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Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine
David Mills1,2, Alexis Schmid3, Mohammad Najajreh4
1Boston Children's Hospital, Boston, USA. david.mills@childrens.harvard.edu.
Insights
Implementing a Pediatric Early Warning Score (PEWS) tool in a low-income country
Area of Science:
- Pediatric critical care medicine
- Implementation science
- Health systems strengthening in low-resource settings
Background:
- Pediatric Early Warning Scores (PEWS) are vital for identifying at-risk children but are underutilized in low- and middle-income countries (LMICs).
- Existing PEWS systems in high-income settings have shown benefits in reducing critical care utilization and mortality.
- Lack of early identification systems in LMICs contributes to preventable patient deterioration.
Purpose of the Study:
- To assess the feasibility and impact of implementing a PEWS tool in a pediatric oncology ward in an LMIC.
- To improve the early detection of clinical deterioration in pediatric patients.
- To establish a sustainable model for PEWS implementation in resource-limited environments.
Main Methods:
- A 16-hour pediatric resuscitation program trained staff on a PEWS tool, followed by implementation in Beit Jala, Palestine.
- Four Plan-Do-Study-Act (PDSA) cycles were used to refine PEWS integration, including EMR integration, job aids, and feedback mechanisms.
- Data audits were conducted to monitor PEWS documentation frequency and accuracy.
Main Results:
- Complete PEWS vital sign documentation reached a mean of 89.9%.
- PEWS scoring frequency and accuracy improved post-implementation, consistently exceeding 89% after the initial integration challenges.
- Successful integration into the EMR was achieved by the third week, resolving initial data auditing issues.
Conclusions:
- Implementing a PEWS scoring tool in an LMIC pediatric oncology unit is feasible.
- The PEWS tool can enhance the frequency of vital sign collection and ensure accurate scoring.
- This study provides a model for effective PEWS implementation and international collaboration in LMICs.
Background:
Pediatric Early Warning Scores (PEWS) are nurse-administered clinical assessment tools utilizing vital signs and patient signs and symptoms to screen for patients at risk for clinical deterioration.1-3 When utilizing a PEWS system, which consists of an escalation algorithm to alert physicians of high risk patients requiring a bedside evaluation and assessment, studies have demonstrated that PEWS systems can decrease pediatric intensive care (PICU) utilization, in-hospital cardiac arrests, and overall decreased mortality in high income settings. Yet, many hospital based settings in low and lower middle income countries (LMIC) lack systems in place for early identification of patients at risk for clinical deterioration.
Methods:
A contextually adapted 16-h pediatric resuscitation program included training of a PEWS tool followed by implementation and integration of a PEWS system in a pediatric hematology/oncology ward in Beit Jala, Palestine. Four PDSA cycles were implemented post-implementation to improve uptake and scoring of PEWS which included PEWS tool integration into an existing electronic medical record (EMR), escalation algorithm and job aid implementation, data audits and ward feedback.
Results:
Frequency of complete PEWS vital sign documentation reached a mean of 89.9%. The frequency and accuracy of PEWS scores steadily increased during the post-implementation period, consistently above 89% in both categories starting from data audit four and continuing thereafter. Accuracy of PEWS scoring was unable to be assessed during week 1 and 2 of data audits due to challenges with PEWS integration into the existing EMR (PDSA cycle 1) which were resolved by the 3rd week of data auditing (PDSA cycle 2).
Conclusions:
Implementation of a PEWS scoring tool in an LMIC pediatric oncology inpatient unit is feasible and can improve frequency of vital sign collection and generate accurate PEWS scores.
Contribution To The Literature:
This study demonstrates how to effectively implement a PEWS scoring tool into an LMIC clinical setting. This study demonstrates how to utilize a robust feedback mechanism to ensure a quality program uptake. This study demonstrates an effective international partnership model that other institutions may utilize for implementation science.
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