Pediatric Early Warning Systems save lives in Latin American hospitals

Children who are hospitalized can experience clinical deterioration, defined as a change in a patient’s status that requires a transfer to the intensive care unit (ICU) or an ICU-level intervention, such as mechanical ventilation or cardiopulmonary resuscitation outside the ICU. Pediatric Early Warning Systems (PEWS) are tools that help identify clinical deterioration in hospitalized children. Through a multicenter collaborative called Proyecto EVAT, investigators from St. Jude worked with partners across Latin America to bring PEWS into hospitals in the region.

PEWS starts at the patient’s bedside with an assessment that includes a scoring tool to evaluate a patient’s neurologic, cardiovascular, and respiratory status alongside staff and family concerns. It considers vital signs, physical examination findings, and treatment requirements. An action algorithm interprets the score and guides the team through the next steps, which are adapted to the local context and health care systems.

“When children with cancer are in the hospital, they may develop clinical changes that, if not recognized early, can become significantly worse, leading to death,” said first and corresponding author Asya Agulnik, MD, MPH, St. Jude Global Critical Care Program director.

“Most hospitals in high-resource settings use some form of PEWS to help identify deterioration, but they are under-utilized in resource-limited settings.”

Through the work of St. Jude Global, Agulnik collaborates with doctors and nurses in hospitals in Latin America to implement PEWS. An analysis of this program, published in The Lancet Oncology, looked at the impact of PEWS in 32 hospitals in 11 countries, demonstrating that PEWS saves lives — often in the hospitals with the greatest need.

“We see this as a real call for the need to scale up PEWS globally,” Agulnik added. “This intervention should be used in the care of every single hospitalized child with cancer.”

The global burden of pediatric cancer is greatest in low- and middle-income countries, where approximately 90% of children at risk of cancer live and where the probability of survival is as low as 20%. Hospitals in low-resource settings frequently lack adequate infrastructure and staff to provide supportive care, resulting in the late identification of clinical deterioration and high rates of preventable deaths. Proyecto EVAT was created to address this gap.

In hospitals that implemented PEWS through Proyecto EVAT, the researchers found an 18% reduction in the rate of clinical deterioration event–related mortality and a reduction in the percentage of events that resulted in mortality. They found fewer cardiac arrests outside of the ICU, and patients with deterioration were identified earlier and transferred to a higher level of care at a lower severity of illness. Notably, ICU resource use remained the same after PEWS implementation. The results also showed that PEWS are most likely to be present in hospitals of higher resource levels but are most effective in settings with higher mortality rates, making them valuable interventions to address global disparities in childhood cancer outcomes.