Table 3. Types of Adaptations.

Domain	Adaptation type	Example
PEWS Adaptation	Scoring tool	Honestly, there haven’t been too many changes to the original scale, just little changes, maybe of vocabulary (implementation leader, San Salvador)
		We changed oxygen, I think in the US...they have other parameters for oxygen saturation, so, we had to modify that, we are higher [altitude] here so we need it to have 90% saturation…we had to change that (implementation leader, Cuenca)
	Algorithm	Some adaptations I remember for example, on the original [algorithm] if there was deterioration you would call directly to ICU, in our case the pediatrician or the oncologist in shift goes first and he evaluates if he calls ICU depending on the action to take (implementation leader, Lima)
		We did modify the flowchart of action because, for example, we don’t have an intensivist in the hospital 24/7…so the resident in charge of the unit was the one doing the evaluations (implementation leader, San Luis Potosi)
	Other	No, we didn’t make changes to the program, we think it’s perfect, with so many places using it, we just needed to adapt (implementation leader, Lima)
		We just adapted to it, but we didn’t change anything of the program (nurse director, Cuenca)
Site adaptation	Physical modifications	We took PEWS to the entire hospital, we posted posters, logos, in the management documents, boards, pins, we would change the PEWS boards constantly (nurse director, Lima)
		We also implemented the whiteboard with the name of the patients, each of them with their PEWS color, so when you go there you can see how our floor is in general and which child requires more attention (director, Cuenca)
	Documentation	Also, the nursing sheet, we had to make the change official, because it’s a legal document that goes apart from the clinical history (implementation leader, Lima)
		We now have the PEWS scale implemented in a digital way in the medical history, it is now part of the digital medical history (implementation leader, Cuenca)
		We had to modify the nursing sheet, because our sheet is way different from what PEWS requires…we had to see what things to remove from the sheet in order to add the scale (nurse director, San Luis Potosi)
	Hospital processes	We take vital signs 1 time during the day and 2 times during the night. So, make the staff understand that they need to take vital signs more frequently for children depending on their category in the scale (implementation leader, San Salvador)
		We had to reorganize the work, reorganize the teams, try to have more beds available, to improve the discharge process for the patients so we don’t have unnecessary occupied beds. We had to work on that aspect (physician director, Lima)
		First, adaptation, because the staff already had a routine related to the evaluation of the patients. The staff would start the day counting their materials, checking their supplies. When you change their routine, their way of work changes in a drastic way, but the staff adapted to that very fast (implementation leader, Xalapa)
		We did some changes…we asked that when this evaluation is made, there should be a note in the clinical record...and also, the ICU physician should write a note saying what he had found and what actions he took and what modifications he made to the treatment (implementation leader, San Luis Potosi)
	Culture	We also adapted the health care staff...we’re going to do the evaluation with the doctor next to the patient, we’re going to call the coordinator, so the doctor would come to us and we had more contact with the doctors. We also adapted to the doctors’ attitudes, the nursing staff as well, improving the relationships with them, even with the intensivist (implementation leader, Lima)

Abbreviations: ICU, intensive care unit; PEWS, pediatric early warning systems.