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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: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Graetz D, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Mack JW, Agulnik A. Qualitative Study of Pediatric Early Warning Systems' Impact on Interdisciplinary Communication in Two Pediatric Oncology Hospitals With Varying Resources. JCO Glob Oncol 2021; 6:1079-1086. [PMID: 32673079 PMCID: PMC7392735 DOI: 10.1200/go.20.00163] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Hospitalized pediatric oncology patients are at high risk of deterioration and require frequent interdisciplinary communication to deliver high-quality care. Pediatric early warning systems (PEWS) are used by hospitals to reduce deterioration, but it is unknown how these systems affect communication about patient care in high- and limited-resource pediatric oncology settings. METHODS This qualitative study included semistructured interviews describing PEWS and subsequent team communication at 2 pediatric cancer centers, 1 in the United States and 1 in Guatemala. Participants included nurses, and frontline and intensive care providers who experienced recent deterioration events. Transcripts were coded and analyzed inductively using MAXQDA software. RESULTS The study included 41 providers in Guatemala and 42 providers in the United States (33 nurses, 30 ward providers, and 20 pediatric intensive care providers). Major themes identified include “hierarchy,” “empowerment,” “quality and method of communication,” and “trigger.” All providers described underlying medical hierarchies affecting the quality of communication regarding patient deterioration events and identified PEWS as empowering. Participants from the United States described the algorithmic approach to care and technology associated with PEWS contributing to impaired clinical judgement and a lack of communication. In both settings, PEWS sparked interdisciplinary communication and inspired action. CONCLUSION PEWS enhance interdisciplinary communication in high- and limited-resource study settings by empowering bedside providers. Traditional hierarchies contributed to negative communication and, in well-resourced settings, technology and automation resulted in lack of communication. Understanding contextual elements is integral to optimizing PEWS and improving pediatric oncology outcomes in hospitals of all resource levels.
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Affiliation(s)
- Dylan Graetz
- St. Jude Children's Research Hospital, Memphis, TN
| | - Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Gia Ferrara
- St. Jude Children's Research Hospital, Memphis, TN
| | - Mario Rodriguez
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | | | | | | | - Jennifer W Mack
- Dana Farber Cancer Institute, Boston Children's Hospital, Boston, MA
| | - Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN
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Garza M, Graetz DE, Kaye EC, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Impact of PEWS on Perceived Quality of Care During Deterioration in Children With Cancer Hospitalized in Different Resource-Settings. Front Oncol 2021; 11:660051. [PMID: 34249696 PMCID: PMC8260684 DOI: 10.3389/fonc.2021.660051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
Background Children with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting. Methods We conducted semi-structured interviews with 83 healthcare staff (nurses, pediatricians, oncology fellows, and intensivists) involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital (SJCRH; n = 42) and Unidad Nacional de Oncología Pediátrica (UNOP; n = 41). Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively. Results Providers discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse. Conclusion Providers that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice.
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Affiliation(s)
- Marcela Garza
- 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
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, 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
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- 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.,Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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Agulnik A, Méndez Aceituno A, Mora Robles LN, Forbes PW, Soberanis Vasquez DJ, Mack R, Antillon-Klussmann F, Kleinman M, Rodriguez-Galindo C. Validation of a pediatric early warning system for hospitalized pediatric oncology patients in a resource-limited setting. Cancer 2017; 123:4903-4913. [PMID: 28881451 DOI: 10.1002/cncr.30951] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/10/2017] [Accepted: 07/21/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource-limited hospital. METHODS A retrospective case-control study comparing the highest documented and corrected PEWS score before unplanned PICU transfer in pediatric oncology patients (129 cases) with matched controls (those not requiring PICU care) was performed. RESULTS Documented and corrected PEWS scores were found to be highly correlated with the need for PICU transfer (area under the receiver operating characteristic, 0.940 and 0.930, respectively). PEWS scores increased 24 hours prior to unplanned transfer (P = .0006). In cases, organ dysfunction at the time of PICU admission correlated with maximum PEWS score (correlation coefficient, 0.26; P = .003), patients with PEWS results ≥4 had a higher Pediatric Index of Mortality 2 (PIM2) (P = .028), and PEWS results were higher in patients with septic shock (P = .01). The PICU mortality rate was 17.1%; nonsurvivors had higher mean PEWS scores before PICU transfer (P = .0009). A single-point increase in the PEWS score increased the odds of mechanical ventilation or vasopressors within the first 24 hours and during PICU admission (odds ratio 1.3-1.4). CONCLUSIONS PEWS accurately predicted the need for unplanned PICU transfer in pediatric oncology patients in this resource-limited setting, with abnormal results beginning 24 hours before PICU admission and higher scores predicting the severity of illness at the time of PICU admission, need for PICU interventions, and mortality. These results demonstrate that PEWS aid in the identification of clinical deterioration in this high-risk population, regardless of a hospital's resource-level. Cancer 2017;123:4903-13. © 2017 American Cancer Society.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee.,Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | - Peter W Forbes
- Clinical Research Program, Boston Children's Hospital, Boston, Massachusetts
| | | | - Ricardo Mack
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica Unit, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Federico Antillon-Klussmann
- Hematology/Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Monica Kleinman
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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