Background The identification of the most unwell children in hospital, and the escalation of their care, is globally challenging, especially in resource-limited settings.
Objectives A Myanmar/UK working group (WG) has developed Paediatric/Neonatal Early Warning Scores and an escalation policy designed for children of all ages in Myanmar hospitals. We present here early data on the impact of a pilot project, to be followed in March 2021 by a full 4-month dataset following implementation in different settings.
Methods Review and design phase
Since January 2020, the Myanmar Paediatric Society (MPS) and Royal College of Paediatrics and Child Health (RCPCH) have collaborated on a pilot programme to design and implement Paediatric and Neonatal Early Warning Scores for different age groups, suitable for use in all Myanmar’s hospitals.
Meeting remotely and regularly, the WG reviewed existing PEWS assessment tools and escalation criteria. They agreed a standardised scoring system and escalation criteria for Myanmar and also developed a teaching package, comprising pre-recorded lectures with commentaries in Burmese and supervised practice on the wards.
Pilot implementation phase Three hospitals were recruited, representing the main types of hospital in Myanmar:
Tertiary Hospital (Medical Ward 2, Yangon Children’s Hospital)
Regional Hospital (Taunggyi Hospital)
District Hospital (Minbu Hospital)
These hospitals audited 127 inpatient paediatric and neonatal records, assessing the completeness of observation charts and the documented response to any clinical deterioration. Following the PEWS chart implementation, the audit is ongoing.
Results Review and design phase
Initial review of existing tools from other countries showed that clinical applicability and staffing constraints in Myanmar precluded their use without some adaptation.
Clinical applicability – Myanmar hospitals treat many children with Dengue Shock Syndrome (DSS) in whom pulse pressure is an important clinical prognostic sign. The Myanmar PEWS scoring chart is the first example in global literature to incorporate this observation.
Workforce – Despite improvements, significant shortages of specialist clinicians remain and therefore escalation policies were adapted to balance the need for rapid clinical response against the backdrop of limited staffing.
Pilot implementation phase We are currently completing data collection following the implementation of the PEWS charts. Early data indicate a positive change (median 24.8%, IQR 22.23%) in observation chart completeness, noting that heart rate is historically well documented; the full dataset, due in early March 2021, should include over 250 charts.
Figure 1-Observation chart change from standard documentation to PEWS incorporation
Conclusions This pilot has shown that collaboration between MPS and RCPCH allowed the development of paediatric and neonatal early warning scores suitable for Myanmar hospitals with limited staffing and their clinical burden, including for the first time, Dengue Shock Syndrome. Implementing these has led to improvements in the accuracy and completeness of observations.
Further data evaluating the impact of this pilot on clinical care will be presented at the meeting.
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