In a study reported in The Lancet Oncology, Agulnik et al found that implementation of pediatric early warning systems resulted in reduced clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America.
Study Details
The Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement pediatric early warning systems in hospitals providing childhood cancer care. The current study included 32 resource-limited hospitals in Latin America that joined Proyecto EVAT and completed pediatric early warning systems implementation between April 2017 and May 2021. The implementation prospectively followed clinical deterioration events in children admitted to hospital. The study included data reported between April 2017 and November 2021. Children with limitations on escalation of care were excluded from the analysis. The primary outcome measure was clinical deterioration event mortality, with incidence rate ratios used to compare clinical deterioration event mortality before and after pediatric early warning systems implementation.
Key Findings
A total of 2,020 clinical deterioration events were documented in 1,651 patients over 556,400 inpatient days. Clinical deterioration event mortality occurred in 664 (32.9%) of 2,020 events. Patients with clinical deterioration events had a median age of 8.5 years (interquartile range [IQR] = 3.9–13.2 years), and 54% of events occurred in male patients.
Data were reported per center for a median of 12 months (IQR = 10–13 months) before pediatric early warning systems implementation and 18 months (IQR = 16–18 months) after pediatric early warning systems implementation. The mortality rate due to a clinical deterioration event was 1.33 events per 1,000 patient-days before pediatric early warning systems implementation and 1.09 events per 1,000 patient-days after pediatric early warning systems implementation (incidence rate ratio [IRR] = 0.82, 95% confidence interval [CI] = 0.69–0.97, P = .021).
In multivariate analysis, factors associated with greater reduction in clinical deterioration event mortality after pediatric early warning systems implementation were:
- Higher clinical deterioration event mortality rates before pediatric early warning systems implementation (IRR = 1.32, 95% CI = 1.22–1.43, P < .0001)
- Treatment receipt in a teaching hospital (IRR = 1.18, 95% CI = 1.09–1.27, P < .0001)
- Not having a separate pediatric hematology-oncology unit (IRR = 1.38, 95% CI = 1.21–1.57, P < .0001)
- Having fewer incorrect pediatric early warning systems omissions (IRR = 0.95, 95% CI = 0.92–0.99, P = .0091).
No association between risk of clinical deterioration event mortality was observed with country income level (IRR = 0.86, 95% CI = 0.68–1.09, P = .22) or clinical deterioration event rates prior to pediatric early warning systems implementation (IRR = 1.04, 95% CI = 0.97–1.12, P = .29).
The investigators concluded, “Pediatric early warning systems implementation was associated with reduced clinical deterioration event mortality in pediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of pediatric early warning systems as an effective evidence-based intervention to reduce disparities in global survival for children with cancer.”
Asya Agulnik, MD, of the Department of Global Pediatric Medicine, Division of Critical Care, St. Jude Children’s Research Hospital, Memphis, is the corresponding author for The Lancet Oncology article.
Disclosure: The study was funded by the American Lebanese Syrian Associated Charities, U.S. National Institutes of Health, and Conquer Cancer Foundation. For full disclosures of the study authors, visit thelancet.com.
