Boston Children's Hospital, Boston, MA, USA.
Inshuti Mu Buzima-Partners in Health Rwanda, Kigali, Rwanda.
Glob Health Sci Pract. 2020 Dec 23;8(4):838-845. doi: 10.9745/GHSP-D-20-00075.
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.
儿科早期预警 (PEW) 评分代表了一种“跟踪和触发系统”，可在发生警戒事件前数小时识别患者病情的临床恶化。在实施之前，由于缺乏技能、词汇和代理权，护士报告说他们对识别和倡导急性病患者感到准备不足。我们在卢旺达的一家农村地区医院与护士一起实施了儿科早期预警评分资源有限设置 (PEWS-RL)。尽管 PEW 评分可以改善临床结果，但赋予资源有限环境中的护士与医生讨论患者病情严重程度的能力是至关重要的第一步。我们的主要目标是培训护士更准确地获取生命体征，并评估其作为临床恶化的早期预警信号的重要性，以及使用 PEW 评分来改善护士与医生之间的沟通。
PEWS-RL 工具的实施始于一个培训计划，该计划是通过与护士、医生和医院医疗主任的讨论而创建的。该计划包括讲座和通过直接临床指导护士应用所学技能，以及培训医生将 PEWS-RL 作为一种沟通工具。
根据前后测试评估 PEWS-RL 协议，以评估护士知识和技能的提高，以及准确识别临床恶化的技能评估。所有 6 名护士都以 >80%的准确率通过了技能测试。通过培训前后的访谈评估护士为患者辩护和升级护理的能力。护士们表示，他们对呼吁医生支持的信心有所增强。
实施 PEW 评分提高了护士的技术技能和信心和授权感；然而，资源匮乏的环境带来了重大挑战。可持续实施的障碍包括快速病房员工更替以及医生参与度有限。尽管如此，如果员工完全接受，PEWS-RL 工具有可能增强护士的能力并改善患者的预后。
