IMPACT OF IMPLEMENTING A PEDIATRIC EARLY WARNING SYSTEM ON OUTCOMES IN HEMATOPOIETIC STEM CELL TRANSPLANT UNITS IN SOUTH AMERICA AND EUROPE

Monica L. Quijano-Lievano^1,2,3,4Oscar Ramirez^2,3,4Yichen Chen⁵Maricela Robles-Murguia⁵Meenakshi Devidas⁵Hilmarie Muniz-Talavera⁵Adolfo Cardenas-Aguirre⁵Carlos Andres Portilla^2,6Diana Paola Castrillon^2,3Diana Rendon^2,3Andreia De Paula⁷Rosdali Diaz-Coronado⁸María Sánchez-Martín^10,9Silvio Fabio Torres¹¹Verónica Soto Chávez¹²Asya Agulnik^5*

• ¹Doctorate in Health, University of the Valley, Cali, Colombia
• ²Bone Marrow Transplant Unit, Clinica Imbanaco, Cali, Colombia
• ³Fundacion POHEMA, Cali, Colombia
• ⁴Registro Poblacional de Cancer de Cali, Cali, Colombia
• ⁵St Jude Children's Research Hospital, Memphis, United States
• ⁶Pediatric Department, Universidad del Valle, Cali, Colombia
• ⁷Hospital de Amor, Barretos, Brazil
• ⁸Instituto Nacional de Enfermedades Neoplasicas, Lima District, Peru
• ⁹Hospital Universitario La Paz, Madrid, Spain
• ¹⁰Universidad Autonoma de Madrid Facultad de Medicina, Madrid, Spain
• ¹¹Hospital Universitario Austral, Buenos Aires, Argentina
• ¹²Hospital Civil de Guadalajara, Guadalajara, Mexico

Background/Aim: Escala de Valoración de Alerta Temprana (EVAT) is a Spanish-language Pediatric Early Warning Score (PEWS) validated to predict the need for unplanned Intensive Care Unit (ICU) transfer in hospitalized children with cancer. We assess the effect of PEWS implementation on hospitalized children undergoing hematopoietic stem cell transplantation (HSCT) in variable-resource centers in South America and Europe. Methods: We analyzed data from a prospective registry of clinical deterioration events (CDE), defined as an unplanned ICU transfer, ICU-level intervention on the ward, ward cardiopulmonary arrest, or deterioration to death, among hospitals implementing PEWS. We included CDE occurring in patients under age 19 hospitalized in an HSCT unit between April 2017 and June 2024. We used the Wilcoxon rank sum test, Chi-Square test, and Fisher's exact test to compare CDE occurring before PEWS implementation (pre-PEWS) and during/after PEWS implementation (post-PEWS). Results: During the study period, we identified 221 CDE among 146 patients from six centers (South America n=5; Europe n=1). The median age was 9 years (IQR, 4-14), 68% (n=150/220) were male, and 20% (n=44/221) experienced more than one CDE. Overall event mortality rate was 18% (n=39/221). Of 221 CDE, 71 occurred pre-and 150 post-PEWS implementation. CDE post-PEWS were less likely due to respiratory distress (38%, n=27/71 vs. 23% n=35/150, p=0.0348); had fewer organ systems with dysfunction at ICU transfer (median 2 [IQR 1-3] vs. 0 [IQR 0-2], p<0.001), and had lower PIM2, which indicates lower severity of illness at ICU transfer (median 5.0 [IQR 1.4-7.9] vs. 1.5 [IQR 1.2-3.4], p<0.001). There was a non-significant decrease in clinical deterioration event mortality post-PEWS implementation (24%, n=17/71 vs. 15%, n=22/150, p=0.1335). Conclusions: PEWS implementation promoted early identification of critical illness as well as ICU transfer at a lower severity of illness for children undergoing HSCT. This work further supports the use of PEWS in the care of all children with cancer and blood disorders globally.