Implementation of a Pediatric Early Warning Score to Improve Communication and Nursing Empowerment in a Rural District Hospital in Rwanda

Shela Sridhar; Alexis Schmid; Francois Biziyaremye; Samantha Hodge; Ngamika Patient; Kim Wilson

doi:10.9745/GHSP-D-20-00075

Key Findings

Nursing staff felt more empowered to communicate clinical findings to the physician team following the Pediatric Early Warning Score for Resource-Limited Settings tool training and implementation process.
The process of implementing the tool triggered more calls from nursing staff to the physician teams to initiate early intervention.

Key Implications

The Pediatric Early Warning Score for Resource-Limited Settings tool has the potential to improve competency and confidence of nurses in their triage capabilities. Although traditionally implemented in tertiary care centers, program managers should consider implementing this tool at the district hospital (secondary) level as well.
Physicians and nurses both play crucial roles in triaging systems. Therefore, program managers should consider engaging both groups with the tool before and during implementation.

ABSTRACT

Background:

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.

Implementation:

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.

Evaluation:

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.

Discussion:

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.

Received: February 13, 2020.
Accepted: August 21, 2020.
Published: December 23, 2020.

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