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Implementing and evaluating a Paediatric Early Warning System (PEWS) at a National Referral Hospital in Botswana
Meredith Rose Hickson1, Samuel T Matula2, Wananani B Tshiamo2
1Michigan State University College of Human Medicine, East Lansing, Michigan, USA hickson5@msu.edu.
Insights
Paediatric Early Warning Systems (PEWS) implementation in Botswana improved patient care and clinician accountability. While mechanical ventilation and inotrope use decreased, unplanned ICU transfers increased, indicating potential for earlier intervention.
Area of Science:
- Pediatric critical care
- Health systems strengthening
- Implementation science
Background:
- Hospitalized children in low-resource settings face higher mortality rates.
- Paediatric Early Warning Systems (PEWS) improve care and reduce mortality in low- and middle-income countries.
- Princess Marina Hospital (PMH) in Botswana sought to improve identification of deteriorating pediatric patients.
Purpose of the Study:
- To create and pilot the PMH PEWS at Botswana's national referral center.
- To assess the effectiveness, acceptability, and feasibility of the PMH PEWS.
- To identify barriers and facilitators to PEWS implementation.
Main Methods:
- Developed the PMH PEWS based on a validated model for resource-limited settings.
- Piloted the PMH PEWS from December 2022 to March 2023.
- Assessed clinical deterioration events, implementation measures, and conducted stakeholder interviews.
Main Results:
- Post-PEWS implementation, mechanical ventilation and inotrope use decreased, while ICU transfers increased (p=0.01).
- PEWS was found to be acceptable and feasible by both doctors and nurses.
- Staff reported improved patient care, accountability, and communication; resource limitations and hierarchies were noted barriers.
Conclusions:
- The PEWS shows potential to enhance care for hospitalized children in Botswana.
- Strengthening interprofessional communication and clinician accountability are key benefits.
- Further research may address identified implementation barriers.
Background:
Mortality among hospitalised children in low-resource settings remains much higher than in high-resource environments. Paediatric Early Warning Systems (PEWSs) have been shown to improve vital signs collection, strengthen interprofessional communication, lower healthcare costs and reduce paediatric hospital mortality in multiple low- and middle-income countries. Providers at Botswana's national referral center, Princess Marina Hospital (PMH), face significant challenges in identifying children at risk for clinical deterioration.
Methods:
We used PEWS previously validated in resource-limited settings to create the PMH PEWS. We piloted the PMH PEWS from December 2022 to March 2023. We assessed (1) effectiveness of PEWS at reducing unplanned escalations of care by comparing pre-implementation and post implementation rates of clinical deterioration events (unplanned intensive care unit (ICU) transfer; use of inotropic medications, mechanical ventilation or mannitol; cardiopulmonary resuscitation; non-palliative mortality), (2) acceptability and feasibility of PEWS adoption using the acceptability and feasibility of implementation measures and (3) barriers and facilitators to implementation through stakeholder interviews structured around Consolidated Framework for Implementation Research domains.
Results:
The relative frequency of clinical deterioration events changed post-PEWS implementation (p=0.01) such that initiation of mechanical ventilation (12.3% vs 23.2%) and inotropes (18.5% vs 35.7%) decreased while ICU transfers increased (27.7% vs 8.9%). Both doctors and nurses found PEWS to be acceptable and feasible. Staff universally reported that PEWS improved patient care, increased clinician provider accountability for deteriorating patients and strengthened interprofessional communication. Nurses reported greater engagement with PEWS adaptation than doctors. Physical resource limitations and inter- and intra-professional hierarchies were widely endorsed barriers to implementation.
Conclusions:
PEWS has the potential to improve the care of hospitalised children in Botswana by strengthening interprofessional communication and increasing clinician accountability for deteriorating patients.
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