OC37 Challenges and successes of implementing a paediatric early warning system in a limited resource paediatric oncology setting

Abstract

Outlining the experience of implementing a paediatric early warning system (PEWS) for Upendo Paediatric Oncology Ward at Muhimbili National Hospital (MNH), Dar Es Salaam, Tanzania. Background Children on the paediatric oncology ward in Muhimbili National Hospital, Dar es Salaam, were experiencing poor clinical outcomes after common emergencies with 100% mortality rates for any child requiring CPR. From 2012 to 2015, a team of Irish paediatric specialists, supported by a Tanzanian NGO called Tumaini la Maisha, provided an annual standard paediatric resuscitation training programme. Despite these efforts, staff knowledge, skill retention and clinical outcomes did not improve. An observational analysis in 2016 revealed poor vital sign assessment practices, lack of documentation and examples of failure to detect, escalate and respond to child clinical deterioration. Intervention We designed five bespoke age-specific paediatric observation charts with inbuilt vital sign triggers, escalation pathway, communication guide, ‘event record’ and a locally appropriate resuscitation course to suit the specific needs of the ward. Implementation Strategy Over three annual visits from 2016–2018, PEWS was introduced to Upendo ward with the tailored education programme for medical and nursing staff. Resources including pdf charts, posters, training slide-set and a PEWS implementation policy were provided to facilitate local ownership of the PEWS. Local champions were identified to act as trainers and peer support during the time between visiting faculty visits. In 2018, Paediatric Pocket Guides were introduced as additional aide-memoires for oncology guidelines and PEWS reference ranges. Challenges Challenges to implementation of the new charts and escalation behaviours included lack of availability of basic monitoring equipment, low staffing ratios, weekly turnover of medical interns, and insufficient acute care facilities. Ward nursing culture of task-based rather than patient-based care, non-structured handover practices and lack of integrated communication between nurses and the medical team presented the greatest challenge to embedding PEWS. Successes and Learning By 2018 two new specifically designed courses were developed for MNH. The Paediatric Assessment of Illness, Resuscitation and Stabilisation (PAIRS) and 8-week paediatric oncology nursing course were conducted. PEWS training was central to the ethos of both courses and removed most of the cultural barriers identified above. PEWS and patient-centred care are now standard on the ward with all staff utilising the Paediatric Pocket Guides to supplement their knowledge of PEWS. Early recognition of the acutely unwell and deteriorating child is now a well understood goal of all staff. This initiative shows the importance of audit and local engagement to bring about successful clinical change.