. 2022 Jan 2;22:9. doi: 10.1186/s12913-021-07314-2

Table 5.

Summary of embedded site initiatives against the PUMA Standard

	Proposition	Site 1 initiatives	Site 2 initiatives	Site 3 initiatives	Site 4 initiatives
DETECT	Detection of deterioration depends on timely and appropriate monitoring, recording and interpretation of vital signs and relevant risk factors.	1. Developed a tool to encourage family engagement 2. Retraining on recognition and response to deterioration including NICE sepsis screening for front-line clinical staff	No relevant initiative	No relevant initiative	1. Observation policy updated and disseminated 2. Posters and cards for staff used to signpost abnormal thresholds for vital signs 3. Observation charts updated to include normal age-related thresholds disseminated 4. Inventory of equipment conducted
PLAN	Planning depends on reviewing indicators of deterioration for each patient, staff being aware at ward level of the status of individual patients and the availability of skills and resources, and preparing an appropriate response.	3. Implemented standard operating procedures (SOP) for out of hours working for on-call medical teams – prioritising sickest children (hospital-wide)	1. Initially planned to introduce second daily huddle, but it was not deemed possible. More frequent telephone calls between the ward and Paediatric Assessment Unit (PAU) introduced and the two areas now share a rotation of Band 6 nurses. A safety huddle takes place at 9 am on the main ward now seems to have taken on the momentum for addressing what the second daily huddle initially set out to do. 2. Initially planned joint handover sheets, using Situation Background Assessment Recommendation (SBAR), but was not deemed possible. Nurses’ handover sheet changed to SBAR.	1. Introduced site board to display ‘4Ss’ (sickest patients, bed status, safeguarding issues and staffing). 2. Senior nurses now phone through to doctors’ handover if they have any concerns about a particular patient	5. Plans to establish a staff training course on situational awareness were amended; situational awareness now included in statutory training days
ACT	Action depends on clear escalation and response and evaluation processes.			3. Introduction of new escalation policy	6. Escalation policy reviewed and disseminated

Proposition

Site 1 initiatives

Site 2 initiatives

Site 3 initiatives

Site 4 initiatives

DETECT

Detection of deterioration depends on timely and appropriate monitoring, recording and interpretation of vital signs and relevant risk factors.

1. Developed a tool to encourage family engagement

2. Retraining on recognition and response to deterioration including NICE sepsis screening for front-line clinical staff

No relevant initiative

1. Observation policy updated and disseminated

2. Posters and cards for staff used to signpost abnormal thresholds for vital signs

3. Observation charts updated to include normal age-related thresholds disseminated

4. Inventory of equipment conducted

PLAN

Planning depends on reviewing indicators of deterioration for each patient, staff being aware at ward level of the status of individual patients and the availability of skills and resources, and preparing an appropriate response.

3. Implemented standard operating procedures (SOP) for out of hours working for on-call medical teams – prioritising sickest children (hospital-wide)

1. Initially planned to introduce second daily huddle, but it was not deemed possible. More frequent telephone calls between the ward and Paediatric Assessment Unit (PAU) introduced and the two areas now share a rotation of Band 6 nurses. A safety huddle takes place at 9 am on the main ward now seems to have taken on the momentum for addressing what the second daily huddle initially set out to do.

2. Initially planned joint handover sheets, using Situation Background Assessment Recommendation (SBAR), but was not deemed possible. Nurses’ handover sheet changed to SBAR.

1. Introduced site board to display ‘4Ss’ (sickest patients, bed status, safeguarding issues and staffing).

2. Senior nurses now phone through to doctors’ handover if they have any concerns about a particular patient

5. Plans to establish a staff training course on situational awareness were amended; situational awareness now included in statutory training days

ACT

Action depends on clear escalation and response and evaluation processes.

3. Introduction of new escalation policy

6. Escalation policy reviewed and disseminated