviewers (AG and SS) will conduct a thorough screening of titles and abstracts against the pre-defined inclusion criteria for the review, eligibility criteria checklist is presented in online supplemental file A table 1. For the selected citations, the full texts will undergo detailed assessment by the two independent reviewers (AG and SS), ensuring alignment with the inclusion criteria. In the event of disagreements between reviewers at any stage, resolution will be achieved through discussion or, if necessary, by involving a senior reviewer (DR). Reasons for excluding sources that do not meet the inclusion criteria during the full-text evaluation will be documented and reported in the scoping review.

The findings of the search and the study inclusion process will be comprehensively reported in the final scoping review. A Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram will be used to present a transparent and structured overview of the study selection process.²⁷

Data extraction

A data extraction form was developed and will be modified and revised as necessary during the process of extracting the data from each included study, as outlined in online supplemental file A table 2. Any changes made to the extraction tool will be documented in the scoping review. Authors of papers will be contacted to obtain any missing or supplementary data, if deemed appropriate.

Critical appraisal of individual sources of evidence

In this scoping review, a critical appraisal of the included studies will be done using the Mixed Methods Appraisal Tool version 2018.²⁸ The purpose of undertaking this quality assessment is to understand and present the methodological rigour and reliability of the current literature.

Data synthesis and presentation

The results of the scoping review will be systematically presented to fulfil the study objectives. Where possible, key demographics and outcome variables from the included publications will be thoroughly summarised using descriptive statistics. Continuous data will be represented either by a mean±SD or as the median (IQR) where applicable, while categorical data will be presented as frequencies with corresponding percentages (%). Statistical analyses will be conducted using SPSS. A narrative summary, complemented by tables and diagrams, will effectively present the findings.

Qualitative data analysis will be carried out using thematic analysis, and charting of the data will be employed. Collaborative discussions will be engaged in by the research team to explore emerging concepts. The outcomes will highlight the themes, quotes, findings and other interpretations. Finally, qualitative data synthesis can pose challenges²⁹; therefore, thorough documentation for the analytical process, including documenting decision-making rationale using techniques such as mind mapping and/or charting, will be done throughout the review of relevant data and papers to ensure clarity and transparency.

The extracted information will be categorised based on the research questions, which cover various aspects:

1. Definition and understanding of POOH clinical deterioration: current understanding and definition of POOH clinical deterioration in existing literature.

2. Impact of recognition methods: observed impact of current recognition methods on patient care and outcomes in the pre-hospital setting.

3. Outcome measures: commonly employed outcome measures to assess POOH clinical deterioration.

4. Validity and reliability of detection methods: Evidence regarding the validity and reliability of methods utilised by ambulance clinicians in detecting paediatric clinical deterioration.

5. Barriers to identification and response: Specific barriers encountered by ambulance clinicians in identifying and responding to paediatric clinical deterioration within the pre-hospital environment.

Data availability statement

Data are available in a public, open access repository.