Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
The Parental Escalation of Care for Kids (PECK) project strengthened the early recognition of clinical deterioration by integrating a 'one question escalation prompt' in the Children's Early Warning Tool (CEWT).
Dates: February 2025 - July 2025
Implementation sites: Queensland statewide
This project was presented as a Poster at CEQ Showcase 2026 (PDF 318KB).
Aim
To pilot the PECK initiative, enabling parents to raise concerns about their child's condition early to support timely escalation of care.
Outcomes
- Parents and carers often noticed signs of deterioration before measurable changes in vital signs
- Parents and carers expressed concern in two percent of cases
- Parent and carer concerns led to changes in the plan of care in 63% of cases
- Over 87% of parents and carers reported PECK helped them feel involved in decisions about their child's care
- Nearly all parents and carers indicated that PECK increased their confidence to speak up about their child's condition
- More than 78% of staff indicated that PECK strengthened parent and carer participation in decision-making
Background
Recognising clinical deterioration in paediatric patients is inherently challenging. Children often present with non-specific symptoms, and their physiological compensatory mechanisms can mask early signs of deterioration. Additionally, many children are unable to clearly articulate how they feel, which further complicates timely assessment and decision-making. These factors contribute to delays in identifying deterioration and escalating care appropriately.
Parents and carers, however, are often the first to notice subtle but important changes in their child's behaviour, appearance or overall condition – sometimes well before physiological abnormalities appear. Parent and carer insights can serve as an essential early warning signal, but parental concerns are not always effectively captured or integrated into clinical assessment processes.
A review of Queensland-wide incident investigations of critically ill children highlighted this gap and found that parental concerns were frequently dismissed, under-recognised or not escalated appropriately. In several instances, parents reported feeling unsure about how to voice their concerns or felt their observations were not taken seriously by healthcare staff. Importantly, many of these concerns only came to light during post-incident reviews, suggesting a missed opportunity for earlier intervention. These findings revealed a disconnect between parental intuition and clinical response pathways, emphasising the need for a more structured, inclusive approach.
The PECK initiative was introduced to address these issues by facilitating clearer, more proactive communication between families and healthcare teams. The project sought to empower parents to raise concerns confidently and to ensure these concerns were met with appropriate acknowledgement and clinical review. By strengthening partnerships between families and staff, PECK aimed to promote patient safety through improved identification of early deterioration and improved alignment between parental observations and clinical action.
Problem Statement
The central challenge addressed by this project is the difficulty in recognising and responding to early signs of deterioration in children, given their unique physiological profiles and communication limitations. The project was designed to answer two key questions:
How can we improve the early identification and clinical response to deterioration in paediatric patients, considering the challenges in recognising subtle or masked symptoms?
How can parental concerns be more effectively incorporated into clinical decision-making to support earlier escalation and intervention?
By exploring these questions, the project aimed to reduce the risk of delayed recognition of deterioration, enhance communication between families and staff, and strengthen the overall safety and responsiveness of paediatric care.
Methods
The PECK project was implemented to strengthen the early identification and response to paediatric deterioration by formally integrating the assessment of parental concern into clinical assessment processes. Recognising that parents and carers often detect changes before physiological signs emerge, the initiative aimed to create a simple, reliable mechanism to capture and escalate these concerns within existing safety processes.
Development of the initiative
A central component of the project was the introduction of a one-question escalation prompt embedded within the Children's Early Warning Tool (CEWT). Parents were asked: 'Do you feel your child's condition is worse, and you are now more worried?'
If a parent answered 'yes', their concern triggered an escalation aligned with local Ryan's Rule processes. This integration ensured that parental concerns were not handled in isolation but incorporated into established clinical safety pathways, enabling timely review and intervention.
Improvement Methodology
The project applied the Institute for Healthcare Improvement's Plan - Do - Study - Act (PDSA) methodology to guide the design, testing, and refinement of the initiative. There were six pilot sites, including five paediatric inpatient wards and one paediatric emergency department. Representatives from each site collaborated with the project team throughout each stage.
Plan
The project team defined the core problem: parental insights were not consistently incorporated into clinical decision-making, potentially delaying recognition of deterioration. Consultation occurred with other Australian jurisdictions experienced in similar parent-escalation models, informing the design of PECK.
The project team facilitated engagement sessions with nursing and medical leaders at each pilot site to ensure alignment with Ryan's Rule processes and address potential barriers. The team developed a suite of resources to support implementation, including staff education materials (presentation slides, information sheets), parent/carer information sheets, and evaluation tools (PECK "Yes" register, documentation audit tools, and parent and staff surveys). Paper CEWT charts incorporating the new prompt were printed and distributed to all participating sites.
Do
Implementation occurred in staged phases. Three sites commenced on 11 February 2025, followed by additional sites over the subsequent three weeks. The project team provided ongoing support through weekly and later fortnightly virtual huddles. Sites were encouraged to share issues, successes, and emerging trends. Escalations were monitored, including the number of “yes†responses and associated clinical actions.
Study
Evaluation focused on understanding how the initiative functioned in practice. Data collected included:
- number of parent "yes" responses
- type and level of escalation initiated
- changes to treatment plans, transfers, or retrieval activity
- parent/carer feedback from surveys
- staff feedback from surveys and online forums
This data was used to assess both feasibility and early indicators of impact.
Act
The project team reviewed insights from the pilot phases to determine what refinements were needed to strengthen the reliability of the PECK process.
Based on staff feedback, the original PECK question was identified as complex. Working collaboratively with pilot sites, the team revised it to a clearer question: "Are you worried your child is getting worse?" In addition to refining the question, staff education materials were updated to highlight key messages that emerged during the pilot. These adjustments positioned the PECK initiative for broader scale-up.
Discussion
The Parental Escalation of Care for Kids (PECK) quality improvement project introduced a new process for listening and responding to parental concerns about a child's clinical condition while in hospital. The initiative aimed to empower parents and carers as active partners in care by strengthening communication pathways and enabling clinicians to recognise and respond to early signs of deterioration informed by parental insight.
Successful implementation relied on strong local leadership and the willingness of clinical teams to embed the process into existing workflows. Pilot sites demonstrated high engagement, with local leaders driving staff education, supporting consistent use of the PECK question, and ensuring alignment with established communication and escalation practices.
The intervention had two main components:
1. Staff asking parents and carers whether they were concerned about their child's condition.
2. Escalating any concerns using existing clinical pathways.
To ensure successful integration, the parental concern question was incorporated into the Children's Early Warning Tool (CEWT), allowing it to be asked routinely during bedside assessments. Alignment with each site's Ryan's Rule process ensured that parental concern triggered a recognised escalation pathway. This approach reinforced parental input as a credible prompt for clinical review.
Staff feedback was central to refining the process. Regular forums enabled staff to raise concerns, reflect on their experiences, and modify procedures in real time. Initial worries included fears of alarming parents or creating additional workload if many answered "yes". Over time, staff confidence increased as they became more comfortable asking the question and managing subsequent escalation steps.
Evaluation findings showed that parents and carers felt safer and more confident raising concerns, and believed the intervention strengthened partnerships with clinical teams. Staff also reported improvements in patient safety, communication, and engagement with families.
The project also highlighted several challenges. It drew attention to existing workflow issues, including CEWT workarounds and communication gaps that influenced parental concern. Staff frequently rephrased the PECK question to suit the situation or the family's literacy level. Some parents repeatedly answered “yes,†making it difficult for staff to gauge when escalation was clinically required. These challenges indicate a need for clearer guidance, further training, and strategies to support consistent staff responses.
The impact of PECK on Ryan's Rule remains unclear due to low existing call rates; however, the initiative enabled parents to raise concerns that might otherwise have resulted in a Ryan's Rule activation. Increased parent engagement and confidence remain significant safety outcomes.
Insights from the pilot informed several refinements to improve clarity and usability. The original question, perceived as complex and double-barrelled, was revised to a clearer version: “Are you worried your child is getting worse?†Staff education materials were also updated to reinforce key messages and support consistent application.
PECK has now been incorporated into the paper-based CEWT for statewide use in Queensland Health facilities, with integration into the integrated electronic Medical Record (ieMR) underway. The project demonstrates potential for broader application as a structured approach to escalating patient and family concerns, including in settings beyond paediatrics.
References
1. de Souza, D., Paul, R., Mozun, R., Sankar, J., Jabornisky, Lim, E., Harley, A., Al Amri, S., Alijuaid, M., Qian. S., Schlapbach, L., Argent, A., Kissoon, N. (2024). Quality improvement programmes in paediatric sepsis from a global perspective. The Lancet Child & Adolescent Health, 8(9), 695-706. Quality improvement programmes in paediatric sepsis from a global perspective - The Lancet Child & Adolescent Health
2. Gill, F., Cooper, A., Falconer, P., Stokes, S., Roberts, A., Szabo, M., Leslie, G. (2024). Feasibility and acceptability of implementing an evidence-based ESCALATION system for paediatric clinical deterioration. Pediatric Research. https://doi.org/10.1038/s41390-024-03459-y
3. Institute for Healthcare Improvement. (n.d.). How to Improve: Model for Improvement. How to Improve: Model for Improvement | Institute for Healthcare Improvement
4. Mills, E., Lin, P., Asghari-Jafarabadi, M. West, A., Craig, S. (2025). Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study. The Lancet, 9(7), 450-458. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(25)00098-7/abstract
5. Saron, H., Carter, B., Siner, S., Preston, J., Peak, M., Mehta, F., Lane, S., Lambert, C., Jones, D., Hughes, H., Harris, J., Evans, L., Dee, S., Eyton-Chong, C., Carrol, E. & Sefton, G. (2022). Parents' experiences and perceptions of the acceptability of a whole hospital, pro-active electronic pediatric early warning system (the DETECT study): A qualitative interview study. Frontiers in Pediatrics. 10. https://doi.org/10.1038/s41390-024-03459-y
Key contact
Associate Professor Steven McTaggart
Medical Lead - Paediatric Patient Safety and Quality
Clinical Excellence Queensland