Pediatric Early Warning Systems (PEWS) / Proyecto EVAT

• Hospitalized children with cancer have frequent clinical deterioration
• In resource-limited settings, event mortality is about 30% (1)
  • https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.33411 (open access)
• Even in high-resource setting, mortality is 10-15% (data from Boston Children’s and St. Jude) (2, 3)
  • https://www.frontiersin.org/articles/10.3389/fonc.2020.00354/full (open access)
  • https://journals.lww.com/pccmjournal/Fulltext/2016/04000/Validation_of_a_Pediatric_Early_Warning_Score_in.26.aspx

• Lots of different scoring systems exist, few are studied associated with action algorithm and consider implementation and correct use of the system
• Scoping Review of PEWS in LMICs (4)
  • https://www.frontiersin.org/articles/10.3389/fped.2018.00410/full (open access)

• PEWS is valid to predict need for unplanned transfer to the ICU (clinical deterioration) in hospitalized children with cancer or post-transplant in high-resource and resource-limited hospitals.
  • HIC (3): https://journals.lww.com/pccmjournal/Fulltext/2016/04000/Validation_of_a_Pediatric_Early_Warning_Score_in.26.aspx
  • LMIC (5): https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.30951
• PEWS also help triage patients to appropriate level of care (ICU vs intermediate care unit) (6)
  • https://onlinelibrary.wiley.com/doi/full/10.1002/pbc.27076

• PEWS has multi-level impacts across the level of the patient, provider, clinical team, and institution (7): https://www.frontiersin.org/articles/10.3389/fonc.2022.1018224/full (open access)
  • Patients/Families
    • PEWS implementation reduces the number of clinical deterioration events and PICU utilization (8): https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.30664
    • PEWS improves communication between providers and the patient family and promotes inclusion of the family as part of the care team (9): https://onlinelibrary.wiley.com/doi/full/10.1002/cam4.5210 (open access)
    • PEWS improves perceived quality of medical care during clinical deterioration in hospitalized children (10): https://www.frontiersin.org/articles/10.3389/fonc.2021.660051/full (open access)
  • Clinicians/Providers
    • Clinicians experience a range of negative emotions when their patients experience clinical deterioration; PEWS increases provider confidence and empowerment  (11): https://www.frontiersin.org/articles/10.3389/fonc.2021.626457/full (open access)
  • Team
    • PEWS improves interdisciplinary communication around patient deterioration (12): https://ascopubs.org/doi/10.1200/GO.20.00163 (open access)
  • Institution
    • PEWS implementation is cost-beneficial, saving >$350,000 per year through reduction of unplanned PICU transfers (13): https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.32436

• PEWS implementation at St. Jude (14)
  • https://journals.lww.com/pqs/Fulltext/2018/04000/Impact_of_Implementing_a_Pediatric_Early_Warning.16.aspx (open access)
• Proyecto EVAT implementation strategy for regional scale-up of PEWS implementation (15)
  • https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.34427 (open access)
    
• Barriers and enablers to PEWS implementation in resource-limited settings (16)
  
  • https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789842 (open access)
    
    • Editorial Commentary (17): https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789850 (open access)
      

• Initial reliability/validation of the Clinical Sustainability Assessment Tool (CSAT) to measure clinical capacity of PEWS sustainability in Proyecto EVAT (18)
  • https://bmjopen.bmj.com/content/11/10/e053116 (open access)
  • CSAT Website: https://sustaintool.org/csat/

1. Agulnik A, Cárdenas A, Carrillo AK, Bulsara P, Garza M, Alfonso Carreras Y, Alvarado M, Calderón P, Díaz R, de León C, Del Real C, Huitz T, Martínez A, Miralda S, Montalvo E, Negrín O, Osuna A, Perez Fermin CK, Pineda E, Soberanis D, Juárez Tobias MS, Lu Z, Rodriguez-Galindo C. Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort. Cancer. 2021;127(10):1668-78. Epub 2021/02/02. doi: 10.1002/cncr.33411. PubMed PMID: 33524166; PMCID: PMC8248122.

2. Agulnik A, Gossett J, Carrillo AK, Kang G, Morrison RR. Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients. Front Oncol. 2020;10:354. Epub 2020/04/09. doi: 10.3389/fonc.2020.00354. PubMed PMID: 32266139; PMCID: PMC7105633.

3. Agulnik A, Forbes PW, Stenquist N, Rodriguez-Galindo C, Kleinman M. Validation of a Pediatric Early Warning Score in Hospitalized Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients. Pediatr Crit Care Med. 2016;17(4):e146-53. doi: 10.1097/PCC.0000000000000662. PubMed PMID: 26914628.

4. Brown SR, Martinez Garcia D, Agulnik A. Scoping Review of Pediatric Early Warning Systems (PEWS) in Resource-Limited and Humanitarian Settings. Frontiers in pediatrics. 2018;6:410. Epub 2019/01/24. doi: 10.3389/fped.2018.00410. PubMed PMID: 30671424; PMCID: PMC6331420.

5. Agulnik A, Mendez 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. Epub 2017/09/08. doi: 10.1002/cncr.30951. PubMed PMID: 28881451.

6. Agulnik A, Nadkarni A, Mora Robles LN, Soberanis Vasquez DJ, Mack R, Antillon-Klussmann F, Rodriguez-Galindo C. Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource-limited hospitals. Pediatr Blood Cancer. 2018;65(8):e27076. Epub 2018/04/11. doi: 10.1002/pbc.27076. PubMed PMID: 29637687.

7. Mirochnick E, Graetz DE, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JdJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Agulnik A. Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals. Frontiers in Oncology. 2022;12. doi: 10.3389/fonc.2022.1018224.

8. Agulnik A, Mora Robles LN, Forbes PW, Soberanis Vasquez DJ, Mack R, Antillon-Klussmann F, Kleinman M, Rodriguez-Galindo C. Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital. Cancer. 2017;123(15):2965-74. Epub 2017/04/26. doi: 10.1002/cncr.30664. PubMed PMID: 28440868.

9. Gillipelli SR, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vasquez DJ, Mendez Aceituno A, Antillón-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A, Graetz DE. Pediatric Early Warning Systems (PEWS) improve provider-family communication from the provider perspective in pediatric cancer patients experiencing clinical deterioration. Cancer medicine. 2022. Epub 2022/09/22. doi: 10.1002/cam4.5210. PubMed PMID: 36128882.

10. 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. Epub 2021/07/13. doi: 10.3389/fonc.2021.660051. PubMed PMID: 34249696; PMCID: PMC8260684.

11. Graetz DE, Giannars E, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vasquez DJ, Mendez Aceituno A, Antillon-Klussmann F, Gattuso JS, Andes KL, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration. Front Oncol. 2021;11:626457. Epub 2021/03/16. doi: 10.3389/fonc.2021.626457. PubMed PMID: 33718195; PMCID: PMC7947818.

12. 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 global oncology. 2020;6:1079-86. Epub 2020/07/17. doi: 10.1200/go.20.00163. PubMed PMID: 32673079; PMCID: PMC7392735 manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/site/misc/authors.html. Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments). No potential conflicts of interest were reported.

13. Agulnik A, Antillon-Klussmann F, Soberanis Vasquez DJ, Arango R, Moran E, Lopez V, Rodriguez-Galindo C, Bhakta N. Cost-benefit analysis of implementing a pediatric early warning system at a pediatric oncology hospital in a low-middle income country. Cancer. 2019;125(22):4052-8. Epub 2019/08/23. doi: 10.1002/cncr.32436. PubMed PMID: 31436324.

14. Agulnik A, Johnson S, Wilkes R, Faughnan L, Carrillo A, Morrison R. Impact of Implementing a Pediatric Early Warning System (PEWS) in a Pediatric Oncology Hospital. Pediatric Quality & Safety. 2018;3(2):e065.

15. 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 ML, 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. Epub 2022/09/27. doi: 10.1002/cncr.34427. PubMed PMID: 36161436.

16. Agulnik A, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz R, Hernandez C, Juárez Tobias S, de Jesus Loeza J, Mendez A, Montalvo E, Penafiel E, Pineda E, Graetz DE. Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings. JAMA Netw Open. 2022;5(3):e221547. Epub 2022/03/10. doi: 10.1001/jamanetworkopen.2022.1547. PubMed PMID: 35262714; PMCID: PMC8908074.

17. Nyandat J, Murthy S, Muttalib F. Challenges and Opportunities for Implementing Pediatric Early Warning Systems in Low- and Middle-Income Countries—Using Resources Wisely. JAMA Network Open. 2022;5(3):e221553-e. doi: 10.1001/jamanetworkopen.2022.1553.

18. Agulnik A, Malone S, Puerto-Torres M, Gonzalez-Ruiz A, Vedaraju Y, Wang H, Graetz D, Prewitt K, Villegas C, Cardenas-Aguierre A, Acuna C, Arana AE, Díaz R, Espinoza S, Guerrero K, Martínez A, Mendez A, Montalvo E, Soberanis D, Torelli A, Quelal J, Villanueva E, Devidas M, Luke D, McKay V. Reliability and validity of a Spanish-language measure assessing clinical capacity to sustain Paediatric Early Warning Systems (PEWS) in resource-limited hospitals. BMJ Open. 2021;11(10):e053116. Epub 2021/10/22. doi: 10.1136/bmjopen-2021-053116. PubMed PMID: 34670767; PMCID: PMC8529978.