Working globally to save critically ill children with cancer

Nearly 40% of children with cancer will experience life-threatening complications requiring attention in a pediatric intensive care unit (PICU). Yet, in many parts of the world, critical care resources are limited. While overall PICU mortality has dropped to 2.7%, mortality for children with cancer who require a PICU stay is much higher at 27.8%. These numbers highlight an urgent need for improved management and targeted interventions for pediatric oncology patients in critical care. 

“General pediatric literature does not address the needs of critically ill children with cancer,” explained Asya Agulnik, MD, MPH, program director of the St. Jude Global Critical Care Transversal program. “This population requires an area of dedicated study to identify and understand the opportunities to enhance impact, improve outcomes and translate those findings to meaningful patient care.”

The St. Jude Global Critical Care Transversal program is strengthening hospital care for critically ill children with cancer and other catastrophic diseases, regardless of location. By providing targeted interventions, resources and support, the program addresses gaps in care and helps enhance health care systems worldwide. From Latin America to sub-Saharan Africa, the program is working to transform pediatric onco-critical care (POCC) through innovative interventions, global collaborations and the creation of new standards that improve survival rates and quality of life. 

The program’s initiatives are rooted in five core pillars: implementation of evidence-based interventions, research, education, assessment, and collaboration. While each pillar serves a unique purpose, they are all interconnected and collectively support the program’s overall mission, ensuring that strides made in global advocacy and knowledge-sharing are put into practice through concrete, actionable strategies. 

“One of our main goals is to transfer knowledge worldwide, ensuring health care professionals have access to the resources and expertise needed to better treat their patients,” said Maria (Puerto-Torres) Lamia, program manager of the Global Critical Care Transversal program. “Additionally, we aim to strengthen a network of collaborators in critical care, as such a network is currently underdeveloped and largely non-existent.”

Establishing pediatric onco-critical care as a global priority

When the Global Critical Care program was established in 2017, POCC did not exist as a recognized field. Critically ill children with cancer had unique needs that were being overlooked in both oncology and critical care training programs, leaving a significant divide between care and research. Recognizing this, St. Jude began building a specialized community focused on this vulnerable population, starting from the ground up. Over the years, this effort has expanded worldwide, reaching clinicians, researchers and institutions in more than 85 countries.

A major milestone in this development was the launch of the Pediatric Onco-Critical Care Symposium, created in collaboration with the St. Jude Division of Critical Care Medicine. What initially began as a local effort to foster knowledge-sharing and awareness evolved into an international platform for education, collaboration and innovation. This year, the first International Pediatric Onco-Critical Care Symposium was held in partnership with the PICU Oncology Kids in Europe Research (POKER) Group and hosted by Great Ormond Street Hospital in London, further expanding the symposium’s global reach. 

Through this and other global efforts, the program continues to strengthen advocacy for better resources and drive the development of evidence-based strategies to improve survival and recovery outcomes for critically ill pediatric oncology patients. 

Strengthening early detection through scalable solutions

This work includes specialized efforts to improve the early detection of clinical deterioration in hospitalized patients. The Pediatric Early Warning System (PEWS) is a key framework that uses evidence-based tools to help healthcare providers recognize early warning signs. PEWS is a scoring system calculated by the nurse with each set of vital signs and paired with an action algorithm to guide the clinical team’s response. It helps nurses and physicians assess patients and communicate effectively to identify the early signs in a child’s deterioration.

To scale the use of PEWS globally, the Global Critical Care program supports three regional initiatives that provide training, tools and ongoing support to help hospitals integrate PEWS into routine practice, each tailored by language and region. The English-based PEWS Adaptation to Support Hospitals in the Alliance (Project PASHA) works with 23 hospitals in sub-Saharan Africa, the Eastern Mediterranean, Asia-Pacific, and Eastern Europe. The Spanish-based Proyecto Escala de Valoracion de Alerta Temprana (Proyacto EVAT), includes 114 centers across Latin America. The Portuguese-based EVAT Escala de Sinais de Alerta Precoce (ESAP Max) serves hospitals in Brazil.  

By equipping care teams with the tools and processes needed to recognize concerning trends earlier, these programs aim to increase the window for timely intervention, ultimately improving recovery outcomes for pediatric patients.

“We’ve published research showing a clear reduction in mortality when hospitals implement PEWS in the care of children with cancer. After working with many of these sites for nearly eight years, we’ve been able to compare data from before and after implementation — and the impact is undeniable. Fewer children are dying because of this system,” said Adolfo Cardenas-Aguirre, MD, program manager of PEWS, Global Critical Care Transversal program.

To ensure these improvements are lasting, the team is also studying the long-term sustainability of PEWS through the Investigating Sustainability of PEWS in Resource-Limited Hospitals (INSPIRE) study, in partnership with Virginia McKay, PhD, and investigators at Washington University at St Louis. This research looks at how hospital environments and organizational factors influence the ongoing use of PEWS. INSPIRE helps identify what supports or hinders long-term success, guiding future efforts to maintain and expand these life-saving practices.

PROACTIVE improvements in pediatric oncology care

While PEWS help detect clinical deterioration, they do not evaluate whether hospitals have the infrastructure, staff or systems in place to respond effectively when a child’s condition worsens. The Pediatric Oncology Capacity Assessment Tool for Intensive Care (PROACTIVE) provides a structured way to assess capacity, quality and readiness of PICU care. This assessment tool enables institutions, especially in resource-limited settings, to identify weaknesses and guide targeted improvements. 

“Since its launch, PROACTIVE has been implemented at 74 sites across 34 countries, with additional sites currently underway,” said Anita Arias-Prado, MD, associate program director of the Global Critical Care Transversal program. “The assessment gives teams concrete data to identify where improvements are needed, making it easier to target areas for quality improvement.”

By standardizing the assessment of PICUs, PROACTIVE provides valuable data that guides targeted improvements and supports evidence-based decision making in resource-limited settings.

Enhancing interdisciplinary communication in critical care

Communication breakdowns between the many members of a medical team can lead to delayed interventions and suboptimal patient outcomes. Critical Communication (CritCom) is a communication assessment tool that evaluates how clinical teams interact during these critical moments, especially in PICUs. 

CritCom evaluates how effectively teams communicate under pressure. Physicians, nurses and other team members anonymously rate their perceptions of communication practices within their unit. It covers domains such as leadership, tone and administrative support — all reported anonymously. The resulting hospital-level report highlights discrepancies in perceptions, identifies areas for improvement and helps teams develop quality improvement plans. Often, it reveals unexpected gaps and motivates teams to enhance communication practices across the board.

“The goal is to help teams visualize how communication is functioning in their unit and where gaps exist,” said Lamia. “The tool often uncovers unexpected challenges and motivates teams to reflect and develop quality-improvement plans.” 

CritCom fills the gap in assessing and improving interdisciplinary communication during critical patient deterioration in PICUs, providing actionable insights that guide teams in strengthening their communication practices and ultimately improving patient care during critical moments.

Enhancing knowledge through education

The Global Academy in Pediatric Onco-Critical Care (GA POCC) is a vital component of the Global Critical Care program, designed to foster international collaboration and enhance the skills of health care professionals worldwide. By offering specialized training and educational resources, the academy equips clinicians with the knowledge and tools necessary to provide high-quality care for critically ill pediatric patients. Through a combination of online courses and in-person workshops, the GA POCC helps health care workers gain a deep understanding of the best practices in POCC. 

“Our participants are always eager to learn and improve patient care. To meet this demand, we’ve evolved our program, introducing basic and advanced courses starting in 2025. While aimed at intensivists (critical-care doctors), we’re also welcoming hematologists-oncologists, general pediatricians, nurses, clinical pharmacists and information-technology specialists,” said Lamia. “The specialized tracks allow deeper learning for those who want it, while others can enhance their knowledge without delving too deeply into critical-care management.”

In addition to the GA POCC courses, the Global Critical Care program also includes the PICU Observership, a 2-3 week immersive experience in the St. Jude PICU, and a Quality Improvement Workshop, an annual three-day virtual workshop designed to build practical skills in implementing quality improvement strategies across diverse care settings.

“The goal of our education programs is to improve provider knowledge on how to manage the care of critically ill children with cancer, regardless of location or level of resources,” explained Stacey Wiedower, MS, program coordinator of the Global Critical Care program. “Through our Global Academy course, PICU Observership program and the Quality Improvement Workshop, we share knowledge to build and strengthen relationships. These connections are key to improving care and outcomes for patients and their families.”

Catalyzing the cycle of change in pediatric oncology critical care

The Global Critical Care program brings together a suite of complementary initiatives that work in concert to strengthen care for pediatric oncology patients. Collaboration is at the heart of the program’s success, bringing together hospitals, clinicians and regional colleagues to share knowledge, experiences and best practices. Together, these tools create a comprehensive framework that not only identifies areas for improvement but also empowers clinicians and hospitals with the data, training and strategies needed to make meaningful, lasting changes in patient outcomes.

“That’s the cycle: identify needs, find solutions, put them into practice, and make them standard. This is just the beginning, there’s much more to do, together,” said Agulnik.

Critical illness in children with cancer can be a dire situation — but with timely, effective care many of these patients can recover. Through research, sharing expertise and enhancing the capacity of health care systems worldwide, St. Jude is helping deliver high-quality critical care to critically ill children.