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Improving care for the deteriorating child
  1. Alice Roueché1,
  2. Jane Runnacles2
  1. 1Department of Paediatrics, Royal Alexandra Children's Hospital, Brighton, UK
  2. 2Department of Paediatrics, Royal Free Hospital, London, UK
  1. Correspondence to Dr Jane Runnacles, Department of Paediatrics, Royal Free Hospital, Pond St, London, NW3 2QG, UK; Jane.runnacles{at}

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To deliver safe care for children we need to be able to correctly identify clinical deterioration and appropriately respond to it. The evidence suggests we do not do this consistently and this should be a prime focus for improvement efforts. Yet, the systems in which we work are complex and change is often daunting. In this article we will look at how a quality improvement approach, using well-established methodologies, can be used to try to address a problem such as identifying the deteriorating child. It will look at large- and small-scale examples and will explore some of the approaches that can make a challenging task into a measurable improvement in care for children and young people (boxes 1 and 2).

Box 1

Quality improvement (QI) in practice: identifying the deteriorating child

  • From the driver diagram in figure 2, we can see that there are multiple factors involved in reducing inpatient cardiorespiratory arrest. One important area to look at is the use of early warning scores to identify deterioration.

  • One of the UK CEMACH recommendations for hospital paediatric care was a ‘standardised and rational monitoring system with embedded early identification systems for children developing critical illness’.7 The exact nature of the chart used should depend on local context but it is clear that a means of documenting and flagging up signs of clinical deterioration is important.

  • In order to introduce a PEWS (Paediatric Early Warning Score) chart, a QI approach, using plan-so-study-act (PDSA) cycles, can be helpful:

    • Plan: Meet with colleagues and brainstorm ideas for implementing PEWS on your ward. Choose an idea that the team can support, for example, trialling a new observations chart.

    • Do: Trial chart for 10 patients.

    • Study: Look at chart completion rates and get feedback from nurses about ease of use, look at clinical …

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  • Contributors This article was commissioned as part of the ADC Equipped series. AR and JR worked closely together on the planning, design, drafting and final approval of this article.

  • Funding The authors did not receive any funding for this work. The quality improvement project outlined in box 2 is supported by The Health Foundation's SHINE programme (UK charity number: 286967).

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.