Interventions that facilitate early identification and management of hospitalized pediatric patients who are at risk for deterioration are associated with decreased mortality. In our large pediatric hospital with a history of success in decreasing unrecognized deterioration, patients at higher risk of deterioration are termed “watchers.” Because communication errors often contribute to unrecognized deterioration, clear and timely communication of watcher status to all team members and contingency planning was desired.


Increase the percentage of eligible watchers with a complete communication, teamwork, and planning bundle within 2 hours of identification from 28% to 80%.


Watchers admitted to Hospital Medicine on 2 targeted units were eligible. Stakeholders were educated to facilitate ownership. Daily data analysis enabled real-time failure identification. Automated physician notification provided reminders for timely communication.


The percentage of watchers with a complete situation awareness bundle within 2 hours increased from 28% to 81% and was sustained for more than 2 years. There was no change in rates of rapid response team calls or ICU transfers on our intervention units, but these both increased throughout the hospital. Education facilitated modest improvement, with marked improvements and sustainment through use of technology.


A novel bundle that included contingency planning and communication expectations was created to improve situation awareness for watchers. Multidisciplinary engagement and use of automated technology facilitated by an electronic health record helped implement and sustain bundle adherence.

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