Project Details

Using implementation science to reduce pediatric mortality at Botswana’s national referral hospital

Charlotte Woods-Hill, MD

Summary

BACKGROUND: Pediatric hospital mortality in Botswana and other resource-limited settings remains unacceptably high. Due to limited technical and human resources, providers struggle to identify hospitalized children at risk for clinical deterioration and mortality. GAP: Pediatric Early Warning Systems (PEWS) have been proven to help providers in resource-limited settings identify children at-risk for deterioration earlier in admission. Botswana’s national referral hospital will be the first facility in the country to adopt a PEWS, providing an opportunity to study PEWS implementation in this setting. HYPOTHESIS: We hypothesize that specific barriers and facilitators to PEWS implementation exist at Botswana’s national referral hospital, and that these can be elicited through semi-structured interviews with pediatric providers. We further hypothesize that PEWS will be effective at reducing unplanned escalations of care, and that pediatric providers will find PEWS to be both acceptable and feasible. METHODS: For this concurrent mixed methods implementation study, we reviewed patient charts before and after PEWS introduction to measure the efficacy of PEWS in reducing unplanned escalations of care. We interviewed pediatric providers about barriers and facilitators experienced during PEWS adoption, and surveyed providers to measure the acceptability and feasibility of PEWS. Botswana’s national referral hospital was supported in PEWS adoption by a peer network of hospitals in Eastern and Southern Africa trained and mentored by a program at St Jude Children’s Research Hospital called Project PASHA (PEWS Adaptation to Support Hospitals in the Alliance). RESULTS: Post-PEWS implementation, accurate nurse identification of abnormal pediatric vital signs in the pediatric medical ward improved from 22% (as of 2019) to >90% and documented notification of physicians regarding children at risk for clinical deterioration improved from 9% (as of 2019) to >90%. There was no change in the rate of clinical deterioration events (7.4 vs 6.8, p=0.60) or event-related mortality (50.0% vs 40.7%, p=0.33) but the relative frequency of transfers to the ICU increased (27.7% vs 8.9%) while initiation of ventilation (12.3% vs 23.2%) and inotropic medications (18.5% vs 35.7%) decreased (p=0.013). 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. IMPACT: This pilot study demonstrated that PEWS was acceptable and feasible and may move care of deteriorating children from the ward to safer, better resourced ICU settings. PEWS has the potential to improve the care of hospitalized children in Botswana by strengthening interprofessional communication and increasing clinician accountability for deteriorating patients.