Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America

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. Cancer 2022;128:4004-4016.

Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America

“…Proyecto EVAT is a quality improvement collaborative of pediatric oncology centers in Latin America which has supported PEWS implementation in over 40 low-resource hospitals (41), with preliminary results showing improvements in patient outcomes (42)(43)(44)(45)(46)(47). Recent work by our team identified multiple barriers to PEWS implementation among centers participating in Proyecto EVAT, with many of these barriers converted to enablers by local implementation teams during the implementation process (48).…”

Management of septic shock in children with cancer—Common challenges and research priorities

“… 12 Multiple studies have noted the effectiveness of quality improvement initiatives to promote proactive identification and management of critical illness, such as Pediatric Early Warning Systems (PEWS), to improve hospital outcomes in children with cancer. 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 Hospital and provider experience managing children with cancer are also important, with high-volume centers typically having lower PICU mortality for these patients. 18 , 29 Finally, strong interdisciplinary (oncology, intensive care, etc.)…”

“…The study by Azevedo et al highlights multiple urgent research priorities to improve outcomes for children with cancer who develop sepsis. Strategies for early identification of critical illness 28 and novel diagnostic techniques to rapidly identify infectious etiology 49 and distinguish infection from inflammation 17 remain a priority. Management approaches for children with cancer who develop sepsis, including risk stratification, appropriate contextually informed antimicrobial, and supportive care protocols are also essential.…”

Challenge implementing Pediatric Early Warning Systems to improve early identification of clinical deterioration in hospitalized children with cancer: Is it the score?

“…Clinical deterioration mortality for children with cancer in resource‐limited hospitals is significantly higher, 14 and variable material and human resources to manage critical illness 15 result in multiple barriers to implementation of evidence‐based interventions like PEWS 16 . These barriers, however, can be overcome through targeted implementation strategies leveraging horizontal collaboration between hospitals and regional clinical expertise 17 . As we seek strategies to globally scale‐up adoption of PEWS, we must also look beyond implementation to simultaneously develop strategies that promote sustainment of effective interventions to improve clinical care and outcomes, another scientific gap 18 …”

“…16 These barriers, however, can be overcome through targeted implementation strategies leveraging horizontal collaboration between hospitals and regional clinical expertise. 17…”