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McCaffery K, Carey KA, Campbell V, Gifford S, Smith K, Edelson D, Churpek MM, Mayampurath A. Predicting transfers to intensive care in children using CEWT and other early warning systems. Resusc Plus 2024; 17:100540. [PMID: 38260119 PMCID: PMC10801303 DOI: 10.1016/j.resplu.2023.100540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/15/2023] [Accepted: 12/13/2023] [Indexed: 01/24/2024] Open
Abstract
Background and Objective The Children's Early Warning Tool (CEWT), developed in Australia, is widely used in many countries to monitor the risk of deterioration in hospitalized children. Our objective was to compare CEWT prediction performance against a version of the Bedside Pediatric Early Warning Score (Bedside PEWS), Between the Flags (BTF), and the pediatric Calculated Assessment of Risk and Triage (pCART). Methods We conducted a retrospective observational study of all patient admissions to the Comer Children's Hospital at the University of Chicago between 2009-2019. We compared performance for predicting the primary outcome of a direct ward-to-intensive care unit (ICU) transfer within the next 12 h using the area under the receiver operating characteristic curve (AUC). Alert rates at various score thresholds were also compared. Results Of 50,815 ward admissions, 1,874 (3.7%) experienced the primary outcome. Among patients in Cohort 1 (years 2009-2017, on which the machine learning-based pCART was trained), CEWT performed slightly worse than Bedside PEWS but better than BTF (CEWT AUC 0.74 vs. Bedside PEWS 0.76, P < 0.001; vs. BTF 0.66, P < 0.001), while pCART performed best for patients in Cohort 2 (years 2018-2019, pCART AUC 0.84 vs. CEWT AUC 0.79, P < 0.001; vs. BTF AUC 0.67, P < 0.001; vs. Bedside PEWS 0.80, P < 0.001). Sensitivity, specificity, and positive predictive values varied across all four tools at the examined thresholds for alerts. Conclusion CEWT has good discrimination for predicting which patients will likely be transferred to the ICU, while pCART performed the best.
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Affiliation(s)
- Kevin McCaffery
- Queensland Health Patient Safety Centre, Brisbane, Queensland, Australia
| | - Kyle A. Carey
- Department of Medicine, University of Chicago, Chicago IL, United States
| | - Victoria Campbell
- Queensland Health Patient Safety Centre, Brisbane, Queensland, Australia
| | - Shaune Gifford
- Queensland Health Patient Safety Centre, Brisbane, Queensland, Australia
| | - Kate Smith
- Queensland Health Patient Safety Centre, Brisbane, Queensland, Australia
| | - Dana Edelson
- Department of Medicine, University of Chicago, Chicago IL, United States
| | - Matthew M. Churpek
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
| | - Anoop Mayampurath
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
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McKay V, Chen Y, Prewitt K, Malone S, Puerto-Torres M, Acuña-Aguirre C, Alfonso-Carreras Y, Alvarez-Arellano SY, Andrade-Sarmiento LA, Arce-Cabrera D, Argüello-Vargas D, Barragán-García MDC, Batista-Del-Cid R, Blasco-Arriaga EE, Cach-Castaneda MDC, Ceballo-Batista GI, Chávez-Rios M, Costa ME, Cuencio-Rodriguez ME, Diaz-Coronado R, Fing-Soto EA, García-Sarmiento TDJ, Gómez-García WC, Hernández-González CJ, Jimenez-Antolinez YV, Juarez-Tobias MS, León-López EM, Lopez-Facundo NA, Martínez Soria RA, Miralda-Méndez ST, Montalvo E, Pérez-Alvarado CM, Perez-Fermin CK, Quijano-Lievano ML, Salas-Mendoza B, Sanchez-Fuentes EE, Serrano-Landivar MX, Soto-Chavez V, Tejocote-Romero I, Valle S, Vasquez-Roman EA, Costa JT, Cardenas-Aguirre A, Devidas M, Luke DA, Agulnik A. Connecting Clinical Capacity and Intervention Sustainability in Resource-Variable Pediatric Oncology Centers in Latin America. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2024; 4:102-115. [PMID: 38566954 PMCID: PMC10987010 DOI: 10.1007/s43477-023-00106-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/10/2023] [Indexed: 04/04/2024]
Abstract
Clinical capacity for sustainability, or the clinical resources needed to sustain an evidence-based practice, represent proximal determinants that contribute to intervention sustainment. We examine the relationship between clinical capacity for sustainability and sustainment of PEWS, an evidence-based intervention to improve outcomes for pediatric oncology patients in resource-variable hospitals. We conducted a cross-sectional survey among Latin American pediatric oncology centers participating in Proyecto Escala de Valoración de Alerta Temprana (EVAT), an improvement collaborative to implement Pediatric Early Warning Systems (PEWS). Hospitals were eligible if they had completed PEWS implementation. Clinicians were eligible to participate if they were involved in PEWS implementation or used PEWS in clinical work. The Spanish language survey consisted of 56 close and open-ended questions about the respondent, hospital, participants' assessment of clinical capacity to sustain PEWS using the clinical sustainability assessment tool (CSAT), and perceptions about PEWS and its use as an intervention. Results were analyzed using a multi-level modeling approach to examine the relationship between individual, hospital, intervention, and clinical capacity determinants to PEWS sustainment. A total of 797 responses from 37 centers in 13 countries were included in the analysis. Eighty-seven percent of participants reported PEWS sustainment. After controlling for individual, hospital, and intervention factors, clinical capacity was significantly associated with PEWS sustainment (OR 3.27, p < .01). Marginal effects from the final model indicate that an increasing capacity score has a positive influence (11% for every additional CSAT point) of predicting PEWS sustainment. PEWS is a sustainable intervention and clinical capacity to sustain PEWS contributes meaningfully to PEWS sustainment.
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Affiliation(s)
- Virginia McKay
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kim Prewitt
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Sara Malone
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
- Division of Population Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Maria E. Costa
- Hospital del Nino de la Santísima Trinidad, Cordoba, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Clara K. Perez-Fermin
- Hospital Infantil Regional Universitario Dr. Arturo Grullon, Santiago, Dominican Republic
| | | | | | | | | | | | | | - Sergio Valle
- Unidad Nacional de Oncologia Pediatrica (UNOP), Guatemala, Guatemala
| | | | - Juliana Texeira Costa
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Adolfo Cardenas-Aguirre
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Douglas A. Luke
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
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Kumwenda M, Assies R, Snik I, Chatima G, Langton J, Chimalizeni Y, Romaine ST, van Woensel JB, Pallmann P, Carrol ED, Calis JC. Identifying critically ill children in Malawi: A modified qSOFA score for low-resource settings. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002388. [PMID: 38271303 PMCID: PMC10810502 DOI: 10.1371/journal.pgph.0002388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Abstract
In low-resource settings, a reliable bedside score for timely identification of children at risk of dying, could help focus resources and improve survival. The rapid bedside Liverpool quick Sequential Organ Failure Assessment (LqSOFA) uses clinical parameters only and performed well in United Kingdom cohorts. A similarly quick clinical assessment-only score has however not yet been developed for paediatric populations in sub-Saharan Africa. In a development cohort of critically ill children in Malawi, we calculated the LqSOFA scores using age-adjusted heart rate and respiratory rate, capillary refill time and Blantyre Coma Scale, and evaluated its prognostic performance for mortality. An improved score, the Blantyre qSOFA (BqSOFA), was developed (omitting heart rate, adjusting respiratory rate cut-off values and adding pallor), subsequently validated in a second cohort of Malawian children, and compared with an existing score (FEAST-PET). Prognostic performance for mortality was evaluated using area under the receiver operating characteristic curve (AUC). Mortality was 15.4% in the development (N = 493) and 22.0% in the validation cohort (N = 377). In the development cohort, discriminative ability (AUC) of the LqSOFA to predict mortality was 0.68 (95%-CI: 0.60-0.76). The BqSOFA and FEAST-PET yielded AUCs of 0.84 (95%-CI:0.79-0.89) and 0.83 (95%-CI:0.77-0.89) in the development cohort, and 0.74 (95%-CI:0.68-0.79) and 0.76 (95%-CI:0.70-0.82) in the validation cohort, respectively. We developed a simple prognostic score for Malawian children based on four clinical parameters which performed as well as a more complex score. The BqSOFA might be used to promptly identify critically ill children at risk of dying and prioritize hospital care in low-resource settings.
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Affiliation(s)
- Mercy Kumwenda
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Paediatrics and Child Health, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Roxanne Assies
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
| | - Ilse Snik
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Gloria Chatima
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sam T. Romaine
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Job B.M. van Woensel
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Enitan D. Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Job C.J. Calis
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
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McKay V, Carothers B, Graetz D, Malone S, Puerto-Torres M, Prewitt K, Cardenas A, Chen Y, Devidas M, Luke DA, Agulnik A. Sustainability determinants of an intervention to identify clinical deterioration and improve childhood cancer survival in Latin American hospitals: the INSPIRE study protocol. Implement Sci Commun 2023; 4:141. [PMID: 37978404 PMCID: PMC10657009 DOI: 10.1186/s43058-023-00519-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND More than 90% of children with cancer live in low-resourced settings, where survival is only 20%. Sustainable evidence-based (EB) interventions yielding ongoing beneficial patient outcomes are critical to improve childhood cancer survival. A better understanding of factors promoting intervention sustainability in these settings is urgently needed. The aim of this study is to provide an empirical understanding of how clinical capacity for sustainability, or the resources needed to sustain an intervention, impacts the sustainment of Pediatric Early Warning System (PEWS), an EB intervention that improves pediatric oncology outcomes in low-resource hospitals by detecting clinical deterioration and preventing the need for more intense treatment. METHODS We will conduct a prospective, longitudinal study of approximately 100 resource-variable hospitals implementing and sustaining PEWS participating in Proyecto EVAT, a quality improvement collaborative of Latin American pediatric oncology centers. Aim 1: We will evaluate how clinical capacity for sustainability changes over time through 5 to 9 prospective measurements of capacity via survey of clinical staff using PEWS (approximately n = 13 per center) during the phases of PEWS adoption, implementation, and sustainability using the Clinical Sustainability Assessment Tool (CSAT). Aim 2: We will determine the relationship between capacity and a) PEWS sustainment and b) clinical deterioration mortality among pediatric oncology patients at centers sustaining PEWS for 2 to 10 years using chart review and an existing patient outcomes registry. Aim 3: We will develop novel strategies to promote sustainability by gaining a deeper understanding of perceived challenges to building capacity and PEWS sustainment. In combination with quantitative outcomes, we will conduct 24 focus groups with staff (doctors, nurses, and administrators) from hospitals with both high (n = 4) and low capacity (n = 4). We will then use implementation mapping to generate theoretically driven, empirically-supported sustainability strategies. DISCUSSION This study will advance implementation science by providing a theoretically driven, foundational understanding of factors that predict sustainability among a large, diverse cohort of hospitals. We will then use this knowledge to develop sustainability evidence-informed strategies that optimize capacity and promote long-term sustainment of PEWS and improvements in patient outcomes, thus promoting equity in childhood cancer care globally.
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Affiliation(s)
- Virginia McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.
| | - Bobbi Carothers
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Dylan Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sara Malone
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Division of Population Health Science, Washington University in St. Louis School of Medicine, St Louis, MO, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kim Prewitt
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Adolfo Cardenas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Douglas A Luke
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
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Dale NM, Ashir GM, Maryah LB, Shepherd S, Tomlinson G, Briend A, Zlotkin S, Parshuram CS. Evaluating the Validity of the Responses to Illness Severity Quantification Score to Discriminate Illness Severity and Level of Care Transitions in Hospitalized Children with Severe Acute Malnutrition. J Pediatr 2023; 262:113609. [PMID: 37419241 DOI: 10.1016/j.jpeds.2023.113609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/25/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization. STUDY DESIGN A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions. RESULTS Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91). CONCLUSIONS The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.
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Affiliation(s)
- Nancy M Dale
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Garba Mohammed Ashir
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Lawan Bukar Maryah
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - André Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland; Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Christopher S Parshuram
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
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Agulnik A, Muniz-Talavera H, Pham LTD, Chen Y, Carrillo AK, Cárdenas-Aguirre A, Gonzalez Ruiz A, Garza M, Conde Morelos Zaragoza TM, Soberanis Vasquez DJ, Méndez-Aceituno A, Acuña-Aguirre C, Alfonso-Carreras Y, Alvarez Arellano SY, Andrade Sarmiento LA, Batista R, Blasco Arriaga EE, Calderon P, Chavez Rios M, Costa ME, Díaz-Coronado R, Fing Soto EA, Gómez García WC, Herrera Almanza M, Juarez Tobías MS, León López EM, López Facundo NA, Martinez Soria RA, Miller K, Miralda Méndez ST, Mora Robles LN, Negroe Ocampo NDC, Noriega Acuña B, Osuna Garcia A, Pérez Alvarado CM, Pérez Fermin CK, Pineda Urquilla EE, Portilla Figueroa CA, Ríos Lopez LE, Rivera Mijares J, Soto Chávez V, Suarez Soto JI, Teixeira Costa J, Tejocote Romero I, Villanueva Hoyos EE, Villegas Pacheco M, Devidas M, Rodriguez-Galindo C. Effect of paediatric early warning systems (PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a prospective, multicentre cohort study. Lancet Oncol 2023; 24:978-988. [PMID: 37433316 PMCID: PMC10727097 DOI: 10.1016/s1470-2045(23)00285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Paediatric early warning systems (PEWS) aid in the early identification of clinical deterioration events in children admitted to hospital. We aimed to investigate the effect of PEWS implementation on mortality due to clinical deterioration in children with cancer in 32 resource-limited hospitals across Latin America. METHODS Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement PEWS in hospitals providing childhood cancer care. In this prospective, multicentre cohort study, centres joining Proyecto EVAT and completing PEWS implementation between April 1, 2017, and May 31, 2021, prospectively tracked clinical deterioration events and monthly inpatient-days in children admitted to hospital with cancer. De-identified registry data reported between April 17, 2017, and Nov 30, 2021, from all hospitals were included in analyses; children with limitations on escalation of care were excluded. The primary outcome was clinical deterioration event mortality. Incidence rate ratios (IRRs) were used to compare clinical deterioration event mortality before and after PEWS implementation; multivariable analyses assessed the correlation between clinical deterioration event mortality and centre characteristics. FINDINGS Between April 1, 2017, and May 31, 2021, 32 paediatric oncology centres from 11 countries in Latin America successfully implemented PEWS through Proyecto EVAT; these centres documented 2020 clinical deterioration events in 1651 patients over 556 400 inpatient-days. Overall clinical deterioration event mortality was 32·9% (664 of 2020 events). The median age of patients with clinical deterioration events was 8·5 years (IQR 3·9-13·2), and 1095 (54·2%) of 2020 clinical deterioration events were reported in male patients; data on race or ethnicity were not collected. Data were reported per centre for a median of 12 months (IQR 10-13) before PEWS implementation and 18 months (16-18) after PEWS implementation. The mortality rate due to a clinical deterioration event was 1·33 events per 1000 patient-days before PEWS implementation and 1·09 events per 1000 patient-days after PEWS implementation (IRR 0·82 [95% CI 0·69-0·97]; p=0·021). In the multivariable analysis of centre characteristics, higher clinical deterioration event mortality rates before PEWS implementation (IRR 1·32 [95% CI 1·22-1·43]; p<0·0001), being a teaching hospital (1·18 [1·09-1·27]; p<0·0001), not having a separate paediatric haematology-oncology unit (1·38 [1·21-1·57]; p<0·0001), and having fewer PEWS omissions (0·95 [0·92-0·99]; p=0·0091) were associated with a greater reduction in clinical deterioration event mortality after PEWS implementation; no association was found with country income level (IRR 0·86 [95% CI 0·68-1·09]; p=0·22) or clinical deterioration event rates before PEWS implementation (1·04 [0·97-1·12]; p=0·29). INTERPRETATION PEWS implementation was associated with reduced clinical deterioration event mortality in paediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of PEWS as an effective evidence-based intervention to reduce disparities in global survival for children with cancer. FUNDING American Lebanese Syrian Associated Charities, US National Institutes of Health, and Conquer Cancer Foundation. TRANSLATIONS For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Asya Agulnik
- St Jude Children's Research Hospital, Memphis, TN, USA.
| | | | - Linh T D Pham
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Yichen Chen
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Marcela Garza
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kenia Miller
- Hospital del Niño "Jose Renan Esquivel", Panama, Panama
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jorge Iván Suarez Soto
- Hospital del Niño. Sistema integral para el Desarrollo de la Familia (DIF), Pachuca, Mexico
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Fuijkschot J, Stevens J, Teheux L, de Loos E, Rippen H, Meurs M, de Groot J. Development of the national Dutch PEWS: the challenge against heterogeneity and implementation difficulties of PEWS in the Netherlands. BMC Pediatr 2023; 23:387. [PMID: 37550704 PMCID: PMC10405440 DOI: 10.1186/s12887-023-04219-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/28/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND For the early recognition of deteriorating patients several Pediatric Early Warning Score (PEWS) systems have been developed with the assumption that early detection can prevent further deterioration. Although PEWS are widely being used in hospitals in the Netherlands, there is no national consensus on which score to use and how to embed the score into a PEWS system. This resulted in a substantial heterogeneity of PEWS systems, of which many are unvalidated or self-designed. The primary objective of this study was to develop a pragmatic consensus-based PEWS system that can be utilized in all Dutch hospitals (University Medical Centers, teaching hospitals, and general hospitals). METHODS This study is an iterative mixed-methods study. The methods from the Core Outcome Measures in Effectiveness Trials (COMET) initiative were used and consisted of two Delphi rounds, two inventories set out to all Dutch hospitals and a focus group session with parents. The study was guided by five expert meetings with different stakeholders and a final consensus meeting that resulted in a core PEWS set. RESULTS The first Delphi round was completed by 292 healthcare professionals, consisting of pediatric nurses and physicians. In the second Delphi round 217 healthcare professionals participated. Eventually, the core PEWS set was been developed comprising of the parameters work of breathing, respiratory rate, oxygen therapy, heart rate and capillary refill time, and AVPU (Alert, Verbal, Pain, and Unresponsive). In addition, risk stratification was added to the core set with standardized risk factors consisting of [1] worried signs from healthcare professionals and parents and [2] high-risk treatment, with the option to add applicable local defined risk factors. Lastly, the three categories of risk stratification were defined (standard, medium, and high risk) in combination with standardized actions of the professionals for each category. CONCLUSION This study demonstrates a way to end a country's struggle with PEWS heterogeneity by co-designing a national Dutch PEWS system. Currently, the power of the system is being investigated in a large multi-center study in the Netherlands.
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Affiliation(s)
- Joris Fuijkschot
- Radboud University Medical Center, Radboudumc Amalia Childrens Hospital, Nijmegen, The Netherlands.
| | - Jikke Stevens
- Radboud University Medical Center, Radboudumc Amalia Childrens Hospital, Nijmegen, The Netherlands
| | - Lara Teheux
- Radboud University Medical Center, Radboudumc Amalia Childrens Hospital, Nijmegen, The Netherlands
| | - Erica de Loos
- Dutch Hospital Association, Utrecht, The Netherlands
| | - Hester Rippen
- Dutch Foundation Child & Hospital, Utrecht, The Netherlands
| | - Maaike Meurs
- Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Janke de Groot
- Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Knowledge Institute for Medical Specialists, Utrecht, The Netherlands
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Abutineh F, Graetz DE, Muniz-Talavera H, Ferrara G, Puerto-Torres M, Chen Y, Gillipelli SR, Elish P, Gonzalez-Ruiz A, Alfonso Carreras Y, Alvarez S, Arce Cabrera D, Arguello Vargas D, Armenta Cruz M, Barra C, Calderon Sotelo P, Carpio Z, Chavez Rios M, Covarrubias D, de Leon Vasquez L, Diaz Coronado R, Fing Soto EA, Gomez-Garcia W, Hernandez C, Juarez Tobias MS, Leon E, Loeza Oliva JDJ, Mendez A, Miller K, Montalvo Cozar E, Negroe Ocampo NDC, Penafiel E, Pineda E, Rios L, Rodriguez Ordonez E, Soto Chavez V, Devidas M, Agulnik A. Impact of hospital characteristics on implementation of a Pediatric Early Warning System in resource-limited cancer hospitals. Front Oncol 2023; 13:1122355. [PMID: 37207162 PMCID: PMC10189109 DOI: 10.3389/fonc.2023.1122355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Background Pediatric Early Warning Systems (PEWS) aid in identification of deterioration in hospitalized children with cancer but are underutilized in resource-limited settings. Proyecto EVAT is a multicenter quality improvement (QI) collaborative in Latin America to implement PEWS. This study investigates the relationship between hospital characteristics and time required for PEWS implementation. Methods This convergent mixed-methods study included 23 Proyecto EVAT childhood cancer centers; 5 hospitals representing quick and slow implementers were selected for qualitative analysis. Semi-structured interviews were conducted with 71 stakeholders involved in PEWS implementation. Interviews were recorded, transcribed and translated to English, then coded using a priori and novel codes. Thematic content analysis explored the impact of hospital characteristics and QI experience on time required for PEWS implementation and was supplemented by quantitative analysis exploring the relationship between hospital characteristics and implementation time. Results In both quantitative and qualitative analysis, material and human resources to support PEWS significantly impacted time to implementation. Lack of resources produced various obstacles that extended time necessary for centers to achieve successful implementation. Hospital characteristics, such as funding structure and type, influenced PEWS implementation time by determining their resource-availability. Prior hospital or implementation leader experience with QI, however, helped facilitate implementation by assisting implementers predict and overcome resource-related challenges. Conclusions Hospital characteristics impact time required to implement PEWS in resource-limited childhood cancer centers; however, prior QI experience helps anticipate and adapt to resource challenges and more quickly implement PEWS. QI training should be a component of strategies to scale-up use of evidence-based interventions like PEWS in resource-limited settings.
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Affiliation(s)
- Farris Abutineh
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | | | | | - Shillel Alvarez
- Pediatric Oncology, Benemérito Hospital General con Especialidades “Juan María de Salvatierr”, La Paz, Mexico
| | - Daniela Arce Cabrera
- Pediatric Hemato-Oncology Unit, Hospital Pediatrico de Sinaloa, Culiacan, Mexico
| | | | | | - Camila Barra
- Pediatric Oncology, Centro de Investigacion Bradford Hill, Santiago, Chile
| | | | - Zulma Carpio
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru
| | | | - Daniela Covarrubias
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | - Lucy de Leon Vasquez
- Pediatric Oncology, Hospital Infantil Regional Universitario Dr. Arturo Grullon, Santiago, Dominican Republic
| | | | | | - Wendy Gomez-Garcia
- Oncology Unit, Hospital Infantil Dr. Robert Reid Cabral, Santo, Domingo, Dominican Republic
| | | | | | - Esmeralda Leon
- Medical Oncology, Hospital Guillermo Almenara Irigoyen, Lima, Peru
| | | | - Alejandra Mendez
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kenia Miller
- Pediatric Hemato-Oncology, Hospital del Niño “Jose Renan Esquivel”, Panama City, Panama
| | - Erika Montalvo Cozar
- Pediatric Intensive Care Unit, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | | | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Hemato-Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Ligia Rios
- Pediatric Hemato-Oncology, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | | | | | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Asya Agulnik,
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Reuland C, Shi G, Deatras M, Ang M, Evangelista PPG, Shilkofski N. A qualitative study of barriers and facilitators to pediatric early warning score (PEWS) implementation in a resource-limited setting. Front Pediatr 2023; 11:1127752. [PMID: 37009287 PMCID: PMC10050749 DOI: 10.3389/fped.2023.1127752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Objectives Globally, pediatric hospitals have implemented Pediatric Early Warning Scores (PEWS) to standardize escalation of care and improve detection of clinical deterioration in pediatric patients. This study aims to utilize qualitative methodology to understand barriers and facilitators of PEWS implementation at Philippine Children's Medical Center (PCMC), a tertiary care hospital in Manila, Philippines. Methods Semi-structured interviews querying current processes for clinical monitoring, Pediatric Intensive Care Unit (PICU) transfer, and clinician attitudes towards PEWS implementation were audio recorded. In-person hospital observations served to triangulate interview findings. The Systems Engineering Initiative for Patient Safety (SEIPS) framework guided content coding of interviews to characterize work systems, processes, and outcomes related to patient monitoring and care escalation. Thematic coding was performed using Dedoose software. This model allowed identification of barriers and facilitators to PEWS implementation. Results Barriers within PCMC workflow included: limited bed capacity, delay in referral, patient overflow, limited monitoring equipment, and high patient to staff ratio. Facilitators of PEWS implementation included support for PEWS adaptation and existence of systems for vital sign monitoring. Observations by study personnel confirmed validity of themes. Conclusion Utilizing qualitative methodology to understand barriers and facilitators to PEWS in specific contexts can guide implementation at resource-limited hospitals.
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Affiliation(s)
- Carolyn Reuland
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Correspondence: Carolyn Reuland
| | - Galen Shi
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mark Deatras
- Philippine Children’s Medical Center Department of Pediatric Critical Care, Quezon, Philippines
| | - Mellinor Ang
- Philippine Children’s Medical Center Department of Pediatric Critical Care, Quezon, Philippines
| | | | - Nicole Shilkofski
- Johns Hopkins University School of Medicine Department of Pediatrics, Baltimore, MD, United States
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Agarwal D, Alam S, Mazahir R, Singh RR, Maini B. Utility of Pediatric Early Warning Sign Score in Predicting Outcome of PICU Admissions at a Suburban Tertiary Care Hospital. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1759730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AbstractAssessment of the severity of illness is very important in intensive care unit care for quality assessment, assessing prognosis, and proper counseling. The goal of the study was to see how well the Pediatric Early Warning Sign (PEWS) score predicted the outcome of pediatric intensive care unit patients. This prospective cross-sectional study included children younger than 18 years. PEWS was calculated at presentation. The outcomes analyzed were mortality (primary outcome), need for mechanical ventilation, inotropic support, and length of stay (LOS). A median score was calculated and compared across the outcome groups. The performance of the PEWS was assessed for calibration and discrimination, and the best cutoff was determined. This study included 237 patients with a median score of 6 (range 4–9). Twenty-two (9.3%) patients required ventilator support and 66 (26.6%) inotropic support. The overall mortality rate was 5.1%, and 16.4% had prolonged LOS (>4 days). The median score of patients was significantly higher among those who died (8.5 vs. 6; p = 0.001), required ventilator support (8 vs. 6; p = 0.001), inotropic support (7 vs. 6; p = 0.030), and prolonged LOS (7 vs. 6; p = 0.001). On calibration, PEWS was found to have a good fit to predict mortality, the need for ventilator support, inotropic support, and prolonged LOS. Receiver operating characteristic curves for the PEWS model yield an area under the curve of 0.966 for mortality, 0.951 for ventilator support, 0.626 for inotropic support, and 0.760 for prolonged LOS. A cutoff value of > 7 was found to be the best to predict the outcome. PEWS is a robust tool to easily prognosticate the patient on the basis of clinical parameters.
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Affiliation(s)
- Deepika Agarwal
- Department of Pediatrics, Teerthanker Mahaveer Medical College & Research Centre, Moradabad, Uttar Pradesh, India
| | - Shahzad Alam
- Department of Pediatrics, Teerthanker Mahaveer Medical College & Research Centre, Moradabad, Uttar Pradesh, India
| | - Rufaida Mazahir
- Department of Pediatrics, Teerthanker Mahaveer Medical College & Research Centre, Moradabad, Uttar Pradesh, India
| | - Rupa Rajbhandari Singh
- Department of Pediatrics, Teerthanker Mahaveer Medical College & Research Centre, Moradabad, Uttar Pradesh, India
| | - Baljeet Maini
- Department of Pediatrics, Teerthanker Mahaveer Medical College & Research Centre, Moradabad, Uttar Pradesh, India
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Agulnik A, Gonzalez Ruiz A, Muniz‐Talavera H, Carrillo AK, Cárdenas A, Puerto‐Torres MF, Garza M, Conde T, Soberanis Vasquez DJ, Méndez Aceituno A, Acuña Aguirre C, Alfonso Y, Álvarez Arellano SY, Argüello Vargas D, Batista R, Blasco Arriaga EE, Chávez Rios M, Cuencio Rodríguez ME, Fing Soto EA, Gómez‐García W, Guillén Villatoro RH, Gutiérrez Rivera MDL, Herrera Almanza M, Jimenez Antolinez YV, Juárez Tobias MS, López Facundo NA, Martínez Soria RA, Miller K, Miralda S, Morales R, Negroe Ocampo N, Osuna A, Pascual Morales C, Pérez Fermin CK, Pérez Alvarado CM, Pineda E, Andrés Portilla C, Rios López LE, Rivera J, Sagaón Olivares AS, Saguay Tacuri MC, Salas Mendoza BT, Solano Picado I, Soto Chávez V, Tejocote Romero I, Tatay D, Teixeira Costa J, Villanueva E, Villegas Pacheco M, McKay VR, Metzger ML, Friedrich P, Rodriguez‐Galindo C. Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America. Cancer 2022; 128:4004-4016. [PMID: 36161436 PMCID: PMC9828186 DOI: 10.1002/cncr.34427] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pediatric early warning systems (PEWS) aid in the early identification of deterioration in hospitalized children with cancer; however, they are under-used in resource-limited settings. The authors use the knowledge-to-action framework to describe the implementation strategy for Proyecto Escala de Valoracion de Alerta Temprana (EVAT), a multicenter quality-improvement collaborative, to scale-up PEWS in pediatric oncology centers in Latin America. METHODS Proyecto EVAT mentored participating centers through an adaptable implementation strategy to: (1) monitor clinical deterioration in children with cancer, (2) contextually adapt PEWS, (3) assess barriers to using PEWS, (4) pilot and implement PEWS, (5) monitor the use of PEWS, (6) evaluate outcomes, and (7) sustain PEWS. The implementation outcomes assessed included the quality of PEWS use, the time required for implementation, and global program impact. RESULTS From April 2017 to October 2021, 36 diverse Proyecto EVAT hospitals from 13 countries in Latin America collectively managing more than 4100 annual new pediatric cancer diagnoses successfully implemented PEWS. The time to complete all program phases varied among centers, averaging 7 months (range, 3-13 months) from PEWS pilot to implementation completion. All centers ultimately implemented PEWS and maintained high-quality PEWS use for up to 18 months after implementation. Across the 36 centers, more than 11,100 clinicians were trained in PEWS, and more than 41,000 pediatric hospital admissions had PEWS used in their care. CONCLUSIONS Evidence-based interventions like PEWS can be successfully scaled-up regionally basis using a systematic approach that includes a collaborative network, an adaptable implementation strategy, and regional mentorship. Lessons learned can guide future programs to promote the widespread adoption of effective interventions and reduce global disparities in childhood cancer outcomes. LAY SUMMARY Pediatric early warning systems (PEWS) are clinical tools used to identify deterioration in hospitalized children with cancer; however, implementation challenges limit their use in resource-limited settings. Proyecto EVAT is a multicenter quality-improvement collaborative to implement PEWS in 36 pediatric oncology centers in Latin America. This is the first multicenter, multinational study reporting a successful implementation strategy (Proyecto EVAT) to regionally scale-up PEWS. The lessons learned from Proyecto EVAT can inform future programs to promote the adoption of clinical interventions to globally improve childhood cancer outcomes.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Alejandra Gonzalez Ruiz
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Hilmarie Muniz‐Talavera
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Angela K. Carrillo
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Adolfo Cárdenas
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Maria F. Puerto‐Torres
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Marcela Garza
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | | | | | | | | | - Yvania Alfonso
- Pediatric Hemato‐oncologyHospital St DamienPort‐Au‐PrinceHaiti
| | | | | | - Rosario Batista
- Pediatric Hemato‐OncologyHospital Jose Domingo De ObaldíaChiriquiPanama
| | | | | | | | | | - Wendy Gómez‐García
- Pediatric Hemato‐OncologyHospital Infantil Dr Robert Reid CabralSanto DomingoDominican Republic
| | | | | | - Martha Herrera Almanza
- Pediatric Hemato‐OncologyHospital Infantil de Especialidades de ChihuahuaChihuahuaMexico
| | - Yajaira V. Jimenez Antolinez
- Pediatric Hemato‐OncologyHospital Universitario Dr José Eleuterio González, Universidad Autónoma de Nuevo LeónMonterreyMexico
| | | | - Norma Araceli López Facundo
- Pediatric Hemato‐OncologyInstituto de Seguridad Social del Estado de México y Municipos Hospital Materno InfantilTolucaMexico
| | | | - Kenia Miller
- Pediatric Hemato‐OncologyHospital del Niño “Jose Renan Esquivel”PanamaPanama
| | | | - Roxana Morales
- Pediatric Hemato‐OncologyInstituto Nacional de Enfermedades NeoplásicasLimaPeru
| | | | - Alejandra Osuna
- Pediatric Hemato‐OncologyHospital Pediátrico de SinaloaCuliacanMexico
| | | | - Clara Krystal Pérez Fermin
- Pediatric Hemato‐OncologyHospital Infantil Regional Universitario Dr Arturo GrullónSantiagoDominican Republic
| | | | - Estuardo Pineda
- Pediatric Hemato‐OncologyHospital de Niños Benjamín BloomSan SalvadorEl Salvador
| | | | | | - Jocelyn Rivera
- Department of PediatricsHospital Infantil Teletón de Oncología (HITO)QueretaroMexico
| | | | | | | | | | | | | | - Daniel Tatay
- Pediatric Hemato‐OncologyHospital del Niños de la Santísima Trinidad de CórdobaCordobaArgentina
| | | | | | | | | | - Monika L. Metzger
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Paola Friedrich
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
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12
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Mirochnick E, Graetz DE, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Agulnik A. Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals. Front Oncol 2022; 12:1018224. [PMID: 36313665 PMCID: PMC9597682 DOI: 10.3389/fonc.2022.1018224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes.
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Affiliation(s)
- Emily Mirochnick
- The Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Srinithya R. Gillipelli
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- School of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | | | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer Solca Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Asya Agulnik,
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Buowari DY, Owoo C, Gupta L, Schell CO, Baker T. Essential Emergency and Critical Care: A Priority for Health Systems Globally. Crit Care Clin 2022; 38:639-656. [PMID: 36162903 DOI: 10.1016/j.ccc.2022.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided, and the potential for reversibility. An estimated 45 million adults become critically ill each year. While some are treated in emergency departments or intensive care units, most are cared for in general hospital wards. We outline a priority for health systems globally: the first-tier care that all critically ill patients should receive in all parts of all hospitals: Essential Emergency and Critical Care. We describe its relation to other specialties and care and opportunities for implementation.
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Affiliation(s)
- Dabota Yvonne Buowari
- Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Along East West Road, Alakahia, Port Harcourt, Rivers State 23401, Nigeria
| | - Christian Owoo
- Department of Anaesthesia, University of Ghana Medical School, College of Health Sciences, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Department of Anaesthesia, Korle Bu Teaching Hospital, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Ghana Infectious Disease Centre, Kwabenya, Ga East, Municipal Hospital, GE-255-9501 (PQ47+FGV), Accra, Ghana; University of Ghana Medical Centre, Indian Ocean Link, University of Ghana, GA-337-6980 (JRJ7+WJP) Accra, Ghana
| | - Lalit Gupta
- Department of Anaesthesia and Critical Care, Maulana Azad Medical College, 2 Bahadur Shah Zafar Marg, New Delhi 110002, India
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Sveavägen entré 9 Mälarsjukhuset, Eskilstuna, 631 88 Sweden; Department of Medicine, Nyköping Hospital, Nyköping 61185, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, United Nations Road, Dar es Salaam, P.O. Box 65001, Tanzania; Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; Ifakara Health Institute, 5 Ifakara Street, Plot 463 Mikocheni, Dar es Salaam, P.O. Box 78 373, Tanzania.
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Carter B, Saron H, Blake L, Eyton-Chong CK, Dee S, Evans L, Harris J, Hughes H, Jones D, Lambert C, Lane S, Mehta F, Peak M, Preston J, Siner S, Sefton G, Carrol ED. Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals. PLoS One 2022; 17:e0273666. [PMID: 36107953 PMCID: PMC9477367 DOI: 10.1371/journal.pone.0273666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 08/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Paediatric early warning systems (PEWS) are a means of tracking physiological state and alerting healthcare professionals about signs of deterioration, triggering a clinical review and/or escalation of care of children. A proactive end-to-end deterioration solution (the DETECT surveillance system) with an embedded e-PEWS that included sepsis screening was introduced across a tertiary children’s hospital. One component of the implementation programme was a sub-study to determine an understanding of the DETECT e-PEWS in terms of its clinical utility and its acceptability. Aim This study aimed to examine how parents and health professionals view and engage with the DETECT e-PEWS apps, with a particular focus on its clinical utility and its acceptability. Method A prospective, closed (tick box or sliding scale) and open (text based) question, e-survey of parents (n = 137) and health professionals (n = 151) with experience of DETECT e-PEWS. Data were collected between February 2020 and February 2021. Results Quantitative data were analysed using descriptive and inferential statistics and qualitative data with generic thematic analysis. Overall, both clinical utility and acceptability (across seven constructs) were high across both stakeholder groups although some challenges to utility (e.g., sensitivity of triggers within specific patient populations) and acceptability (e.g., burden related to having to carry extra technology) were identified. Conclusion Despite the multifaceted nature of the intervention and the complexity of implementation across a hospital, the system demonstrated clinical utility and acceptability across two key groups of stakeholders: parents and health professionals.
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Affiliation(s)
- Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
- * E-mail:
| | - Holly Saron
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Lucy Blake
- Department of Social Sciences, University of West of England, Bristol, United Kingdom
| | - Chin-Kien Eyton-Chong
- Department of General Paediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Sarah Dee
- High Dependency Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Leah Evans
- High Dependency Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Jane Harris
- Faculty of Health, Public Health Institute, Liverpool John Moores University, United Kingdom
| | - Hannah Hughes
- Oncology Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Dawn Jones
- Clinical Research Division, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Caroline Lambert
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Steven Lane
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Fulya Mehta
- Department of General Paediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Matthew Peak
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Jennifer Preston
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Sarah Siner
- Clinical Research Division, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Gerri Sefton
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Enitan D. Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
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Chong SL, Goh MSL, Ong GYK, Acworth J, Sultana R, Yao SHW, Ng KC, Scholefield B, Aickin R, Maconochie I, Atkins D, Couto TB, Guerguerian AM, Kleinman M, Kloeck D, Nadkarni V, Nuthall G, Reis A, Rodriguez-Nunez A, Schexnayder S, Tijssen J, Van de Voorde P, Morley P. Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis. Resusc Plus 2022; 11:100262. [PMID: 35801231 PMCID: PMC9253845 DOI: 10.1016/j.resplu.2022.100262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022] Open
Abstract
Aim We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS? Methods We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias. Results Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies. Conclusions Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems. PROSPERO registration: CRD42021269579.
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Song Y, Wang H, Tao YH. Risk factors and optimal predictive scoring system of mortality for children with acute paraquat poisoning. World J Clin Cases 2022; 10:4799-4809. [PMID: 35801032 PMCID: PMC9198859 DOI: 10.12998/wjcc.v10.i15.4799] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/31/2021] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is no suitable scoring system that can be used to predict mortality in children with acute paraquat intoxication (APP).
AIM To optimize a predictive scoring system for mortality in children with APP.
METHODS A total of 113 children with APP from January 1, 2010 to January 1, 2020 were enrolled in this study. These patients were divided into survivors and non-survivors. We compared the clinical characteristics between the two groups and analyzed the independent prognostic risk factors. The survival rates of patients with different values of the pediatric critical illness score (PCIS) were assessed using kaplan-meier survival analysis. The best scoring system was established by using the area under the receiver operating characteristic curve analysis.
RESULTS The overall mortality rate was 23.4%. All non-survivors died within 20 days; 48.1% (13/27) died within 3 days, and 70.3% (19/27) died within 7 days. Compared to survivors, the non-survivors were older, had higher white blood cell count, alanine aminotransferase (ALT), aspartate aminotransferase, serum creatinine, blood urea nitrogen, glucose, and pediatric early warning score, and had lower platelet count, albumin, Serum sodium (Na+) and PCIS. ALT and PCIS were the independent prognostic risk factors for children with APP. The survival rate of children classified as extremely critical patients (100%) was lower than that of children classified as critical (60%) or noncritical (6.7%) patients. The specificity of ALT was high (96.51%), but the sensitivity was low (59.26%). The sensitivity and specificity of ALT combined with PCIS were high, 92.59% and 87.21%, respectively. The difference in mortality was significantly higher for ALT combined with PCIS (area under the receiver operating characteristic: 0.937; 95%CI: 0.875-0.974; P < 0.05).
CONCLUSION In our study, ALT and PCIS were independent prognostic risk factors for children with APP. ALT combined with PCIS is an optimal predictive mortality scoring system for children with APP.
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Affiliation(s)
- Yue Song
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hua Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yu-Hong Tao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu 610041, Sichuan Province, China
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Agulnik A, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz R, Hernandez C, Juárez Tobias S, de Jesus Loeza J, Mendez A, Montalvo E, Penafiel E, Pineda E, Graetz DE. Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings. JAMA Netw Open 2022; 5:e221547. [PMID: 35262714 PMCID: PMC8908074 DOI: 10.1001/jamanetworkopen.2022.1547] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. OBJECTIVE To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. MAIN OUTCOMES AND MEASURES Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. RESULTS Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. CONCLUSIONS AND RELEVANCE To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine and Division of Critical Care, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Miriam Armenta
- Department of Pediatric Oncology, Hospital General de Tijuana, Tijuana, México
| | - Camila Barra
- Department of Pediatric Oncology, Hospital Dr Luis Calvo Mackenna, Santiago, Chile
| | - Rosdali Diaz
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú
| | - Cinthia Hernandez
- Department of Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, México
| | | | - Jose de Jesus Loeza
- Department of Pediatric Oncology, Hospital Centro Estatal de Cancerología, Xalapa, México
| | - Alejandra Mendez
- Department of Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Department of Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Department of Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Department of Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
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Nyandat J, Murthy S, Muttalib F. Challenges and Opportunities for Implementing Pediatric Early Warning Systems in Low- and Middle-Income Countries-Using Resources Wisely. JAMA Netw Open 2022; 5:e221553. [PMID: 35262722 DOI: 10.1001/jamanetworkopen.2022.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joram Nyandat
- Faculty of Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Directorate of Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Srinivas Murthy
- Faculty of Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fiona Muttalib
- Faculty of Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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Tran A, Valo P, Rouvier C, Dos Ramos E, Freyssinet E, Baranton E, Haas O, Haas H, Pradier C, Gentile S. Validation of the Computerized Pediatric Triage Tool, pediaTRI, in the Pediatric Emergency Department of Lenval Children's Hospital in Nice: A Cross-Sectional Observational Study. Front Pediatr 2022; 10:840181. [PMID: 35592843 PMCID: PMC9113392 DOI: 10.3389/fped.2022.840181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION A reliable pediatric triage tool is essential for nurses working in pediatric emergency departments to quickly identify children requiring priority care (high-level emergencies) and those who can wait (low-level emergencies). In the absence of a gold standard in France, the objective of our study was to validate our 5-level pediatric triage tool -pediaTRI- against the reference tool: the Pediatric Early Warning Score (PEWS) System. MATERIALS AND METHODS We prospectively included 100,506 children who visited the Pediatric Emergency Department at Lenval Children's Hospital (Nice, France) in 2016 and 2017. The performance of pediaTRI to identify high-level emergencies (severity levels 1 and 2) was evaluated in comparison with a PEWS ≥ 4/9. Data from 2018-19 was used as an independent validation cohort. RESULTS pediaTRI agreed with the PEWS score for 84,896 of the patients (84.5%): 15.0% (14.8-15.2) of the patients were over-triaged and 0.5% (0.5-0.6) under-triaged compared with the PEWS score. pediaTRI had a sensitivity of 76.4% (74.6-78.2), a specificity of 84.7% (84.4-84.9), and positive and negative likelihood ratios of 5.0 (4.8-5.1) and 0.3 (0.3-0.3), respectively, for the identification of high-level emergencies. However, the positive likelihood ratios were lower for patients presenting with a medical complaint [4.1 (4.0-4.2) v 10.4 (7.9-13.7 for trauma), and for younger children [1.2 (1.1-1.2) from 0 to 28 days, and 1.9 (1.8-2.0) from 28 days to 3 months]. CONCLUSION pediaTRI has a moderate to good validity to triage children in a Pediatric Emergency Department with a tendency to over-triage compared with the PEWS system. Its validity is lower for younger children and for children consulting for a medical complaint.
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Affiliation(s)
- Antoine Tran
- Pediatric Emergency Department, Lenval University Children's Hospital, Nice, France.,School of Medicine, Université Côte d'Azur, Nice, France.,Research Team EA 3279 "Santé Publique, Maladies Chroniques et Qualité de Vie", School of Medicine, Aix-Marseille Université, Marseille, France
| | - Petri Valo
- Pediatric Emergency Department, Lenval University Children's Hospital, Nice, France.,School of Computing, University of Eastern Finland, Joensuu, Finland
| | - Camille Rouvier
- Pediatric Emergency Department, Lenval University Children's Hospital, Nice, France
| | - Emmanuel Dos Ramos
- Department of Medical Computing, General Hospital "les Palmiers", Hyères, France.,Innovation e-Santé Sud, Groupement d'Intérêt Public, Hyères, France
| | - Emma Freyssinet
- Pediatric Emergency Department, Lenval University Children's Hospital, Nice, France
| | - Emma Baranton
- Pediatric Emergency Department, Lenval University Children's Hospital, Nice, France
| | - Olivier Haas
- Pediatric Emergency Department, Lenval University Children's Hospital, Nice, France
| | - Hervé Haas
- Department of Pediatrics, Centre Hospitalier Princesse-Grace, Monaco, Monaco
| | - Christian Pradier
- School of Medicine, Université Côte d'Azur, Nice, France.,Department of Public Health, Archet University Hospital, Nice, France
| | - Stéphanie Gentile
- Research Team EA 3279 "Santé Publique, Maladies Chroniques et Qualité de Vie", School of Medicine, Aix-Marseille Université, Marseille, France
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Sharif AF, Gameel DEGE, Abdo SAEF, Elgebally EI, Fayed MM. Evaluation of Pediatric Early Warning System and Drooling Reluctance Oropharynx Others Leukocytosis scores as prognostic tools for pediatric caustic ingestion: a two-center, cross-sectional study. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:5378-5395. [PMID: 34420162 PMCID: PMC8380116 DOI: 10.1007/s11356-021-15988-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
Caustic chemicals are widely distributed in our environment. Exposure to caustic agents is a lifelong problem associated with severe tissue and mucous membrane injuries. In pediatrics, corrosive exposure is the most common cause of nonpharmaceutical exposure presenting to poison control centers. Therefore, this study evaluated the role of the Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) scores as early in-hospital outcome predictors following corrosive ingestion. The current study was a two-center, retrospective, cross-sectional study carried out among pediatric patients diagnosed with acute caustic ingestion during the past 4 years. Most exposure occurred accidentally among boys (59.4%) living in rural areas (51.9%) of preschool age (50% were 2-4 years old). Residence, body temperature, respiratory rate, vomiting, skin and mucosal burns, retrosternal pain, respiratory distress, Oxygen (O2) saturation, Glasgow Coma Scale score, HCO3 level, total bilirubin level, anemia, leukocytosis, and presence of free peritoneal fluid were significant predictors of esophageal injuries (p < 0.05). DROOL and PEWS scoring were the most significant predictors of esophageal injuries with worthy predictive power, where odds ratio (95% confidence interval (CI)) was 1.76 (0.97-3.17) and 0.47 (0.21-0.99) for PEWS and DROOL, respectively. At a cutoff of < 6.5, the DROOL score could predict esophageal injuries excellently, with AUC = 0.931; sensitivity, 91.7%; specificity, 72.5%; and overall accuracy, 91.3%. At a cutoff of > 6.5, PEWS could significantly predict unfavorable outcomes, with AUC = 0.893; sensitivity, 94.4%; specificity, 71.9%; and overall accuracy, 89.3%. However, PEWS better predicted the need for admittance to the intensive care unit (ICU). Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) are potentially useful accurate scorings that could predict the esophageal injuries and ICU admission following corrosive ingestion in pediatrics.
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Affiliation(s)
- Asmaa Fady Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Dina El Gameel El Gameel
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Poison Control Center, Aseer, Saudi Arabia
| | - Sanaa Abd El-Fatah Abdo
- Public Health and Community Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Elsayed Ibrahim Elgebally
- Department of Pediatric, Menoufia University, Shebeen Al-kom, Egypt
- Pediatric Department, Saudi German Hospital, Aseer, Saudi Arabia
| | - Manar Maher Fayed
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt.
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21
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Agulnik A, Schmidt-Grimminger G, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Graetz DE, McKay V. Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America. FRONTIERS IN HEALTH SERVICES 2022; 2:1004805. [PMID: 36925775 PMCID: PMC10012640 DOI: 10.3389/frhs.2022.1004805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022]
Abstract
Background Sustainability, or continued use of evidence-based interventions for long-term patient benefit, is the least studied aspect of implementation science. In this study, we evaluate sustainability of a Pediatric Early Warning System (PEWS), an evidence-based intervention to improve early identification of clinical deterioration in hospitalized children, in low-resource settings using the Clinical Capacity for Sustainability Framework (CCS). Methods We conducted a secondary analysis of a qualitative study to identify barriers and enablers to PEWS implementation. Semi-structured interviews with PEWS implementation leaders and hospital directors at 5 Latin American pediatric oncology centers sustaining PEWS were conducted virtually in Spanish from June to August 2020. Interviews were recorded, professionally transcribed, and translated into English. Exploratory thematic content analysis yielded staff perceptions on PEWS sustainability. Coded segments were analyzed to identify participant perception about the current state and importance of sustaining PEWS, as well as sustainability successes and challenges. Identified sustainability determinants were mapped to the CCS to evaluate its applicability. Results We interviewed 71 staff including physicians (45%), nurses (45%), and administrators (10%). Participants emphasized the importance of sustaining PEWS for continued patient benefits. Identified sustainability determinants included supportive leadership encouraging ongoing interest in PEWS, beneficial patient outcomes enhancing perceived value of PEWS, integrating PEWS into the routine of patient care, ongoing staff turnover creating training challenges, adequate material resources to promote PEWS use, and the COVID-19 pandemic. While most identified factors mapped to the CCS, COVID-19 emerged as an additional external sustainability challenge. Together, these challenges resulted in multiple impacts on PEWS sustainment, ranging from a small reduction in PEWS quality to complete disruption of PEWS use and subsequent loss of benefits to patients. Participants described several innovative strategies to address identified challenges and promote PEWS sustainability. Conclusion This study describes clinician perspectives on sustainable implementation of evidence-based interventions in low-resource settings, including sustainability determinants and potential sustainability strategies. Identified factors mapped well to the CCS, however, external factors, such as the COVID pandemic, may additionally impact sustainability. This work highlights an urgent need for theoretically-driven, empirically-informed strategies to support sustainable implementation of evidence-based interventions in settings of all resource-levels.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | | | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Virginia McKay
- Brown School, Washington University, St. Louis, MO, United States
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22
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Agulnik A, Malone S, Puerto-Torres M, Gonzalez-Ruiz A, Vedaraju Y, Wang H, Graetz D, Prewitt K, Villegas C, Cardenas-Aguierre A, Acuna C, Arana AE, Díaz R, Espinoza S, Guerrero K, Martínez A, Mendez A, Montalvo E, Soberanis D, Torelli A, Quelal J, Villanueva E, Devidas M, Luke D, McKay V. Reliability and validity of a Spanish-language measure assessing clinical capacity to sustain Paediatric Early Warning Systems (PEWS) in resource-limited hospitals. BMJ Open 2021; 11:e053116. [PMID: 34670767 PMCID: PMC8529978 DOI: 10.1136/bmjopen-2021-053116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Paediatric Early Warning Systems (PEWSs) improve identification of deterioration, however, their sustainability has not been studied. Sustainability is critical to maximise impact of interventions like PEWS, particularly in low-resource settings. This study establishes the reliability and validity of a Spanish-language Clinical Sustainability Assessment Tool (CSAT) to assess clinical capacity to sustain interventions in resource-limited hospitals. METHODS Participants included PEWS implementation leadership teams of 29 paediatric cancer centres in Latin America involved in a collaborative to implement PEWS. The CSAT, a sustainability assessment tool validated in high-resource settings, was translated into Spanish and distributed to participants as an anonymous electronic survey. Psychometric, confirmatory factor analysis (CFA), and multivariate analyses were preformed to assess reliability, structure and initial validity. Focus groups were conducted after participants reviewed CSAT reports to assess their interpretation and utility. RESULTS The CSAT survey achieved an 80% response rate (n=169) with a mean score of 4.4 (of 5; 3.8-4.8 among centres). The CSAT had good reliability with an average internal consistency of 0.77 (95% CI 0.71 to 0.81); and CFAs supported the seven-domain structure. CSAT results were associated with respondents' perceptions of the evidence for PEWS, its implementation and use in their centre, and their assessment of the hospital culture and implementation climate. The mean CSAT score was higher among respondents at centres with longer time using PEWS (p<0.001). Focus group participants noted the CSAT report helped assess their centre's clinical capacity to sustain PEWS and provided constructive feedback for improvement. CONCLUSIONS We present information supporting the reliability and validity of the CSAT tool, the first Spanish-language instrument to assess clinical capacity to sustain evidence-based interventions in hospitals of variable resource levels. This assessment demonstrates a high capacity to sustain PEWS in these resource-limited centres with improvement over time from PEWS implementation.
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Affiliation(s)
- Asya Agulnik
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
- Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sara Malone
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Maria Puerto-Torres
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Yuvanesh Vedaraju
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Huiqi Wang
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Dylan Graetz
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
- Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kim Prewitt
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Cesar Villegas
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carlos Acuna
- Pediatric Critical Care, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Ana Edith Arana
- Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Rosdali Díaz
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Silvana Espinoza
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Queretaro, Mexico
| | | | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncologia Pediatrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Dora Soberanis
- Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Antonella Torelli
- Pediatric Oncology, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Janeth Quelal
- Pediatric Oncology, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Erika Villanueva
- Pediatric Oncology, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Meenakshi Devidas
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
- Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Douglas Luke
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Virginia McKay
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
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Ong GYK, Ngiam N, Tham LP, Mok YH, Ong JSM, Lee KP, Ganapathy S, Chong SL, Pek JH, Chew SY, Lim YC, Shen GQ, Kua J, Tan J, Ng KC. Singapore Paediatric Resuscitation Guidelines 2021. Singapore Med J 2021; 62:372-389. [PMID: 35001111 PMCID: PMC8804481 DOI: 10.11622/smedj.2021107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.
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Affiliation(s)
- Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Nicola Ngiam
- Division of Paediatric Critical Care, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Lai Peng Tham
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Yee Hui Mok
- Children’s Intensive Care Unit, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
| | - Jacqueline SM Ong
- Division of Paediatric Critical Care, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Su Yah Chew
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Yang Chern Lim
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | | | - Jade Kua
- Department of Emergency Medicine, Woodlands Health Campus, Singapore
| | - Josephine Tan
- Department of Paediatric Anaesthesia, KK Women’s and Children’s Hospital, Singapore
| | - Kee Chong Ng
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
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van der Fluit KS, Boom MC, Brandão MB, Lopes GD, Barreto PG, Leite DCF, Gurgel RQ. How to implement a PEWS in a resource-limited setting: A quantitative analysis of the bedside-PEWS implementation in a hospital in northeast Brazil. Trop Med Int Health 2021; 26:1240-1247. [PMID: 34192384 PMCID: PMC8596539 DOI: 10.1111/tmi.13646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Quantitative analysis of the implementation of the bedside paediatric early warning system (B-PEWS) in a resource-limited setting. The B-PEWS serves to pre-emptively identify hospitalised children who are at risk for cardiopulmonary arrest and subsequently to provide critical care in time. METHODS We performed a retrospective review through the medical data records of patients after discharge from the paediatric ward of a philanthropic hospital in Brazil. Nurses' performance using the system was measured with various parameters. RESULTS A total of 499 patients were included, and a total of 8024 scores were checked. During the 21-week research period, the implementation rate increased significantly from 66.5% (SD 26.0) in Period 1 to 93.1% (SD 16.6) in Period 2. The number of scores that resulted in a correct total score went from 7.5% in Period 1 to 32.2% in Period 2, p < 0.001. There was an improvement in the correct choice of age group between the two periods (from 32.2% to 53.4%). There was no difference in the mean admission time of patients in the two periods: in the first period 4.8 days (SD 2.9) and in the second period 4.8 days (SD 4.1). CONCLUSIONS It is possible to implement a PEWS in resource-limited settings while achieving high implementation rates. However, this is a time- and energy-consuming process. Having an active and involved team that is responsible for implementation is key for a successful implementation. Factors that likely hindered implementation were a large change in workflow for the nursing staff, non-native speakers as main investigators.
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Affiliation(s)
- Karin S van der Fluit
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthijs C Boom
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Marlon B Brandão
- Department of Pediatrics, Hospital e Maternidade Santa Isabel, Aracaju, Brazil.,Professional Graduate Program in Health Technological Management and Innovation, Federal University of Sergipe, Aracaju, Brazil
| | - Gabriel D Lopes
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Paula G Barreto
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Deborah C F Leite
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Ricardo Q Gurgel
- Graduate Program in Health Sciences and Professional Graduate Program in Health Technological Management and Innovation, Federal University of Sergipe, Aracaju, Brazil
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von Saint Andre-von Arnim AO, Kumar RK, Oron AP, Nguyen QUP, Mutonga DM, Zimmerman J, Walson JL. Feasibility of Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Income Settings. Pediatr Crit Care Med 2021; 22:e115-e124. [PMID: 33031354 DOI: 10.1097/pcc.0000000000002582] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the feasibility of having caregivers assist in recognition of clinical deterioration in children hospitalized with febrile illness in a resource-limited setting. DESIGN Single-center, prospective, interventional pilot study. SETTING General pediatric wards at Kenyatta National Hospital, Nairobi, Kenya's largest public tertiary-care hospital. PATIENTS Children hospitalized with acute febrile illness, accompanied by caregivers available at the bedside for 24 hours soon after hospital admission. INTERVENTIONS Caregivers were trained to recognize signs of critical illness using the Family-Assisted Severe Febrile Illness Therapy tool, which quantifies patients' work of breathing, mental status, and perfusion, producing color-coded flags to signal illness severity. Caregivers' Family-Assisted Severe Febrile Illness Therapy assessments were compared with healthcare professional assessments and to established Pediatric Early Warning Scores (PEWS). An initial study stage was followed by refinement of training and a larger second stage with intervention/control arms. MEASUREMENTS AND MAIN RESULTS A total of 107 patient/caregiver pairs were enrolled in the interventional arm; 106 caregivers underwent Family-Assisted Severe Febrile Illness Therapy training and were included in the analysis. Patient characteristics included median age 1.1 years (0.2-10 yr), 55 (52%) female, and diagnoses: pneumonia (64 [60%]), meningitis (38 [36%]), gastroenteritis (24 [23%]), and malaria (21 [20%]). Most caregivers had primary (34 [32%]) or secondary (53 [50%]) school education. Fourteen of 106 patients (13%) died during their stay, six within 2 days. Across all severity levels, caregiver Family-Assisted Severe Febrile Illness Therapy assessments matched professionals in 87% and 94% for stages 1 and 2, respectively. Caregiver Family-Assisted Severe Febrile Illness Therapy assessments had a moderate to strong correlation with coinciding Pediatric Early Warning Scores and were sensitive to life-threatening deterioration: for all six patients who died within 2 days of admission, caregiver assessment reached the highest alert level. CONCLUSIONS Caregiver involvement in recognition of critical illness in hospitalized children in low-resource settings may be feasible. This may facilitate earlier detection of clinical deterioration where staffing is severely limited by constrained resources. Further validation of the Family-Assisted Severe Febrile Illness Therapy tool is warranted, followed by its application in a larger multisite patient population to assess provider response and associated clinical outcomes.
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Affiliation(s)
- Amelie O von Saint Andre-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children's, University of Washington, Seattle, WA
- Department of Global Health, Seattle Children's, University of Washington, Seattle, WA
| | - Rashmi K Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Assaf P Oron
- Maternal, Newborn, and Child Health, Institute for Disease Modeling, Seattle, WA
| | - Quynh-Uyen P Nguyen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Stanford, CA
| | - Daniel M Mutonga
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Jerry Zimmerman
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children's, University of Washington, Seattle, WA
| | - Judd L Walson
- Departments of Global Health, Epidemiology, Infectious Disease, University of Washington, Seattle, WA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
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26
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Gardner Yelton SE, McCaw JM, Reuland CJ, Steppan DA, Evangelista PPG, Shilkofski NA. Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting. Front Pediatr 2021; 9:738975. [PMID: 34722421 PMCID: PMC8555020 DOI: 10.3389/fped.2021.738975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Children in resource-limited settings are disproportionately affected by common childhood illnesses, resulting in high rates of mortality. A major barrier to improving child health in such regions is limited pediatric-specific training, particularly in the care of children with critical illness. While global health rotations for trainees from North America and Europe have become commonplace, residency and fellowship programs struggle to ensure that these rotations are mutually beneficial and do not place an undue burden on host countries. We created a bidirectional, multimodal educational program between trainees in Manila, Philippines, and Baltimore, Maryland, United States, to improve the longitudinal educational experience for all participants. Program Components: Based on stakeholder input and a needs assessment, we established a global health training program in which pediatricians from the Philippines traveled to the United States for observerships, and pediatric residents from a tertiary care center in Baltimore traveled to Manila. Additionally, we created and implemented a contextualized simulation-based shock curriculum for pediatric trainees in Manila that can be disseminated locally. This bidirectional program was adapted to include telemedicine and regularly scheduled "virtual rounds" and educational case conferences during the COVID-19 pandemic. Providers from the two institutions have collaborated on educational and clinical research projects, offering opportunities for resource sharing, bidirectional professional development, and institutional improvements. Conclusion: Although creating a mutually beneficial global health partnership requires careful planning and investment over time, establishment of a successful bidirectional educational and professional development program in a limited-resource setting is feasible and benefits learners in both countries.
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Affiliation(s)
- Sarah E Gardner Yelton
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Julia M McCaw
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carolyn J Reuland
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Diana A Steppan
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Paula Pilar G Evangelista
- Department of Pediatric Critical Care Medicine, Philippine Children's Medical Center, Quezon City, Philippines
| | - Nicole A Shilkofski
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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27
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Sridhar S, Schmid A, Biziyaremye F, Hodge S, Patient N, Wilson K. Implementation of a Pediatric Early Warning Score to Improve Communication and Nursing Empowerment in a Rural District Hospital in Rwanda. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:838-845. [PMID: 33361246 PMCID: PMC7784060 DOI: 10.9745/ghsp-d-20-00075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022]
Abstract
Implementation of the Pediatric Early Warning Score for Resource-Limited Settings tool improved nurses’ competency and confidence in their triage capabilities. This tool has the potential to improve patient outcomes. However, staff turnover and limited physician buy-in were barriers to sustainability of the tool in low-resource settings. Background: Pediatric early warning (PEW) scores represent a “track-and-trigger system” that identifies clinical deterioration in a patient’s condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. Implementation: The PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool. Evaluation: The PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses’ knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses’ feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support. Discussion: Implementation of PEW scores increased nurses’ technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff.
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Affiliation(s)
| | | | | | | | | | - Kim Wilson
- Boston Children's Hospital, Boston, MA, USA
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28
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A120-A155. [PMID: 33098916 PMCID: PMC7576321 DOI: 10.1016/j.resuscitation.2020.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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29
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S140-S184. [PMID: 33084393 DOI: 10.1161/cir.0000000000000894] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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30
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Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, Levy A, Lin Y, Magid DJ, Mahgoub M, Peberdy MA, Rodriguez AJ, Sasson C, Lavonas EJ. Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S580-S604. [PMID: 33081524 DOI: 10.1161/cir.0000000000000899] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.
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31
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Muttalib F, Clavel V, Yaeger LH, Shah V, Adhikari NKJ. Performance of Pediatric Mortality Prediction Models in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. J Pediatr 2020; 225:182-192.e2. [PMID: 32439313 DOI: 10.1016/j.jpeds.2020.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/11/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To describe the performance of prognostic models for mortality or clinical deterioration events among hospitalized children developed or validated in low- and middle-income countries. STUDY DESIGN A medical librarian systematically searched EMBASE, Ovid Medline, Scopus, Cochrane Library, EBSCO Global Health, LILACS, African Index Medicus, African Journals Online, African Healthline, Med-Carib, and Global Index Medicus (from 2000 to October 2019). We included citations that described the development or validation of a pediatric prognostic model for hospital mortality or clinical deterioration events in low- and middle-income countries. In duplicate and independently, we extracted data on included populations and model prognostic performance and evaluated risk of bias using the Prediction model Risk Of Bias Assessment Tool. RESULTS Of 41 279 unique citations, we included 15 studies describing 15 prognostic models for mortality and 3 models for clinical deterioration events. Six models were validated in >1 external cohort. The Lambarene Organ Dysfunction Score (0.85 [0.77-0.92]) and Signs of Inflammation in Children that Kill (0.85 [0.82-0.88]) had the highest summary C-statistics (95% CI) for discrimination. Calibration and classification measures were poorly reported. All models were at high risk of bias owing to inappropriate selection of predictor variables and handling of missing data and incomplete performance measure reporting. CONCLUSIONS Several prognostic models for mortality and clinical deterioration events have been validated in single cohorts, with good discrimination. Rigorous validation that conforms to current standards for prediction model studies and updating of existing models are needed before clinical implementation.
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Affiliation(s)
- Fiona Muttalib
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Virginie Clavel
- Faculty of Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Lauren H Yaeger
- Becker Medical Library Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Vibhuti Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Neill K J Adhikari
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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32
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Clinical audit of a Paediatric Emergency Warning Score (PEWS) in the paediatric oncology unit of a newly established tertiary cancer institute. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2020. [DOI: 10.1016/j.phoj.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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33
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Ngwalangwa F, Phiri CHA, Dube Q, Langton J, Hildenwall H, Baker T. Risk Factors for Mortality in Severely Ill Children Admitted to a Tertiary Referral Hospital in Malawi. Am J Trop Med Hyg 2020; 101:670-675. [PMID: 31287044 PMCID: PMC6726928 DOI: 10.4269/ajtmh.19-0127] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In low-resource settings, many children are severely ill at arrival to hospital. The risk factors for mortality among such ill children are not well-known. Understanding which of these patients are at the highest risk could assist in the allocation of limited resources to where they are most needed. A cohort study of severely ill children treated in the resuscitation room of the pediatric emergency department at Queen Elizabeth Central Hospital in Malawi was conducted over a 6-month period in 2017. Data on signs and symptoms, vital signs, blood glucose levels, and nutritional status were collected and linked with in-hospital mortality data. The factors associated with in-hospital mortality were analyzed using multivariable logistic regression. Data for 1,359 patients were analyzed and 118 (8.7%) patients died. The following factors were associated with mortality: presence of any severely deranged vital sign, unadjusted odds ratio (UOR) 2.6 (95% CI 1.7–4.0) and adjusted odds ratio (AOR) 3.2 (95% CI 2.0–5.0); severe dehydration, UOR 2.6 (1.4–5.1) and AOR 2.8 (1.3–6.0); hypoglycemia glycemia (< 5 mmol/L), UOR 3.6 (2.2–5.8) and AOR 2.7 (1.6–4.7); and severe acute malnutrition, UOR 5.8 (3.5–9.6) and AOR 5.7 (3.3–10.0). This study suggests that among severely sick children, increased attention should be given to those with hypo/low glycemia, deranged vital signs, malnutrition, and severe dehydration to avert mortality among these high-risk patients.
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Affiliation(s)
- Fatsani Ngwalangwa
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Queen Dube
- Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Helena Hildenwall
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Global Health-Health System and Policy Research Group, Stockholm, Sweden
| | - Tim Baker
- Department of Public Health Sciences, Karolinska Institutet, Global Health-Health System and Policy Research Group, Stockholm, Sweden.,Queen Elizabeth Central Hospital, Blantyre, Malawi.,Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
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34
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Agulnik A, Antillon-Klussmann F, Soberanis Vasquez DJ, Arango R, Moran E, Lopez V, Rodriguez-Galindo C, Bhakta N. Cost-benefit analysis of implementing a pediatric early warning system at a pediatric oncology hospital in a low-middle income country. Cancer 2019; 125:4052-4058. [PMID: 31436324 DOI: 10.1002/cncr.32436] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/06/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in low-income and middle-income countries (LMICs). Pediatric early warning systems (PEWS) assist with the early identification of deterioration. To the authors' knowledge, no studies to date have evaluated the cost-benefit of PEWS in LMICs. METHODS A PEWS was implemented at the National Pediatric Oncology Unit (Unidad Nacional de Oncologia Pediatrica [UNOP]), a pediatric oncology hospital in Guatemala, resulting in a reduction in unplanned pediatric intensive care unit (PICU) transfers. Variable costs of maintaining the PICU and hospital floor were calculated for the year prior to and after the implementation of PEWS using administrative data. PEWS implementation costs were tabulated. The number of PICU inpatient days averted due to reduced unplanned PICU transfers after implementation was calculated, adjusting for changes in hospital inpatient days. Savings per inpatient day from unplanned PICU transfers were calculated. All costs were adjusted for inflation. RESULTS There were 457 fewer PICU inpatient days due to unplanned transfers noted the year after implementation of PEWS, adjusting for changes in hospital volume. The variable costs of an unplanned PICU transfer versus a bed on the hospital floor was $806 per day. The total cost of implementing PEWS at UNOP was $13,644 ($7 per admission). Through reductions in variable PICU costs, UNOP saved a net $173 per admission ($354,514 annual net savings) after implementation of PEWS. The cost savings were sustained in a series of more conservative 1-way sensitivity analyses. CONCLUSIONS Implementation of PEWS at UNOP resulted in an incremental savings due to a reduction in the number of unplanned PICU transfers. The results of the current study demonstrate that hospital investment in PEWS can improve the quality of pediatric cancer care, optimize PICU use, and reduce costs.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Federico Antillon-Klussmann
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | - Rosa Arango
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala
| | - Elmer Moran
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala
| | - Victor Lopez
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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