Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review

Emma Bourke-Matas, Emma Bosley, Paul Gowens, Karen Smith, Kelly-Ann Bowles




Early identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting.



In December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken.



A total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS.



This review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes. 


clinical deterioration, critical illness, early warning system, prehospital care, recognition

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