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 implementation study, we will review patient charts before and after PEWS introduction to measure the efficacy of PEWS in reducing unplanned escalations of care. We will interview pediatric providers about barriers and facilitators experienced during PEWS adoption, and survey providers to measure the acceptability and feasibility of PEWS. Botswana’s national referral hospital will be supported in PEWS adoption by a peer network of hospitals in Eastern and Southern Africa all introducing PEWS simultaneously. RESULTS: The average rate of unplanned deterioration events in the pediatric medical ward at the national referral hospital was PEWS was 6.9 events per 100 admissions between July and December 2022. The average event-attributable mortality was 41.2%. PEWS was fully implemented in the pediatric medical ward between December 2022 and March 2023. 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%. Data collection on post-implementation unplanned deterioration events and mortalities is on-going. IMPACT: We hope to use the national referral hospitals’ experience with introducing PEWS to optimize implementation strategies for other facilities in Botswana and expand adoption of this important tool for child mortality reduction.