Table 3.

Negative perception of care delivery during deterioration.

Theme		Provider	Example
Indirect impact of PEWS	Limited Material Resources	UNOP ICU Physician	“That part of not having a [ICU] bed, I think we were late and maybe we would have done another intervention before.”
	Challenges with Technology	St. Jude ICU APP	“We were finally called to the [PEWS] that morning—and it was kind of a sticky situation because the paging system was down.”
Direct impact of PEWS	False Positive Score	UNOP ICU Physician	“Maybe we will have more alarms that sound and are false alarms, and I know that that in general is an annoying for ICU fellows and even for some ICU attendings.”
		St. Jude ICU Physician	“And just my concern it’s put a lot of workload on the ICU to the point that sometimes it’s the boy who cried wolf and we maybe don’t pay much attention to it like we should.”
	Objective Tool	St. Jude ICU Physician	I think, that’s what I was worried about that people do not use a score, a number rather than a clinical judgment to say, “There’s something wrong with my patient.”
		St. Jude ICU APP	Now I’m seeing it across the board, I even see now, nurses who I deemed experienced in tenure, rely heavily on these systems and I know them previously, and I know they know, you know, better, for lack of a better description.
Lack of Communication		UNOP Ward Physician	“The nurse didn’t communicate to the doctor and the doctor didn’t monitor the patient.”
		St. Jude Ward Physician	“If the nurse doesn’t know to notify the provider, like not being notified that your patient is being transferred to the ICU is really bad.”
Inexperience with Deterioration		UNOP Ward Physician	“Maybe she is a person who doesn’t have too much relation or contact with critical patient and that’s why she is not concerned.”
		St. Jude Ward Physician	“Providers who have more difficulty with that would most likely be the residents because they do not rotate through the ICU as an intern actually, so they don’t have that level of experience of intubating a kid and seeing them on pressors.”

St. Jude, St. Jude Children’s Research Hospital; UNOP, Unidad Nacional de Oncología Pediátrica; PEWS, Pediatric Early Warning System; APP, Advance Practice Provider; ICU, Intensive Care Unit.