Table 2 Overview of study measures

Hospital Characteristics

Hospital type; funding; bed capacity; pediatric oncology and ICU staffing; annual volume of new diagnoses; and dates of PEWS adoption, training, pilot, and implementation completion.

• Collected at entry into Proyecto EVAT, confirmed by local site lead at study enrollment.

Participant Demographics

6 demographic questions on profession, role in PEWS implementation, years working in profession, gender, age, and hospital of employment.

• Anonymous Spanish or Portuguese paper or electronic Qualtrics survey, requiring 10–15 min to complete.

• Distributed to (estimated n = 27 per hospital):

• PEWS implementation leadership team (nurses and physicians, mean n = 7, range 4–15).

• Frontline clinical staff (all ward and ICU physicians and nurses using PEWS, mean n = 20, range 9–61).

• Participants allowed 3 weeks to complete survey with 3 reminders.

Clinical Capacity for Sustainability

CSAT: 7 domains with 5 questions (35 total), ranked on a 5-point Likert scale (1 = low to 5 = high agreement). Domain scores are the mean of domain items, and overall score is the mean of all domain scores; higher scores represent greater capacity.

PEWS Adaptation

3 close-ended and 1 open-ended question on adaptations made to the PEWS scoring tool and algorithm [49]. Reported adaptations will be summed per respondent then averaged across all participants at each hospital.

PEWS Sustainment

PEWS use and fidelity indicated by 3 types of errors (omission, scoring, and algorithm) in the 2 months before each CSAT data collection following implementation completion (sustainability phase).

• Errors: (1) omissions (documented vital signs without using PEWS), (2) errors in PEWS scoring, and (3) PEWS algorithm nonadherence.

• Dichotomous (yes/no < 15% in all three error types) and continuous (% errors).

• Assess by the implementation team by reviewing nursing documentation of vital signs and PEWS in all hospitalized patients.

• Assessed weekly during implementation until implementation completion.

• Assessed for 2 months prior to survey assessment during the sustainability phase.

• Submitted electronically.

• Data aggregated to calculate monthly error %.

Patient Outcomes

• CDE: an unplanned transfer to a higher level of care (i.e., ICU), use of an ICU intervention on the ward (vasoactive infusion, invasive or noninvasive mechanical ventilation, or cardiopulmonary resuscitation), or a ward death in a patient without limitations on resuscitation [10].

• CDE mortality rate: percent of death occurring during event or within 24 h of event conclusion [10].

• Reported for 2 months before each CSAT data collection time point during sustainability phase.

• Prospective de-identified registry of all CDEs in hospitalized pediatric oncology patients collected by the PEWS implementation team from start of participation in Proyecto EVAT.

• For each CDE, a de-identified case report form is completed by local site leads and entered into a RedCAP database [50].

• Data analysis checks for missing and incorrect values assure data quality.

Challenges to Capacity and Sustainability

Perspectives from hospital staff on challenges to capacity development, PEWS adaptation, and PEWS sustainability, as well as possible interventions to support sustainability.

• Focus groups of 5–7 physicians, nurses, and hospital administrators (3 focus groups per hospital) at 4 high- and 4 low-capacity hospitals as assessed by the CSAT.