Abstract
Pediatric early warning (PEW) scores represent a "track-and-trigger system" that identifies clinical deterioration in a patient's condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. The PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool. The PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses' knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses' feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support. Implementation of PEW scores increased nurses' technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff.
Highlights
Pediatric early warning (PEW) scores represent a “track-and-trigger system” that identifies clinical deterioration in a patient’s condition in the hours preceding a sentinel event
We describe our process for implementation of the Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) at the district hospital level, including areas of success, challenges, and lessons learned
We reviewed several versions of the PEW triage tools collaboratively with staff and leadership at Kirehe District Hospital (KDH), including the medical director, clinical director, and the primary general practitioner who rounded on the pediatric wards
Summary
Pediatric early warning (PEW) scores represent a “track-and-trigger system” that identifies clinical deterioration in a patient’s condition in the hours preceding a sentinel event. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. Discussion: Implementation of PEW scores increased nurses’ technical skills and feelings of confidence and empowerment; the low-resource setting presented major challenges. Kirehe District Hospital (KDH) is a public hospital in rural Rwanda, supported by a partnership with the nongovernmental organization (NGO) Inshuti Mu. Implementation of a Pediatric Early Warning Score in Rural Rwanda www.ghspjournal.org. A U.S.-trained pediatrician affiliated with Partners in Health works with the hospital to conduct on-site clinical capacity building for several months each year
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