Table 4.

Confidence in synthesised findings using the GRADE-CERQual framework

Summary of review finding	Studies contributing to the finding	Methodological limitations	Coherence	Adequacy	Relevance	CERQual confidence assessment	Explanation of the CERQual evidence
Information packaging (using quantifiable evidence of patient deterioration) affected perceived communication credibility	15 33–39	Low concerns regarding study methodology	Low concerns about coherence	Low concerns about adequacy	Low concerns about relevance	High Confidence	All studies, demonstrated good methodology, data were considered moderately thick with high numbers of participants and methods, a high no of studies contributed to review finding,
Flattened hierarchy and were organisational components affecting escalation of care	15 31 32 34 35 41–46	Low concerns regarding methodology	Low concerns about coherence	Low concerns about adequacy	Low concerns about relevance	High Confidence	One study with minor concerns regarding methodology (survey), high no of studies contributing to finding, data were considered moderately thick with high numbers of participants and methods
Workload and staffing were factors considered by clinical staff to affect their Situational awareness of patient deterioration.	15 32 34–36 41 42 45 47–52	Minor concerns regarding methodology	Low concerns about coherence	Low concerns about adequacy	Low concerns about relevance	High confidence	Two studies with minor methodological concerns with one study where using a survey, and another study using participants for a focus group put forward by head nurse, high no of studies contributing to review finding, rich data sources and multiple methods of data collection, data were considered moderately thick with high numbers of participants and methods
Team functioning caused problems or facilitated care during escalation	15 32 33 35 36 41–45 47–51	Minor concerns regarding methodology	Low concerns about coherence	Low concerns about adequacy	Low concerns about relevance	High confidence	Two studies with methodological concerns, one study where using a survey, and another study using participants for a focus group put forward by head nurse, all other studies demonstrate good methodology, high no of studies contributing to review finding, data were considered moderately thick with high numbers of participants and methods
Soft signal of patient deterioration used by clinical staff indicating a patient’s worsening condition, not adequately represented in Early Warning Score	15 31 33 35 36 38 41 42 44 46 49–51 54–56	Moderate concerns regarding methodology	Low concerns about coherence	Moderate concerns about adequacy	Low concerns about relevance	Moderate Confidence	Three studies had methodological concerns. One utilising a survey methodology with open ended-questions, the other was being observed by the implementer of the local Medical Emergency Team (MET), the last one using participants for a focus group put forward by head nurse, large no of studies contributing to synthesis finding,
Clinician confidence affected decision making during escalation of care	31–36 38 43–45 47 49–52 55	Moderate concerns about methodology	Low concerns about coherence	Moderate concerns about adequacy	Low concerns about relevance	Moderate confidence	Four studies had methodological concerns, two studies utilised a survey methodology with open ended-questions, the other study had a focus group where participants were selected by head nurse, the other had observation completed by the implementer of the local RRT, data were considered moderately thick with high numbers of participants and different methods, large no of studies contributing to synthesis finding
Clinical Assessment skills relating to patient assessment and staff experience positively or negatively affected deterioration detection by clinical staff	15 35 36 38 42 43 46 49–51 54 55	Moderate concerns regarding methodology	Low concerns about coherence	Moderate concerns about adequacy	Low concerns about relevance	Moderate Confidence	Two studies with methodological concerns. One had observations completed by the implementer of the local RRT, the other study had a focus group where participants were selected by head nurse, data were considered moderately thick

GRADE, Grading of Recommendations Assessment, Development and Evaluation; RRT, rapid response ream.