Reliability and validity of a Spanish-language measure assessing clinical capacity to sustain Paediatric Early Warning Systems (PEWS) in resource-limited hospitals
Open accessAbstract
Background: Paediatric Early Warning Systems (PEWSs) improve identification of deterioration, however, their sustainability has not been studied. Sustainability is critical to maximise impact of interventions like PEWS, particularly in low-resource settings. This study establishes the reliability and validity of a Spanish-language Clinical Sustainability Assessment Tool (CSAT) to assess clinical capacity to sustain interventions in resource-limited hospitals. Methods: Participants included PEWS implementation leadership teams of 29 paediatric cancer centres in Latin America involved in a collaborative to implement PEWS. The CSAT, a sustainability assessment tool validated in high-resource settings, was translated into Spanish and distributed to participants as an anonymous electronic survey. Psychometric, confirmatory factor analysis (CFA), and multivariate analyses were preformed to assess reliability, structure and initial validity. Focus groups were conducted after participants reviewed CSAT reports to assess their interpretation and utility. Results: The CSAT survey achieved an 80% response rate (n=169) with a mean score of 4.4 (of 5; 3.8–4.8 among centres). The CSAT had good reliability with an average internal consistency of 0.77 (95% CI 0.71 to 0.81); and CFAs supported the seven-domain structure. CSAT results were associated with respondents’ perceptions of the evidence for PEWS, its implementation and use in their centre, and their assessment of the hospital culture and implementation climate. The mean CSAT score was higher among respondents at centres with longer time using PEWS (p<0.001). Focus group participants noted the CSAT report helped assess their centre’s clinical capacity to sustain PEWS and provided constructive feedback for improvement. Conclusions: We present information supporting the reliability and validity of the CSAT tool, the first Spanish-language instrument to assess clinical capacity to sustain evidence-based interventions in hospitals of variable resource levels. This assessment demonstrates a high capacity to sustain PEWS in these resource-limited centres with improvement over time from PEWS implementation.
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An adaptation of the PSAT was developed that focuses on clinical programs and practices.
“To assess these settings, an adaptation of the PSAT was developed that focuses on clinical programs and practices.”
From Assessing the sustainability capacity of evidence-based programs in community and health settings (2022) · cites this paper as [35]
The Background and Methods (CSAT adaptation; page not provided) describe the Clinical Sustainability Assessment Tool as a measure for sustaining clinical practices and report adapting it into Spanish. The paper cites work on the PSAT when describing the CSAT’s domains, but our copy does not explicitly say the CSAT was developed as an adaptation of the PSAT; that relationship is not fully supported. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe Clinical Sustainability Assessment Tool (CSAT) had been previously developed with established reliability and validity.
“Both measures had been previously developed with established reliability and validity, and have been widely used across a variety of contexts and settings.”
From Lowering the burden: Shorter versions of the Program Sustainability Assessment Tool (PSAT) and Clinical Sustainability Assessment Tool (CSAT) (2024) · cites this paper as [9]
The Methods (CSAT adaptation; page not provided) state that the CSAT had previously been developed and tested, with excellent internal consistency. They describe only trends toward discriminant validity, however, so the claim that its validity was already established overstates the evidence. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThe Clinical Sustainability Assessment Tool has been translated for use in other languages and has been demonstrated as reliable in both domestic and global settings.
“The Clinical Sustainability Assessment Tool has also been translated for use in other languages and has been demonstrated as reliable in both domestic and global settings (35).”
From Assessing the sustainability capacity of evidence-based programs in community and health settings (2022) · cites this paper as [35]
The PSAT and CSAT have been completed online over 13,000 times to measure sustainability capacity across a variety of settings.
“Together, the PSAT and CSAT have been completed online over 13,000 times to measure the sustainability capacity of programs and practices across a variety of settings, including public health [10, 13], clinical care [9, 14], behavioral health [15], and education [16].”
From Lowering the burden: Shorter versions of the Program Sustainability Assessment Tool (PSAT) and Clinical Sustainability Assessment Tool (CSAT) (2024) · cites this paper as [9]
The CSAT contains seven domains with five items each, for a total of 35 items.
“The CSAT contains seven different domains with five items in each domain for a total of 35 items.”
From Lowering the burden: Shorter versions of the Program Sustainability Assessment Tool (PSAT) and Clinical Sustainability Assessment Tool (CSAT) (2024) · cites this paper as [9]
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Sorted by citations
Agulnik, A., Ferrara, G., Puerto‐Torres, M., Gillipelli, S. R., Elish, P. N., Muñiz‐Talavera, H., Gonzalez‐Ruiz, A., Armenta, M., Barra, C., Díaz, R., et al. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.1547 · Cited by 44 · see citing works
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“Future work is needed to evaluate the clinical impact of PEWS on patient outcomes, resource utilization, and hospital cost of care, and to identify factors that promote the sustainability of PEWS use and continued impact on patient outcomes at these centers over time.(60)”
BackgroundSelf-citationAssessing the sustainability capacity of evidence-based programs in community and health settings
Bacon, C., Malone, S., Prewitt, K., Hackett, R., Hastings, M., Dexter, S., & Luke, D. A. (2022) · Frontiers in Health Services · doi:10.3389/frhs.2022.1004167 · Cited by 22 · see citing works
“The Clinical Sustainability Assessment Tool has also been translated for use in other languages and has been demonstrated as reliable in both domestic and global settings (35).”
MethodSelf-citationArias, A. V., Sakaan, F. M., Puerto‐Torres, M., Zebin, Z. A., Bhattacharyya, P., Cárdenas, A., Gunasekera, S., Kambugu, J., Киргизов, К. И., Libes, J. M., et al. (2022) · Cancer Medicine · doi:10.1002/cam4.5395 · Cited by 17 · see citing works
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“Prior work suggests that an institution’s capacity to sustain an evidence-based practice such as PEWS increases with time (21), and the cycle of reinforcement described in this work identifies a potential mechanism to explain this finding.”
BackgroundSelf-citationMalone, S., Prewitt, K., McKay, V., Zabotka, L., Bacon, C., & Luke, D. A. (2024) · Implementation Science Communications · doi:10.1186/s43058-024-00656-y · Cited by 12 · see citing works
“…informed measures of sustainability capacity, the Program Sustainability Assessment Tool (PSAT) [7, 8], designed to assess sustainability in public health settings, and the Clinical Sus-tainability Assessment Tool (CSAT) [6, 9], designed to assess sustainability in healthcare settings.”
BackgroundMethodSelf-citationAgulnik, A., Schmidt-Grimminger, G., Ferrara, G., Puerto‐Torres, M., Gillipelli, S. R., Elish, P. N., Muñiz‐Talavera, H., Gonzalez‐Ruiz, A., Armenta, M., Barra, C., et al. (2022) · Frontiers in Health Services · doi:10.3389/frhs.2022.1004805 · Cited by 14 · see citing works
“Our team recently integrated serial assessment of clinical capacity for sustainability into the Proyecto EVAT implementation process, with preliminary results suggesting that clinical capacity for sustainability increased over time using PEWS (53).”
MethodSelf-citationMalone, S., Newland, J., Kudchadkar, S. R., Prewitt, K., McKay, V., Prusaczyk, B., Proctor, E., Brownson, R. C., & Luke, D. A. (2022) · Frontiers in Health Services · doi:10.3389/frhs.2022.1005802 · Cited by 6 · see citing works
“This instrument has demonstrated reliability and is one of the few instruments developed to assess sustainability in clinical settings (42).”
BackgroundSelf-citationAbutineh, F., Graetz, D. E., Muñiz‐Talavera, H., Ferrara, G., Puerto‐Torres, M., Chen, Y., Gillipelli, S. R., Elish, P. N., Gonzalez‐Ruiz, A., Carreras, Y. A., et al. (2023) · Frontiers in Oncology · doi:10.3389/fonc.2023.1122355 · Cited by 6 · see citing works
Self-citationMcKay, V., Chen, Y., Prewitt, K., Malone, S. M., Puerto‐Torres, M., Acuña, C., Alfonso, Y., Alvarez-Arellano, S. Y., Andrade-Sarmiento, L. A., Arce‐Cabrera, D., et al. (2023) · Global Implementation Research and Applications · doi:10.1007/s43477-023-00106-2 · Cited by 5 · see citing works
“Subsequently, children with cancer in low-resource settings have high mortality, particularly if they experience clinical deterioration during cancer treatment (Agulnik et al., 2021a, b, c; Wösten-van Asperen et al., 2019).”
Self-citationWang, C., Sakita, F. M., Sumner, S. F., Shayo, F. M., Martin, Z., Msangi, W., Munisi, J. J., Mulesi, E. M., Aboud, A. M., Bettger, J. P., et al. (2026) · Implementation Science Communications · doi:10.1186/s43058-026-00860-y · Cited by 3 · see citing works
McKay, V., Carothers, B. J., Graetz, D. E., Malone, S. M., Puerto‐Torres, M., Prewitt, K., Cárdenas, A., Chen, Y., Devidas, M., Luke, D. A., et al. (2023) · Implementation Science Communications · doi:10.1186/s43058-023-00519-y · Cited by 4 · see citing works
“An electronic version of the tool was piloted among 19 EVAT SC members to establish acceptability within the context of Proyecto EVAT, and feedback was used to create the final tool [49].”
BackgroundMethodInfluentialSelf-citationKurakbayev, Y., Turdaliyeva, B., Manzhuova, L., Omarova, K., Abdilova, G., Кусаинов, А., Saparbayev, S. S., & Shchukin, V. V. (2023) · Oncologia i radiologia Kazakhstana · doi:10.52532/2521-6414-2023-2-68-69-75 · Cited by 3 · see citing works
Quesada-Stoner, A. C., Islam, M. S., Siječić, A., Malone, S. M., Puerto‐Torres, M., Cárdenas, A., Prewitt, K., Carreras, Y. A., Alvarez-Arellano, S. Y., Vargas, D. A., et al. (2024) · Implementation Science Communications · doi:10.1186/s43058-024-00664-y · Cited by 2 · see citing works
“Participants at included centers completed an anonymous electronic survey based on the Clinical Sus-tainability Assessment Tool (CSAT), which assesses sustainability capacity across seven domains [37, 38].”
MethodSelf-citationValidation of the Turkish version of the pediatric early warning score
Akdeniz, S., Kuşderci, H. S., Adıgüzel, Ş. C., Özbudak, P., Doğru, S., Akdeniz, E., Başaranoğlu, M., & Süren, M. (2023) · Turkish Journal of Clinics and Laboratory · doi:10.18663/tjcl.1343952 · Cited by 1 · see citing works
Counts, L., Rivera, J., Wiphatphumiprates, P., Puerto‐Torres, M., Prewitt, K., Luke, D. A., Graetz, D. E., Malone, S. M., & Agulnik, A. (2024) · Frontiers in Oncology · doi:10.3389/fonc.2024.1384597 · Cited by 1 · see citing works
Self-citationArriaga, J. A. Q., Méndez, S. T. M., & García, J. A. P. (2022) · Honduras Pediátrica · doi:10.5377/hp.v35i1.15546
Miranda, J. D. O. F., Oliveira, T. D. L., Bulhosa, L. F., Souza, M. M. D. C., Sobrinho, C. L. N., de Camargo, C. L., & Rosa, D. D. O. S. (2024) · Ciência Cuidado e Saúde · doi:10.4025/ciencuidsaude.v23i0.69249
Agulnik, A., Graetz, D. E., Carothers, B. J., Rivera, J., Blakeney, E. A., Hayes, S., Chaitan, V. L., Cabassa, L. J., Goss, C. W., Luke, D. A., et al. (2025) · Implementation Science Communications · doi:10.1186/s43058-025-00811-z · Cited by 1 · see citing works
Self-citation
- Authors
- Agulnik, A., Malone, S., Puerto-Torres, M., Gonzalez-Ruiz, A., Vedaraju, Y., Wang, H., Graetz, D., Prewitt, K., Villegas, C., Cardenas-Aguierre, A., Acuna, C., Arana, A. E., Díaz, R., Espinoza, S., Guerrero, K., Martínez, A., Mendez, A., Montalvo, E., Soberanis, D., Torelli, A., Quelal, J., Villanueva, E., Devidas, M., Luke, D., & McKay, V.
- Affiliations
- St. Jude Children's Research Hospital (US)
- Washington University in St. Louis (US)
- Instituto Nacional de Enfermedades Neoplásicas (PE)
- SOLCA Núcleo de Quito (EC)
- Hospital Luis Calvo Mackenna (CL)
- Corresponding author
- Agulnik, Asya
- ORCID
- Venue
- BMJ Open
- Publisher
- BMJ
- Published
- 2021-10
- Volume
- 11
- Issue
- 10
- Pages
- e053116
- ISSN
- 2044-6055 (ISSN-L)
- PMC
- PMC8529978
- OpenAlex
- W3207525512
- Cited by
- 20
- References
- 41
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 4 · 2023: 6 · 2022: 8
- FWCI
- 5.06
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMJ Open (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- American Lebanese Syrian Associated Charities (n/a)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Social Sciences › Education › Health Education and Validation
- Keywords
- paediatric early warning systems, Spanish-language instrument, psychometric validation, resource-limited hospitals, implementation climate, hospital culture, clinical deterioration, resource-limited settings
- MeSH terms
- Child, Hospitals, Humans, Language, Neoplasms, Reproducibility of Results
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