| Sumario: | Objective: To identify factors influencing implementation and integration of the paediatric ESCALATION system in country Western Australia. Setting and Participants: Health professionals (nurses and doctors) working in country Western Australia. Design and Methods: A multi‐methods study using an interpretive descriptive approach guided by the Practical Robust Implementation and Sustainability Model (PRISM) and Normalisation Process Theory (NPT). Data collection across six sites included patient chart audit, health professional survey and focus groups/interviews. Data were analysed descriptively (audit and survey) and thematically (focus groups/interviews). Results: An audit of 94 patient charts showed 61.7% met escalation of care criteria, while 69.0% of cases were escalated per policy. Among 114 survey responses, findings indicated system integration, with 95.6% reporting ESCALATION was part of their role, 93.5% agreeing it supported early detection of clinical deterioration and 93.8% reporting ease of use. Fewer identified local champions (66.7%), had confidence in others' use of the system (61.1%), reported sufficient training (69.0%), or were aware of reports demonstrating system effectiveness (55.0%). Seventy‐eight health professionals participated in focus groups/interviews. Three themes were interpreted through the PRISM and NPT frameworks: (i) Enhanced patient safety (intervention characteristics and participants' perspectives; coherence; cognitive participation), (ii) Strengthening clinical decision‐making (implementation and sustainability infrastructure; cognitive participation; collective action), (iii) Monitoring and fidelity (implementation and sustainability infrastructure, external; collective action; reflexive monitoring). Conclusion: The paediatric ESCALATION system is embedded and valued, but sustaining fidelity through scale‐up requires ongoing training, teamwork, confident communication and organisational support across regional, rural and remote WA health services. Summary: What Is Already Known on This Subject? ○Early warning systems like the paediatric ESCALATION system are designed to support timely recognition and response to clinical deterioration in hospitalised children to enhance patient safety.○The long‐term sustainability of the Western Australian paediatric ESCALATION systems depends on addressing implementation challenges, including variability in practice, staff engagement and training needs in regional, rural and remote healthcare services.What Does This Paper Add? ○Health professionals view the paediatric ESCALATION system as a valuable and user‐friendly tool that enhances early recognition and response to clinical deterioration, empowering nurses to escalate care effectively.○This study highlights that scale‐up and acceptance of the paediatric ESCALATION system do not automatically translate into high‐fidelity use in regional, rural and remote WA healthcare settings. Targeted education, local leadership and system‐level support are important for maintaining system fidelity across diverse clinical settings.
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