Table 2

The core components of a paediatric early warning system: the PUMA standard

PropositionConceptual requirements
DetectionDetection of deterioration depends on timely and appropriate monitoring of vital signs and relevant risk factorsAt a minimum, this requires:
  • Staff are aware of which vital signs need to be monitored

  • Staff are aware of the minimum frequency of observations required for the children in their care

  • Staff are aware of the need to review the frequency of observations for children in their care

  • Staff are aware of additional clinical assessments required for children with prior risk factors

  • Monitoring tasks are allocated to staff members with appropriate skills to conduct them

  • Staff have access to appropriate equipment to accurately monitor vital signs, and conduct other clinical assessments

  • Staff are aware of roles and responsibilities for monitoring

  • Staff have time to conduct accurate timely and appropriate monitoring of vital signs, alongside other work commitments

  • Staff concern is formally recognised as a valid indicator of deterioration

  • Staff are supported to develop and use their intuition in detecting signs of deterioration

  • Staff understand the value of family concerns in the detection of deterioration

  • Families are involved with defining normal physiological parameters for their child

  • Families receive guidance about what to do if they are concerned that their child’s condition is deteriorating

  • Staff keep families informed about developments in their child’s care and treatment

Detection of deterioration depends on timely and appropriate recording of signs of deteriorationAt a minimum this requires:
  • Staff are aware of the need to record vital signs, family concern and staff concern promptly and accurately

  • Staff are aware of roles and responsibilities for recording vital signs, family concern and staff concern

  • Staff have appropriate skills to accurately record vital signs, family concern and staff concern

  • Staff have access to appropriate equipment to accurately record vital signs, family concern and staff concern

  • There are an appropriate number of staff to carry out required tasks

Detection of deterioration depends on timely and appropriate interpretation of signs of deteriorationAt a minimum this requires:
  • Staff are aware of prior factors that increase children’s risk of deterioration (eg, premature birth)

  • Staff are aware of roles and responsibilities for interpreting signs of deterioration

  • Staff take into account vital signs, family concern and staff concern in assessing the condition of children in their care

  • Teams have appropriate skills to discern patterns and trends of signs and symptoms

  • Staff have the opportunity to learn how to interpret signs of deterioration from shadowing more senior staff

  • Care is organised to enable staff to recognise patterns and trends for children

  • Families are in a position to discern patterns of signs and symptoms in their child

Proposition Conceptual requirements
PlanningPlanning depends on reviewing indicators of deterioration for each patientAt a minimum this requires:
  • For each child, all indicators of deterioration are brought together and kept up to date

  • There is a regular mechanism for reviewing the status of all children in the ward to identify those children who are a concern

  • The is a regular mechanism for reviewing staffing levels and skills mix, workload, acuity and admissions

Planning depends on staff being aware at ward level of the status of individual patients and the availability of skills and resources, and preparing an appropriate responseAt a minimum this requires:
  • There is a regular mechanism for communicating the review of all children, staffing levels and other resources to the rest of the team and senior managers

  • There is a regular mechanism for planning appropriate response to deterioration

  • Senior staff members are allocated responsibility for managing demand and resources

  • Senior staff members are allocated responsibility for communicating response plans

  • There is an action plan for children at risk of deterioration which is shared with families and staff caring for them

Proposition Conceptual requirements
ActionAction depends on clear escalation and response processesAt a minimum this requires:
  • A trigger or prompt to act from detection or planning phases

  • Clearly defined graded escalation and response procedures—agreed at organisational level

  • Staff receive guidance about how to escalate and respond

  • Staff understand their roles and responsibilities in the escalation procedure as activators and responders

  • Staff are encouraged and supported in raising concerns

  • Families are encouraged and supported in raising concerns

  • Staff are able to communicate information across professional hierarchies using a structured approach to sharing information

  • Clear structures to support action, including the use of a ‘no false alarms’ policy so staff are not deterred from escalating care

Action depends on evaluation At a minimum this requires:
  • Escalation and response processes are reviewed to promote learning

  • There is opportunity for staff to discuss differences of opinion in the need for escalation

  • No blame is assigned to those who escalate