Search

Pediatric palliative care (PPC) is a priority to improve pediatric hematology oncology (PHO) care in Eurasia. However, there are limited regional opportunities for PPC education. We describe the adaptation and implementation of a bilingual end-user Education in Palliative and End-of-Life Care (EPEC)-Pediatrics course for PHO clinicians in Eurasia.Due to COVID-19, this course was delivered virtually, consisting of prerecorded, asynchronous lectures, and a bilingual workshop with interactive lectures and small group sessions. A pre-postcourse design was used to evaluate the knowledge acquisition of the participants including their knowledge alignment with World Health Organization (WHO) guidance, ideal timing of palliative care, and comfort in providing palliative care to their patients. Questions were mostly quantitative with multiple choice or Likert scale options, supplemented by free-text responses.A total of 44 (76%) participants from 14 countries completed all components of the course including pre- and postcourse assessments. Participant alignment with WHO guidance improved from 75% in the pre- to 90% in the postcourse assessments (p 0.001). After participation, 93% felt more confident controlling the suffering of children at the end of life, 91% felt more confident in prescribing opioids and managing pain, and 98% better understood how to hold difficult conversations with patients and families. Most participants (98%) stated that they will change their clinical practice based on the skills and knowledge gained in this course.We present a successful regional adaptation of the EPEC-Pediatrics curriculum, including novel delivery of course content via a virtual bilingual format. This course resulted in significant improvement in participant attitudes and knowledge of PPC along with an understanding of the ideal timing of palliative care consultation and comfort in providing PPC to children with cancer. We plan to incorporate participant feedback to improve the course and repeat it annually to improve access to high-quality palliative care education for PHO clinicians in Eurasia.

IntroductionChildren with cancer have a higher risk of adverse outcomes during critical illness than general pediatric populations. In Low- and middle-income countries, lack of resources can further negatively impact outcomes in critically ill children with cancer.MethodsIn this study, we describe the outcomes of a large cohort of children with cancer including mortality and resource utilization. We performed a retrospective review of all patients admitted to our PICU between December 12th, 2013 and December 31st, 2019. Outcomes were defined as recovery or death and resource utilization was described via use of critical care interventions, Length of stay as well as PICU- and Mechanical Ventilation- free days.ResultsOverall mortality was 6.9% while mortality in the unplanned admissions was 9.1%. This remained lower than expected mortality based on PIM2 scoring. Type of PICU admission, Neurological Deterioration as a cause of PICU admission, and PIM2 were significant as risk factors in univariate analysis, but only PIM2 remained significant in the multivariate analysis.DiscussionOur Study shows that high survival rates are achievable for children with cancer with critical illness in resource-limited settings with provision of high-quality critical care. Organizational and clinical practice facilitating quality improvement and early identification and management of critical illness may attenuate the impact of known risk factors for mortality in this population.

BACKGROUND: Although mortality due to COVID-19 has been reportedly low among children with cancer, changes in health-care services due to the pandemic have affected cancer care delivery. This study aimed to assess the effect of the COVID-19 pandemic on childhood cancer care worldwide. METHODS: A cross-sectional survey was distributed to paediatric oncology providers worldwide from June 22 to Aug 21, 2020, through the St Jude Global Alliance and International Society for Paediatric Oncology listservs and regional networks. The survey included 60 questions to assess institution characteristics, the number of patients diagnosed with COVID-19, disruptions to cancer care (eg, service closures and treatment abandonment), adaptations to care, and resources (including availability of clinical staff and personal protective equipment). Surveys were included for analysis if respondents answered at least two thirds of the items, and the responses were analysed at the institutional level. FINDINGS: Responses from 311 health-care professionals at 213 institutions in 79 countries from all WHO regions were included in the analysis. 187 (88%) of 213 centres had the capacity to test for SARS-CoV-2 and a median of two (range 0-350) infections per institutution were reported in children with cancer. 15 (7%) centres reported complete closure of paediatric haematology-oncology services (median 10 days, range 1-75 days). Overall, 2% (5 of 213) of centres were no longer evaluating new cases of suspected cancer, while 43% (90 of 208) of the remaining centers described a decrease in newly diagnosed paediatric cancer cases. 73 (34%) centres reported increased treatment abandonment (ie, failure to initiate cancer therapy or a delay in care of 4 weeks or longer). Changes to cancer care delivery included: reduced surgical care (153 [72%]), blood product shortages (127 [60%]), chemotherapy modifications (121 [57%]), and interruptions to radiotherapy (43 [28%] of 155 institutions that provided radiotherapy before the pandemic). The decreased number of new cancer diagnoses did not vary based on country income status (p=0·14). However, unavailability of chemotherapy agents (p=0·022), treatment abandonment (p

BackgroundChildren with cancer are at risk of critical disease and mortality from COVID-19 infection. In this study, we describe the clinical characteristics of pediatric patients with cancer and COVID-19 from multiple Latin American centers and risk factors associated with mortality in this population.MethodsThis study is a multicenter, prospective cohort study conducted at 12 hospitals from 6 Latin American countries (Argentina, Bolivia, Colombia, Ecuador, Honduras and Peru) from April to November 2021. Patients younger than 14 years of age that had an oncological diagnosis and COVID-19 or multisystemic inflammatory syndrome in children (MIS-C) who were treated in the inpatient setting were included. The primary exposure was the diagnosis and treatment status, and the primary outcome was mortality. We defined “new diagnosis” as patients with no previous diagnosis of cancer, “established diagnosis” as patients with cancer and ongoing treatment and “relapse” as patients with cancer and ongoing treatment that had a prior cancer-free period. A frequentist analysis was performed including a multivariate logistic regression for mortality.ResultsTwo hundred and ten patients were included in the study; 30 (14%) died during the study period and 67% of patients who died were admitted to critical care. Demographics were similar in survivors and non-survivors. Patients with low weight for age (p = 0.019). There was statistically significant difference of mortality between patients with new diagnosis (36.7%), established diagnosis (1.4%) and relapse (60%), (p p= 0.032). Patients with concomitant bacterial infections had higher mortality (40%, p = 0.001). MIS-C, respiratory distress, cardiovascular symptoms, altered mental status and acute kidney injury on admission were associated with higher mortality. Acidosis, hypoxemia, lymphocytosis, severe neutropenia, anemia and thrombocytopenia on admission were also associated with mortality. A multivariate logistic regression showed risk factors associated with mortality: concomitant bacterial infection OR 3 95%CI (1.1–8.5), respiratory symptoms OR 5.7 95%CI (1.7–19.4), cardiovascular OR 5.2 95%CI (1.2–14.2), new cancer diagnosis OR 12 95%CI (1.3–102) and relapse OR 25 95%CI (2.9–214).ConclusionOur study shows that pediatric patients with new onset diagnosis of cancer and patients with relapse have higher odds of all-cause mortality in the setting of COVID-19. This information would help develop an early identification of patients with cancer and COVID-19 with higher risk of mortality.

Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation.To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals.In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020.Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation.Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS.To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.

PURPOSE Hospitalized pediatric oncology patients are at high risk of deterioration and require frequent interdisciplinary communication to deliver high-quality care. Pediatric early warning systems (PEWS) are used by hospitals to reduce deterioration, but it is unknown how these systems affect communication about patient care in high- and limited-resource pediatric oncology settings. METHODS This qualitative study included semistructured interviews describing PEWS and subsequent team communication at 2 pediatric cancer centers, 1 in the United States and 1 in Guatemala. Participants included nurses, and frontline and intensive care providers who experienced recent deterioration events. Transcripts were coded and analyzed inductively using MAXQDA software. RESULTS The study included 41 providers in Guatemala and 42 providers in the United States (33 nurses, 30 ward providers, and 20 pediatric intensive care providers). Major themes identified include “hierarchy,” “empowerment,” “quality and method of communication,” and “trigger.” All providers described underlying medical hierarchies affecting the quality of communication regarding patient deterioration events and identified PEWS as empowering. Participants from the United States described the algorithmic approach to care and technology associated with PEWS contributing to impaired clinical judgement and a lack of communication. In both settings, PEWS sparked interdisciplinary communication and inspired action. CONCLUSION PEWS enhance interdisciplinary communication in high- and limited-resource study settings by empowering bedside providers. Traditional hierarchies contributed to negative communication and, in well-resourced settings, technology and automation resulted in lack of communication. Understanding contextual elements is integral to optimizing PEWS and improving pediatric oncology outcomes in hospitals of all resource levels.

BackgroundPaediatric Early Warning Systems (PEWSs) improve identification of deterioration, however, their sustainability has not been studied. Sustainability is critical to maximise impact of interventions like PEWS, particularly in low-resource settings. This study establishes the reliability and validity of a Spanish-language Clinical Sustainability Assessment Tool (CSAT) to assess clinical capacity to sustain interventions in resource-limited hospitals.MethodsParticipants included PEWS implementation leadership teams of 29 paediatric cancer centres in Latin America involved in a collaborative to implement PEWS. The CSAT, a sustainability assessment tool validated in high-resource settings, was translated into Spanish and distributed to participants as an anonymous electronic survey. Psychometric, confirmatory factor analysis (CFA), and multivariate analyses were preformed to assess reliability, structure and initial validity. Focus groups were conducted after participants reviewed CSAT reports to assess their interpretation and utility.ResultsThe CSAT survey achieved an 80% response rate (n=169) with a mean score of 4.4 (of 5; 3.8–4.8 among centres). The CSAT had good reliability with an average internal consistency of 0.77 (95% CI 0.71 to 0.81); and CFAs supported the seven-domain structure. CSAT results were associated with respondents’ perceptions of the evidence for PEWS, its implementation and use in their centre, and their assessment of the hospital culture and implementation climate. The mean CSAT score was higher among respondents at centres with longer time using PEWS (pConclusionsWe present information supporting the reliability and validity of the CSAT tool, the first Spanish-language instrument to assess clinical capacity to sustain evidence-based interventions in hospitals of variable resource levels. This assessment demonstrates a high capacity to sustain PEWS in these resource-limited centres with improvement over time from PEWS implementation.

Coronavirus disease 2019 (COVID-19) disrupted pediatric oncology care globally, increasing demands on health care providers (HCPs) who adapted to continue care. This study sought to characterize the pandemic's impact on pediatric oncology HCPs worldwide.A 60-item survey focused on changes to clinical care, resources, and effects on clinicians. A diverse subgroup of institutions was purposefully selected for focus groups that explored teamwork, communication, and changes to care delivery.The survey included 311 responses from 213 institutions representing 79 countries. Sixteen institutions participated in 19 multidisciplinary focus groups in 8 languages. Decreased clinical staff availability was cited by 51% of institutions as a major impact. Staffing modifications included decreased provider availability (66% of institutions), roles or responsibility changes, and transfer outside the specialty. Physical effects included frequent COVID-19 illness; 8% of respondents reported HCP deaths. Fifty percent of providers did not have the necessary personal protective equipment. HCPs also experienced psychological distress and financial concerns. Findings indicated more frequent impact on nurses than other providers. Impacts were described across all hospital resource levels, with staffing modifications more frequent in countries with higher COVID-19 incidence (P.001) and mortality rate (P = .004). Focus groups revealed negative impacts were stabilized by increased teamwork, communication, contributions outside usual roles, policies aimed at optimizing safety, and feeling that they were contributing.COVID-19 had a profound impact on the pediatric oncology workforce, creating challenging modifications to staffing and resulting in physical, psychological, and financial distress. Despite these challenges, HCPs caring for children with cancer came together to continue to provide high-quality care.

Background Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in low-income and middle-income countries (LMICs). Pediatric early warning systems (PEWS) assist with the early identification of deterioration. To the authors' knowledge, no studies to date have evaluated the cost-benefit of PEWS in LMICs. Methods A PEWS was implemented at the National Pediatric Oncology Unit (Unidad Nacional de Oncologia Pediatrica [UNOP]), a pediatric oncology hospital in Guatemala, resulting in a reduction in unplanned pediatric intensive care unit (PICU) transfers. Variable costs of maintaining the PICU and hospital floor were calculated for the year prior to and after the implementation of PEWS using administrative data. PEWS implementation costs were tabulated. The number of PICU inpatient days averted due to reduced unplanned PICU transfers after implementation was calculated, adjusting for changes in hospital inpatient days. Savings per inpatient day from unplanned PICU transfers were calculated. All costs were adjusted for inflation. Results There were 457 fewer PICU inpatient days due to unplanned transfers noted the year after implementation of PEWS, adjusting for changes in hospital volume. The variable costs of an unplanned PICU transfer versus a bed on the hospital floor was $806 per day. The total cost of implementing PEWS at UNOP was $13,644 ($7 per admission). Through reductions in variable PICU costs, UNOP saved a net $173 per admission ($354,514 annual net savings) after implementation of PEWS. The cost savings were sustained in a series of more conservative 1-way sensitivity analyses. Conclusions Implementation of PEWS at UNOP resulted in an incremental savings due to a reduction in the number of unplanned PICU transfers. The results of the current study demonstrate that hospital investment in PEWS can improve the quality of pediatric cancer care, optimize PICU use, and reduce costs.

Introduction: Diffuse alveolar hemorrhage (DAH) is an early pulmonary complication of hematopoietic cell transplantation (HCT) associated with severe hypoxemic respiratory failure and mortality. Extracorporeal membrane oxygenation (ECMO) support is often used for respiratory failure refractory to conventional interventions; however, its use has been limited in HCT patients with DAH due to potential for worsening alveolar hemorrhage and reported high mortality.Case Presentation: We report two cases of DAH following HCT who developed refractory hypoxemic respiratory failure despite cessation of bleeding and were successfully supported with ECMO.Conclusion: DAH after HCT should not automatically preclude ECMO support; rather, these patients must be evaluated individually for ECMO within the context of their overall clinical picture.

BackgroundThe burden of pediatric critical illness and resource utilization by children with critical illness in resource limited settings (RLS) are largely unknown. Without specific data that captures key aspects of critical illness, disease presentation, and resource utilization for pediatric populations in RLS, development of a contextual framework for appropriate, evidence-based interventions to guide allocation of limited but available resources is challenging. We present this methods paper which describes our efforts to determine the prevalence, etiology, hospital outcomes, and resource utilization associated with pediatric acute, critical illness in RLS globally.MethodsWe will conduct a prospective, observational, multicenter, multinational point prevalence study in sixty-one participating RLS hospitals from North, Central and South America, Africa, Middle East and South Asia with four sampling time points over a 12-month period. Children aged 29 days to 14 years evaluated for acute illness or injury in an emergency department) or directly admitted to an inpatient unit will be enrolled and followed for hospital outcomes and resource utilization for the first seven days of hospitalization. The primary outcome will be prevalence of acute critical illness, which Global PARITY has defined as death within 48 hours of presentation to the hospital, including ED mortality; or admission/transfer to an HDU or ICU; or transfer to another institution for a higher level-of-care; or receiving critical care-level interventions (vasopressor infusion, invasive mechanical ventilation, non-invasive mechanical ventilation) regardless of location in the hospital, among children presenting to the hospital. Secondary outcomes include etiology of critical illness, in-hospital mortality, cause of death, resource utilization, length of hospital stay, and change in neurocognitive status. Data will be managed via REDCap, aggregated, and analyzed across sites.DiscussionThis study is expected to address the current gap in understanding of the burden, etiology, resource utilization and outcomes associated with pediatric acute and critical illness in RLS. These data are crucial to inform future research and clinical management decisions and to improve global pediatric hospital outcomes.

OBJECTIVES To describe the infrastructure and resources for pediatric emergency and critical care delivery in resource-limited settings worldwide. DESIGN Cross-sectional survey with survey items developed through literature review and revised following piloting. SETTING The electronic survey was disseminated internationally in November 2019 via e-mail directories of pediatric intensive care societies and networks and using social media. PATIENTS Healthcare providers who self-identified as working in resource-limited settings. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Results were summarized using descriptive statistics and resource availability was compared across World Bank country income groups. We received 328 responses (238 hospitals, 60 countries), predominantly in Latin America and Sub-Saharan Africa (n = 161, 67.4%). Hospitals were in low-income (28, 11.7%), middle-income (166, 69.5%), and high-income (44, 18.4%) countries. Across 174 PICU and adult ICU admitting children, there were statistically significant differences in the proportion of hospitals reporting consistent resource availability ("often" or "always") between country income groups (p < 0·05). Resources with limited availability in lower income countries included advanced ventilatory support, invasive and noninvasive monitoring, central venous access, renal replacement therapy, advanced imaging, microbiology, biochemistry, blood products, antibiotics, parenteral nutrition, and analgesic/sedative drugs. Seventy-seven ICUs (52.7%) were staffed 24/7 by a pediatric intensivist or anesthetist. The nurse-to-patient ratio was less than 1:2 in 71 ICUs (49.7%). CONCLUSIONS Contemporary data demonstrate significant disparity in the availability of essential and advanced human and material resources for the care of critically ill children in resource-limited settings. Minimum standards for essential pediatric emergency and critical care in resource-limited settings are needed.

The World Health Organization (WHO) designates early integration of palliative care as an ethical responsibility in the treatment of children with serious illness. Although structural barriers may influence provision of pediatric palliative care (PPC) for children with cancer in resource-limited settings, underlying physician perceptions may also impede early integration of PPC in cancer care.To investigate perceptions among physicians in Latin America about the integration of palliative care for children with cancer.This survey study used the Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey, which was developed for physicians who care for children with cancer and was initially distributed in Eurasia. The survey was modified for use in Latin America, including translation into Spanish and adaptation for cultural context. The survey was distributed between August 21, 2020, and January 31, 2021, to physicians treating children with cancer in 17 Latin American countries. Each country had a specific survey distribution method based on guidance of local experts.The ADAPT survey evaluated physicians' understanding of palliative care principles, comfort in addressing patient and family suffering, and identification of barriers to PPC integration for children with cancer. Univariate and multivariable linear regression analyses were used to assess factors associated with physicians' knowledge about and comfort with PPC practice and whether independent physician variables were associated with survey response alignment with WHO guidance on PPC. Open-ended questions were analyzed qualitatively to supplement the quantitative data.A total of 874 physicians from 17 countries participated, with an overall response rate of 39.9% (874 of 2193) and a median country response rate of 51.4% (range, 23.7%-100%). Most respondents were aged 35 years or older (577 [66.0%]), and 594 (68.0%) identified as female. Most physicians (486 [55.6%]) had no formal PPC training, and 303 (34.7%) had no access to PPC experts for consultation. Physician perspectives on PPC were generally aligned with WHO guidance (mean [SD] alignment, 83.0% [14.1%]; range among respondents, 24.0%-100%). However, only 438 respondents (50.1%) felt comfortable addressing physical symptoms of patients receiving PPC, 295 (33.8%) felt comfortable addressing emotional symptoms, and 216 (24.7%) felt comfortable addressing grief and bereavement needs of the patient's family. A total of 829 participants (94.8%) desired further education and training in PPC.Although physicians' perspectives aligned well with WHO guidance for PPC, this survey study identified opportunities for improving physician training in symptom management and emotional support for children with cancer and their families. These findings may inform the development of targeted interventions to improve the quality of PPC for children with cancer in Latin America.

BackgroundPediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians’ emotional responses to deterioration events.MethodsSemi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children’s Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants’ native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content.ResultsEmotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children’s Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study.ConclusionClinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.

BACKGROUND The early integration of palliative care significantly improves quality of life for children with cancer. However, cultural, structural, and socioeconomic barriers can delay the integration of palliative care into cancer care, particularly in low-income and middle-income countries. To date, little is known regarding the timing of and barriers to palliative care integration in Eurasia. METHODS The Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey evaluates physician perceptions regarding palliative care integration into pediatric oncology in Eurasia. This evidence-based survey was adapted to the regional context; iteratively reviewed by US and regional panelists; and piloted in English, Russian, and Mongolian. After distribution to physicians caring for children with cancer, statistical analysis was complemented by qualitative analysis of open-ended responses. RESULTS A total of 424 physician responses were received from 11 countries in the Eurasian region. Study findings demonstrated wide variability in access to palliative care experts across countries (18%-96%), with the majority of providers (64%) reporting that the initial palliative care consultation typically occurs when curative options are no longer available. Providers desired an earlier initial palliative care consultation than what currently occurs in their setting (P

Background Hospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients. Methods A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys. Results PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care. Conclusions PROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement., In this study, an international expert panel with diverse experience in oncology and critical care in high and low resource settings, identified and selected the most relevant capacity and quality indicators to be included in a tool to measure service delivery gaps for critically ill pediatric hematology‐oncology patients in resource‐limited settings.

Introduction: Hospitalized pediatric hematology-oncology and post-hematopoietic cell transplant (HCT) patients have frequent deterioration requiring Pediatric Intensive Care Unit (PICU) care. Critical deterioration (CD), defined as unplanned PICU transfer requiring life-sustaining interventions within 12 h, is a pragmatic metric to evaluate emergency response systems (ERS) in pediatrics, however, it has not been investigated in these patients. The goal of this study was to evaluate if CD is an appropriate metric to assess effectiveness of ERS in pediatric hematology-oncology and post-HCT patients and if it is preceded by an actionable period of vital sign changes.Methods: A retrospective review of all unplanned PICU transfers and floor cardiopulmonary arrests in a dedicated pediatric hematology-oncology hospital between August 2014 and July 2016. Vital signs and physical exam findings 48 h prior to events were converted to Pediatric Early Warning System-Like Scores (PEWS-LS) using cardiovascular, respiratory, and neurologic criteria.Results: There were 220 deterioration events, with 107 (48.6%) meeting criteria for CD, representing a rate of 2.98 per 1,000-inpatient-days. Using the first event per hospitalization (n = 184), patients with CD had higher mortality (17.4 vs. 7.6%, p = 0.045), fewer median ICU-free-days (21 vs. 24, p = 0.011), ventilator-free-days (25 vs. 28, p < 0.001), and vasoactive-free-days (27 vs. 28, p < 0.001). Using vital sign data 48 h prior to deterioration events, those with CD had higher PEWS-LS on PICU admission (p < 0.001), spent more time with elevated PEWS-LS prior to PICU transfer (p = 0.008 to 0.023) and had a longer time from first abnormal PEWS-LS (p = 0.007 to 0.043). Significant difference between the two groups was observed as early as 4 h prior to the event (p = 0.047).Conclusion: Hospitalized pediatric hematology-oncology and post-HCT patients have frequent deterioration resulting in a high mortality. In these patients, CD is over 13 times more common than floor cardiopulmonary arrests and associated with higher mortality and fewer event-free days, making it a useful metric in these patients. CD is preceded by a long duration of abnormal vital signs, making it potentially preventable through earlier recognition.

Background The World Health Organization (WHO) advocates for early integration of palliative care for all children with life-threatening illness. Provider awareness and misperceptions, however, can impede this imperative. In the Eurasian region, little is known about physician knowledge and perspectives on palliative care. Methods The Assessing Doctors' Attitudes on Palliative Treatment survey was developed as an evidence-based and culturally relevant assessment of physician perceptions on palliative care integration into childhood cancer care in Eurasia. Iteratively tested by American and Eurasian palliative care experts, the survey was culturally adapted, translated, and piloted in English, Russian, and Mongolian. The survey was distributed to physicians caring for children with cancer. Fifteen statements were scored in accordance with WHO guidelines to evaluate provider knowledge. The statistical analysis was complemented by a qualitative analysis of open-ended responses. Results This study received 424 responses from 11 countries in Eurasia. The mean alignment between provider perspectives and WHO recommendations was 70% (range, 7%-100%). Significant independent predictors of higher alignment included country, prior palliative care education, and greater experience with patient death. Respondents primarily described palliative care as end-of-life care and symptom management. Two-thirds of respondents (67%) reported not feeling confident about delivering at least 1 component of palliative care. Conclusions This is the first study assessing physician perspectives and knowledge of palliative care in Eurasia and reveals wide variability in alignment with WHO guidelines and limited confidence in providing palliative care. Study findings will inform targeted educational interventions, which must be tailored to the local political, economic, and cultural context.

Background Infection and sepsis are important contributors to mortality in children with cancer. Although pediatric risk prediction scores have improved identification of children at high risk of death in the PICU, the value of these tests in immunocompromised children is unknown. Methods In this IRB-approved retrospective study performed at St. Jude Children’s Research Hospital, we evaluated the performance of 4 pediatric risk scores, the Pediatric Risk of Mortality (PRISM), Pediatric Sequential Organ Failure Assessment (pSOFA), Quick Sequential Organ Failure Assessment (qSOFA) scores (using data available at 1, 6, 12 and 24 hours) and the Paediatric Index of Mortality 3 (PIM-3) score (at 1 hour), to predict attributable mortality (death ≤ 60 days without organ dysfunction recovery). Inclusion criteria: Age < 24 years, active cancer therapy (other than bone marrow transplantation), and admission to PICU between 2013 and 2019 with suspected infection (collection of a blood culture and initiation of antibiotic therapy). Scores were calculated using the worst value obtained for each variable. Score distributions were compared by the Mann-Whitney U test, and optimal cutoffs selected by maximizing Youden’s index. An unadjusted p-value < 0.05 was considered statistically significant. Results Of 202 episodes of PICU admission for suspected infection in 168 participants, there were 12 attributable (6%) and 4 unrelated (2%) deaths. Demographic and cancer-related characteristics were not associated with mortality (Table 1). Of the 4 prediction scores, only the PRISM score at 24 hours was associated with mortality (P = 0.012; Table 2). For PRISM score ≥ 18, sensitivity was 58.3%, specificity was 81.6%, positive predictive value was 16.7%, and negative predictive value was 96.9% for attributable mortality. Table 1. Risk factors for attributable mortality in pediatric patients with cancer admitted to the intensive care unit with suspected infection. Table 2. Association between risk prediction scores and attributable mortality in pediatric patients with cancer admitted to the intensive care unit with suspected infection. Conclusion In children with cancer admitted to PICU with suspected infection, early pediatric risk prediction scores did not predict mortality. The PRISM score calculated at 24 hours did predict mortality but was relatively insensitive. Further research is needed to develop a risk score for immunocompromised children and to validate the 24 hour PRISM score in this population. Disclosures Joshua Wolf, MBBS, PhD, FRACP, Karius Inc. (Research Grant or Support) Joshua Wolf, MBBS, PhD, FRACP, Nothing to disclose

BACKGROUND Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource-limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low-resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncologia Pediatrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes. METHODS A modified PEWS was implemented at UNOP with systems to track errors, transfers to a higher level of care, and high scores. A retrospective cohort study was used to evaluate clinical deterioration events in the year before and after PEWS implementation. RESULTS After PEWS implementation at UNOP, there was 100% compliance with PEWS documentation and an error rate of

Hospitalized pediatric oncology and hematopoietic stem cell transplant patients are a high-risk population with frequent deterioration events requiring critical care. Early identification of critical illness in these patients can improve hospital outcomes and reduce mortality. Pediatric early warning systems (PEWS) and rapid response teams (RRTs) are quality improvement measures that aid in early recognition and management of critical illness in these high-risk patients.

10053 Background: While great strides have transpired in pediatric cancer management in high-income countries (HICs), more than 80% of all children with cancer live in low-and middle-income countries (LMICs),where fewer than 20% will be cured. The World Health Organization (WHO) has stated that early integration of palliative care is an ethical responsibility in the management of children with life-limiting illness. While structural barriers impact the ability to deliver pediatric palliative care (PPC), underlying stigma also prevents early integration of PPC. Methods: The Assessing Doctor’s Attitudes on Palliative Treatment (ADAPT) survey was created for physicians of all specialties who care for children with cancer, initially used in Eurasia. Survey questions evaluated provider perceptions on timing of palliative care integration, scope of palliative treatment, physician responsibility, and ethical issues. This survey was adapted for use in Latin America, including translation to Spanish and reviewed by regional palliative care specialists for syntax, comprehension, and cultural relevance. The survey was then distributed to physicians treating children with cancer in the region. To assess provider’s perspectives on palliative care, we used fifteen statements from the WHO 2018 guidelines, describing general palliative care principles. Results are reported as percent of alignment with guidelines. Results: A total of 1,039 participants from 16 countries in Latin America completed the survey, with a median country response rate of 66% (range 26%-100%). Thirty-six specialties were represented with 34% general pediatricians and 23% pediatric hematologist/oncologists. The majority (59%) had received no PPC training and 37% had no access to PPC experts for consultation in their practice setting. On average, provider’s perspectives on PPC were aligned with the WHO guidelines (81% alignment, range 53%-96%). However, almost half (42%) felt that the integration of pediatric palliative occurred too late in the course of treatment. Additionally, less than half (47%) of respondents felt comfortable addressing the physical symptoms of their patients, 33% felt comfortable addressing emotional symptoms, and only 26% felt comfortable addressing grief and bereavement for the patient’s family. The most common barriers identified were a lack of home-based services (87%), a lack of physician knowledge on the role of PPC (84%), and physician discomfort in discussing palliative care with families (81%). Nearly all (95%) wanted more training in PPC. Conclusions: Most physicians who completed the survey were not confident in providing symptomatic and supportive care for their patients and families. This study will guide targeted interventions for education in PPC for physicians in Latin America as well as interventions to address barriers which impede earlier palliative care integration in the region.

To evaluate the correlation of a Pediatric Early Warning Score with unplanned transfer to the PICU in hospitalized oncology and hematopoietic stem cell transplant patients.We performed a retrospective matched case-control study, comparing the highest documented Pediatric Early Warning Score within 24 hours prior to unplanned PICU transfers in hospitalized pediatric oncology and hematopoietic stem cell transplant patients between September 2011 and December 2013. Controls were patients who remained on the inpatient unit and were matched 2:1 using age, condition (oncology vs hematopoietic stem cell transplant), and length of hospital stay. Pediatric Early Warning Scores were documented by nursing staff at least every 4 hours as part of routine care. Need for transfer was determined by a PICU physician called to evaluate the patient.A large tertiary/quaternary free-standing academic children's hospital.One hundred ten hospitalized pediatric oncology patients (42 oncology, 68 hematopoietic stem cell transplant) requiring unplanned PICU transfer and 220 matched controls.None.Using the highest score in the 24 hours prior to transfer for cases and a matched time period for controls, the Pediatric Early Warning Score was highly correlated with the need for PICU transfer overall (area under the receiver operating characteristic = 0.96), and in the oncology and hematopoietic stem cell transplant groups individually (area under the receiver operating characteristic = 0.95 and 0.96, respectively). The difference in Pediatric Early Warning Score results between the cases and controls was noted as early as 24 hours prior to PICU admission. Seventeen patients died (15.4%). Patients with higher Pediatric Early Warning Scores prior to transfer had increased PICU mortality (p = 0.028) and length of stay (p = 0.004).We demonstrate that our institution's Pediatric Early Warning Score is highly correlated with the need for unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant patients. Furthermore, we found an association between higher scores and PICU mortality. This is the first validation of a Pediatric Early Warning Score specific to the pediatric oncology and hematopoietic stem cell transplant populations, and supports the use of Pediatric Early Warning Scores as a method of early identification of clinical deterioration in this high-risk population.

Pediatric Early Warning Systems (PEWS) aim to identify hospitalized children at increased risk of deterioration by assigning a score based on vital signs and clinical status and guiding interventions using a response algorithm to improve outcomes. When implemented with quality improvement methodology, these systems have been shown to be effective in high-resource settings and have the potential to improve the care of children in humanitarian and resource-limited settings (RLS). The purpose of this review is to summarize the current evidence for use of PEWS in RLS and identify areas for further research. A review of the current PEWS literature in RLS was performed using Web of Science, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Portal Regional da BVS, and TRIP Database. While there is limited research available on this topic, eight studies on the use of PEWS, or a PEWS score in a pediatric population in low- or middle-income countries were identified. Two studies assessed the clinical effect of implementation of PEWS; one reported a reduction in clinical deterioration events and the other a reduction in mortality. The remaining studies assessed the association of a PEWS score with signs of clinical deterioration or mortality without a response algorithm. Further research on the impact of PEWS implementation on inpatient care and outcomes in RLS is needed.

Background Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource-limited hospital. Methods A retrospective case-control study comparing the highest documented and corrected PEWS score before unplanned PICU transfer in pediatric oncology patients (129 cases) with matched controls (those not requiring PICU care) was performed. Results Documented and corrected PEWS scores were found to be highly correlated with the need for PICU transfer (area under the receiver operating characteristic, 0.940 and 0.930, respectively). PEWS scores increased 24 hours prior to unplanned transfer (P = .0006). In cases, organ dysfunction at the time of PICU admission correlated with maximum PEWS score (correlation coefficient, 0.26; P = .003), patients with PEWS results ≥4 had a higher Pediatric Index of Mortality 2 (PIM2) (P = .028), and PEWS results were higher in patients with septic shock (P = .01). The PICU mortality rate was 17.1%; nonsurvivors had higher mean PEWS scores before PICU transfer (P = .0009). A single-point increase in the PEWS score increased the odds of mechanical ventilation or vasopressors within the first 24 hours and during PICU admission (odds ratio 1.3-1.4). Conclusions PEWS accurately predicted the need for unplanned PICU transfer in pediatric oncology patients in this resource-limited setting, with abnormal results beginning 24 hours before PICU admission and higher scores predicting the severity of illness at the time of PICU admission, need for PICU interventions, and mortality. These results demonstrate that PEWS aid in the identification of clinical deterioration in this high-risk population, regardless of a hospital's resource-level. Cancer 2017;123:4903-13. © 2017 American Cancer Society.

Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource-limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low-resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncología Pediátrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes.A modified PEWS was implemented at UNOP with systems to track errors, transfers to a higher level of care, and high scores. A retrospective cohort study was used to evaluate clinical deterioration events in the year before and after PEWS implementation.After PEWS implementation at UNOP, there was 100% compliance with PEWS documentation and an error rate of10%. Implementation resulted in 5 high PEWS per week, with 30% of patients transferring to a higher level of care. Among patients requiring transfer to the pediatric intensive care unit (PICU), 93% had an abnormal PEWS before transfer. The rate of clinical deterioration events decreased after PEWS implementation (9.3 vs 6.5 per 1000-hospitalpatient-days, p = .003). Despite an 18% increase in total hospital patient-days, PICU utilization for inpatient transfers decreased from 1376 to 1088 PICU patient-days per year (21% decrease; P.001).This study describes the successful implementation of PEWS in a pediatric oncology hospital in Guatemala, resulting in decreased inpatient clinical deterioration events and PICU utilization. This work demonstrates that PEWS is a feasible and effective quality improvement measure to improve hospital care for children with cancer in hospitals with limited resources. Cancer 2017;123:2965-74. © 2017 American Cancer Society.

Pediatric oncology patients hospitalized in resource-limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost-effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource-limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care.

Abstract 25 Background: Hospitalized pediatric oncology patients are at high risk for clinical decline and mortality, particularly in resource-limited settings. Pediatric Early Warning Scores (PEWS) are commonly used to aid with early identification of clinical deterioration; however, these scores have never been studied in oncology patients in low-resource settings. We describe the successful implementation of a modified PEWS at Unidad Nacional de Oncología Pediátrica (UNOP), a national pediatric oncology hospital in Guatemala. Methods: The PEWS used at Boston Children's Hospital (BCH) was modified through key informant meetings at UNOP, adjusting for practice variations between the two hospitals. After an initial pilot of the tool, the PEWS was implemented in all non-ICU inpatient areas at UNOP (60 beds with about 2,000 admissions/year). During implementation, systems were created to monitor errors in calculating PEWS, patient transfers to a higher level of care, and high PEWS scores for ongoing quality improvement. Results: Hospital-wide implementation occurred over 6 months, when 113 nurses were trained in the PEWS tool and algorithm. Compliance with PEWS performance and documentation was 100% by the end of the implementation period, with 300 to 400 PEWS measured daily and less than 10% errors. Monitoring of PEWS results reports an average of 5 high PEWS per week with 30% transferring to a higher level of care. Among patients requiring ICU transfer, 86% had an abnormal PEWS prior to transfer, which is similar to results at BCH (90%). Staff surveys showed a high degree of satisfaction with PEWS (4.6/5) and minimal difficulty using the score (2.3/5) (n=67). Conclusions: We describe the successful implementation of a PEWS in a pediatric oncology hospital in Guatemala. This work demonstrates that PEWS is a feasible, well-accepted, and low-cost quality improvement measure in this resource-limited setting. We now plan to evaluate the effects of this implementation on patient care and outcomes. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.

BACKGROUND: Listeria monocytogenes is a food-borne pathogen that primarily affects pregnant women. Cardiac involvement is an uncommon complication of infection. We present a case of a gravida with Listeria bacteremia at 36 weeks of gestation. CASE: Two of a patient's blood cultures grew L monocytogenes after she experienced chills, headache, myalgia, and diarrhea. The patient was treated with antibiotics for 48 hours, and then labor was induced, resulting in a normal delivery with a healthy neonate. On day 5 postpartum, the patient developed progressive heart block, resulting in a third-degree block, which required a pacemaker. An electrocardiogram done 30 days after hospital discharge demonstrated an atrial-sensed, ventricularly paced rhythm, which indicated that the heart block had not resolved. CONCLUSION: Heart block is a rarely reported and possibly overlooked complication of listeriosis. Mothers with listerial infection should be screened for cardiac complications to avoid unexpected decompensation.

Guidelines for management of newborn hyperbilirubinemia have existed in Russia for many years. We sought to determine the degree to which management of hyperbilirubinemia in Russia meets three existing clinical protocols. We performed a cross-sectional chart review in a government-run, academic hospital in an urban setting in Moscow, Russia. Subjects were admitted to Level II nursery at Hospital No.13, were not transferred to a Level III nursery, did not die during hospitalization, and had at least one pairing of total serum bilirubin (TSB) and clinical evaluation of jaundice. We measured physician adherence to three available guidelines based upon TSB levels at which phototherapy and exchange transfusions were performed. We identified 594 infants and 1,924 pairings. Despite availability of TSB to inform decision-making, physicians did not follow the protocols. Under Russian and U.S. guidelines, physicians often failed to start phototherapy, started phototherapy unnecessarily, and missed recommended exchange transfusions. Despite a resource-poor setting, guideline adherence in Russia was remarkably similar to that of U.S. physicians. The data illustrate the challenge of overcoming physician behavior to standardize practice, and raise questions about the presumed higher quality of care in a more developed medical system. A new framework for guideline implementation is needed, and many of the necessary tools already exist.