Clinical deterioration events (CDEs) are the rapid worsening of symptoms in inpatients that result in admission to the intensive care unit (ICU).1 Globally, 40% of paediatric cancer inpatients are admitted to the ICU. Of these admissions, 27% result in mortality. .2 The use of paediatric warning systems (PEWS) has been found to reduce CDEs in children with cancer.3 In 2017, St Jude Children’s Research Hospital set up Proyecto Escala de Valoracion de Alerta Temprana (Proyecto EVAT), a collaboration with many paediatric oncology centres across Latin America, that aimed to improve outcomes for children with cancer by implementing the use of PEWS in hospitals with varying resource levels.4 The implementation of PEWS resulted in an 18% reduction in paediatric CDE mortality.4 The success of the programme has integrated the use of PEWS  into multiple countries’ medical education curriculum. The programme is ongoing and is looking to expand into Africa and Asia.


Globally, 84% of the paediatric cancer burden is in low and middle-income countries, where the average mortality rate is 46%.5 Even in Latin America, a rapidly developing middle-income region, the childhood cancer mortality rate is above 34%.6 This is a stark contrast to the 13% mortality rate in high-income countries.5 The difference in survival outcomes is attributed to delayed diagnoses, misdiagnosis, treatment abandonment, malnourishment, toxicity-related fatalities and inadequate access to effective treatments.7 These issues are also exacerbated by a lack of infrastructure and staffing, leading to many preventable deaths.4

Clinical deterioration events (CDEs) are the rapid worsening of symptoms of inpatients that require an intensive intervention and escalation of treatment, usually in the intensive care unit (ICU).1 During the course of their treatment, 40% of children with cancer will require ICU care due to a CDE. These admissions result in a 27% mortality rate due to a late detection of CDEs.2 8 CDEs are usually preceded by physiological changes; if these are recognised early, it can reduce the likelihood of a CDE.1 Prediction of risk of a CDE is an important measure to reduce ICU admission and CDE-caused mortality.1


It is well documented that paediatric early warning systems (PEWS) can reduce CDEs in children with cancer, optimise ICU use, and improve family and interdisciplinary communication .3 PEWS are bedside scoring tool that is used to recognise the early symptoms of clinical deterioration in hospitalised paediatric oncology patients.4 The score indicates the likelihood of a CDE and allows healthcare staff to action preventative measures, aiming to reduce ICU admission and improve clinical outcomes.

In 2017, St Jude Children’s Research Hospital partnered with 16 paediatric oncology centres across Latin America to initiate Proyecto Escala de Valoracion de Alerta Temprana (Proyecto EVAT).4 This was a multi-centre collaboration to improve outcomes for children with cancer by implementing the use of PEWS in hospitals with varying resource levels.

Centres participating in the Proyecto EVAT collaboration would self-declare as resource-limited, indicating that they faced challenges such as poor staffing levels, limited infrastructure, and patients with low socioeconomic, educational and nutritional levels.9 Each centre then assembles a local PEWS implementation team, consisting of paediatric oncology nurses, ward physicians and intensivists. The team is then guided through the phases of PEWS implementation by a regional training centre that is assigned as part of the programme.4

The process of implementation, which is cyclical in nature, followed these steps:4

  1. Identify the problem.
    1. Monitor CDEs.
    2. Establish the baseline outcomes.
  2. Adapt PEWS to local context.
    1. Educate staff on PEWS protocol.
    2. Establish a training plan.
    3. Adapt PEWS to clinical setting (including language changes and adaptation to available resources).
  3. Assess barriers to use of PEWS.
    1. Conduct stakeholder analysis.
    2. Conduct a SWOT (strengths, weaknesses, opportunities, threats) analysis.
  4. Select, Tailor, Implement, Interventions.
    1. Plan, pilot and implement the use of PEWS.
  5. Monitor PEWS in use.
    1. Track errors in use of PEWS.
    2. Iteratively improve the process.
  6. Evaluate outcomes.
    1. Assess CDE outcomes.
    2. Assess staff satisfaction.
    3. Assess the global impact.
  7. Sustain PEWS.
    1. Create a sustainability plan.
    2. Hold monthly virtual meetings.
    3. Collect data 18 months post-implementation.

What has been achieved?

Since its initiation in 2017, 73 paediatric oncology centres have joined the Proyecto EVAT, with 36 centres from 13 countries having successfully implemented PEWS.4 10 The implementation of PEWS was found to reduce CDE mortality by 18%, while also reducing the number of cardiac arrests outside of the ICU. Additionally, PEWS enabled the identification and transfer of people to a higher level of care, at a lower severity of illness.10 The implementation of PEWS also caused no increase in the use of ICU resources.10 11 This shows that even in low-resource settings, the implementation of PEWS has a positive effect on childhood cancer mortality.

As of October 2021, over 11,100 healthcare staff have been trained in the use of PEWS and over 41,000 patient admissions have benefited from the use of PEWS during care.4 The use of PEWS has now been integrated into the curriculum of select nursing and medical schools across Latin America.4 The programme was also the recipient of quality-improvement awards from the ministries of health in Mexico, Peru and El Salvador.4

Next steps

St Jude Children’s Research Hospital is continuing to recruit centres into the Proyecto EVAT across Latin America, while also looking at how PEWS implementation can be rapidly scaled to reduce the time it takes for hospitals to implement the process.11 St Jude Children’s Research Hospital is also exploring how PEWS can be expanded to be implemented in Asia and Africa.11

There is also a plan to include the use of PEWS in the Peruvian Ministry of Health’s nursing recommendations for the management of children with cancer.4


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