Advancing Pediatric Palliative Care In a Low-Middle Income Country: An  Implementation Study, A challenging but not impossible task

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Efforts to improve the development of Palliative Care (PC) provision have traditionally targeted services for adults, leaving the pediatric population unaddressed. Examples of such services are scarce and should be portrayed in scientific literature to inform decision-makers and service providers on models of care available to tackle the burden of Pediatric Palliative Care (PPC) in Low-and middle-income countries (LMIC). The purpose of this study is to describe the implementation of a pediatric palliative care program, “Taking Care of You ” (TCY) , in a tertiary care, university hospital in Cali, Colombia. Methods: A program’s database was built with children between 0 to 18 years old and their families, from year 2017 to 2019. Descriptive analysis was carried out to evaluate the impact of the program and service delivery. A theory-based method was directed to describe the PPC program, according to the implementation of self-designed taxonomy, mapping theoretical levels and domains. Clinical outcomes in patients were included in the analysis. Results: Since 2017 the program has provided PPC services to 1.965 children. Most of them had an oncologic diagnosis and were referred from hospitalization services (53%). The number of ambulatory patients increased by 80% every trimester between 2017-2018. A 50% increase was reported in hospitalization, emergency, and intensive care units during the same time period. Conclusions: The program addressed a gap in the provision of PPC to children in Cali. It shows effective strategies used to implement a PPC program and how the referral times, coordination of care, communication with other hospital services were improved while providing compassionate/holistic care to children with life-limiting and threatening diseases and in end-of-life. The implementation of this program has required the onset of specific strategies and arrangements to promote awareness and education proving it a hard task, yet not impossible. Anesthesiology & Pain Medicine Pediatrics pediatric pediatric palliative care program palliative medicine implementation terminal care Latin America Figures Figure 1 Figure 2 Figure 3 Background The prevalence of complex life-threatening diseases in children has increased significantly worldwide(1,2). In the United Kingdom, the prevalence of limiting and life-threatening diseases increased from 12 per 10,000 population in 2003 to 16 per 10,000 by 2007(3,4). The prevalence of these diseases in Latin America is still to be determined since there is still a lack of information. The World Health Organization (WHO) stated that such conditions could benefit from the palliative care (PC) approach(5). In this light, the burden of these diseases and thus the need for PC becomes a growing necessity for healthcare systems worldwide and a moral imperative(6). A recent regional study assessing the development of pediatric palliative care (PPC) in Europe estimated that approximately 150,000 children need PPC every year(7). The region offers a total of 680 services to address the need, of which 133 are hospices, 385 are home-care services and 162 are hospital services(7). The statistics about PC need are expected to be larger in Latin America due to the health inequalities that the region faces. The Lancet Commission on Palliative Care reported an unaddressed lack of access to PC and pain relief worldwide which mainly affects low- and middle-income countries (LMICs) where the provision for PPC and pain relief are estimated to be neglected(8). A systematic review reported that 66.7% of the countries in South America did not have any PPC activity until 2011, when the first integrated PPC service was documented(9). The field of PC has continued to develop and become an active area of research and advocacy. Even though a new definition of the concept is available, the generalized provision of healthcare in Latin America has focused on improving access to specialized adult services(10). This results in an untrained health workforce in the field of pediatrics and a lack of PPC services to address the current need(11). The 2012 Atlas of Palliative Care in Latin America reported Colombia as having four hospice-type residencies, only one second-level service, and 13 tertiary care units that serve both adults and children(12). There are still no available data regarding the national need for PC; however, according to the Childhood Cancer Outcomes Surveillance System (VIGICANCER), the incident rate of pediatric cancer from 1977 to 2011 is comparable with affluent countries.(13) To date, national PC services are estimated to have grown almost 500% in the past 5 years. However, developing PPC in Colombia requires overcoming even greater barriers than for adults, mainly due to the absence of PC academic training programs for pediatricians and the lack of related educational objectives for other healthcare professionals(9,14). In light of the pressing need to promote PPC in Latin America and considering the characteristics of PPC in Colombia based on the recommendations from the American Academy of Pediatrics (AAP), the Institute of Medicine (IoM), and the International Meeting for Palliative Care in Children’s Trento (IMPaCCT) for the introduction of PPC teams(12,15,16), the objective of this paper is to report the process of implementing the PPC program “Taking Care of You” ( TCY ) in the city of Cali in Colombia. As with other LMIC health inequalities and a lack of scientific literature on the subject, Cali represents a context where promoting PPC might seem to be an impossible task. This article reflects on the strategies attempted for developing a multidisciplinary program that could provide coordinated care and symptom management to children with life-threatening and limiting conditions, geared toward reducing suffering and improving patients and families’ quality of life. CONTEXTUAL FACTORS Geographic and demographic context Colombia has a population of 48,258,494 inhabitants, 51.2% of the population is female, and 22.6% are between 0 and 14 years of age(17). Cali is a city with 2.5 million inhabitants(18). There is limited data available regarding the number of pediatric patients with a need for PC or PPC services available in the country; however, the age-standardized annual incidence rate of childhood cancer in Cali from 1977 to 2011 was 141 cases per million. (13,19). Colombian legal framework for PC regulation Since 2014, the country has passed relevant measures related to PPC regulation. Important milestones include the regulation of services in the country, including those aimed at the pediatric population(20), guidelines for inclusive care in PC, differentiating attention for adults and children(21), specific standards for Children Cancer Care Units (CCCU) where PC and pain treatment must be guaranteed from the beginning of treatment(22), a cancer control plan with a mention of PC(23), and regulating the process of dignifying death for children and adolescents, allowing euthanasia(24). (Colombian regulatory framework is summarized in Appendix 1 under supplementary data) The program “Taking Care of You” The program operates in the Fundación Valle del Lili, a nonprofit, teaching hospital that functions as a referral center for the southwestern region of Colombia. It has 177 pediatric beds and cares for approximately 50,000 children annually. Our institution has a general PC program that has operated since 2007 and is led by family medicine physicians with a multidisciplinary team. The general PC program had served the entire population including children until late 2017, when the specialized PC program for pediatric patients called Taking Care of You ( TCY) was launched. TCY is led by a pediatrician with a team that includes a family medicine physician, a nurse, a social worker, and a psychologist. The main objective of the program is to provide coordinated, multidisciplinary and humanized care to promote quality of life for patients under the age of 18 with life-threatening and limiting conditions in any hospital care service [emergency room, hospital room, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and outpatient setting]. Patients are treated through an inter-consultation or first-time assessment by the multidisciplinary PPC team. This multidisciplinary team is designed to provide coordination of care, support in clinical decision-making, facilitated communication, pain and other symptom management, advanced care planning, end of life care, and bereavement follow up(25), among others that will be described later. Program strategies To fulfill the baseline program goals and objectives, an eight-step strategy was implemented. This included education and awareness in PPC (a question-based strategy, summarized in A ppendix 2 under supplementary data), institutional support, the participation of the PPC team in academic and healthcare activities, advocacy with other actors in the healthcare system, capacity building in PPC, the formation of a multidisciplinary team led by a pediatrician with training in PPC, and research that is described in Table 1. Methods Two approaches were followed to describe the outcomes of the program. First, a categorization of the strategies was conducted to assist with its implementation, and second, descriptive statistics were used to describe the program’s outcomes. Mapping implementation strategies A theory-based method was applied to describe the implementation process of our program. The approach was based on the Poot et al. article(26) where a matrix was retrospectively developed from descriptive frameworks. To analyze and display the strategies implemented, a matrix exercise was performed. Strategies of the Program TCY in the matrix: The strategies were categorized retrospectively with the Cochrane Effective Practice and Organization of Care(EPOC)(27,28), Review Group Taxonomy 2015(28), and grouped into the categories and subcategories: Implementation Strategies, Financial arrangements and Delivery arrangements Table 2 . The matrix combines two frameworks: first, levels of organization influenced by the implementation(29), and second, the domains of implementation(30) to provide a comprehensive matrix where defined project activities can be positioned according to their intended target domain and level, facilitating a structured description of the project(26,29). The matrix displays the implementation strategies, Financial arrangements, and delivery arrangements. Different sources of information were cross-referenced in a database to improve the quality of the information. Program outcomes A descriptive analysis of the variables was performed using the program´s administrative registry, no clinical chart review took place, nonetheless, this study was submitted to the Institutional Research Board (IRB) and Ethical Committee. The results were reported using measures of central tendency and dispersion, according to data distribution. Categorical variables were summarized as percentages. The variables analyzed included a detailed analysis of the children served and the referral service, type of pathologies (i.e., oncologic vs nononcologic), and place of death per year. All analyses were performed using Microsoft Excel 2016 . Information from referral motive was gathered as part of an internal administrative process through an online survey ( Appendix 3 provided in supplementary data). No literature search took place, but it did undergo IRB and Ethical Committee review. Education Strategies There were continuous educational activities in the pediatric units that emphasized on the importance and health benefits from the early referral of children with limiting and life-threatening conditions to PPC, advancing to the progressive growth of the program. Educational activities include PPC and pain management workshops, communication role play games, printed materials, PPC subjects in the grand rounds, clinical case discussions, among others. Results Coverage Since the beginning of the program in 2017, a total of 1,965 children have been referred. In 2017, before the specific PPC program was created, 146 pediatric patients were assessed by the general PC team, whereas in 2019, one year after the start of the “Taking Care of You” program, 771 children were assessed in the pediatric inpatient services and 324 new patients were assessed in the outpatient setting of the hospital. This represents an 81% and 93% increase PPC demand in the inpatient and outpatient services, respectively ( see Figures 1 and 2 ). A relevant aspect in the program development was making a strategic alliance with the PICU and the pediatric oncology unit, which favored early integration of the PPC team in the unit’s activities and allowed support in decision-making to promote patient quality of life. This also allows continuity of care, interdisciplinary communication, and therapeutic adherence. Disease prevalence at the moment of referral to the program Patients referred to the program were classified as oncological and non-oncological. We found a similar proportion in both categories, including inpatient and outpatient care. In our institution, the most frequent oncological clinical conditions were central nervous system tumors (53%) (mainly medulloblastoma and low- and high-grade gliomas), followed by bone tumors (26%) (Osteosarcoma and Ewing’s sarcoma). On the other hand, non-oncological conditions were mainly related to severe neurological compromise in 38% of the cases (including congenital malformations and chromosomal abnormalities, such as trisomy’s, microcephaly, cerebral palsy), followed by inherited muscle disorders and rare diseases. Cause of referral The main causes for referral in outpatient and inpatient setting was support during therapeutic withholding and withdrawal of a treatment that was already established (89%), followed by end-of-life care (86%), Communication support (70%), Pain and symptom control (69%), Psychosocial support (67%), Decision-making support (63%), and Health Care coordination (57%). The most frequent reasons for referral to the PPC program by departments are summarized in Table 3, the majority came from t he pediatric inpatient ward (52%) and the PICU(23%). The median time from referral to death was 12 days, with an interquartile range of 2 to 61 days. Place of death and bereavement follow-up The place of death of most of the patients was the hospital Table 4 . Eleven percent of the relatives attended the bereavement workshops in the 2017-2018 time period and 25% in the 2018-2019 time period. The TCY program accompanied bereavement of parents and families through, follow-up calls, sending condolence letters, and bereavement support groups, with a symbolic butterfly release in addition to psychological interventions. The program has had around-the-clock availability, it received 81 phone calls in 2018 and 244 phone calls in 2019, related to symptom management (58%) and care coordination (42%). Strategies Figure 3 shows the integration of the EPOC categories on a single matrix displaying the categorization for the domains: implementation strategies, financial arrangements, and delivery arrangements. The program has focused on advancing in educational and professional interaction, through promoting communication between interdisciplinary teams. Second, it aimed on developing organizational change by task shifting, promoting incentives and resources and pursuing change in social, political and legal frameworks. The program has not stressed change at a policy level, though small changes have been reported at generating specific roles for the program, determining the site of services and providing disease management specifically from a PPC perspective. Discussion The program has focused on an unaddressed gap, the provision of PPC for children in Cali. It has improved referral times, coordination of care, availability of compassionate/holistic care to children with limiting and life-threatening diseases, and end-of-life care. The implementation of this program has required the onset of specific strategies and arrangements to promote awareness and education, which has been a difficult task. With this implementation experience, we intend to contribute to the PC philosophy in pediatric patients’ care and hope it serves as a model for other regions and countries. Establishing a PC team with skills, training, and exclusive activity assistance for the pediatric population was a crucial element to expand PPC demand for children with complex chronic diseases and to increase the program demand a three-fold compared with the previous year. As described in the Children’s Hospital of Eastern Ontario, Ottawa, a significant increase in patient referrals was associated with the inclusion of social work resources and experienced PC physicians(31). Additionally, Education was key for the progressive growth of the program(32) and could be a strategy to lower resistance from healthcare professionals, since this has been described to be a barrier(33). When using the theory-based method description applied to our TCY program implementation, we recognized the program has focused on advancing individual professional and groups of professionals in their capacities and competencies and on generating organizational change to find a niche within the hospital without influencing policy. Small changes at the policy level can be accounted for by the definition of specific PPC roles and settings for patient care. Disease prevalence at the moment of referral to the program displayed the most frequent diagnoses in oncological and non-oncological groups were neurological, similar to other implementation studies carried out worldwide(34). We corroborate that children with neurological conditions, even if not progressive, experience high distress due to symptom control difficulties(32,35), the high burden associated with care(36,37), and potential complications that could cause premature death(32,34) , pointing out the important role a PC team plays in the multidisciplinary management of these patients. Referral causes regarding our PPC program were associated with supporting decisions around withholding or withdrawing treatment, and end-of-life care, especially in the NICU and the PICU services, with an average time from referral until death of 12 days. This underlines late integration of PPC in the wide and varied conditions susceptible to the service. In the largest retrospective medical record review for a PPC population in the US by Thrane et al., they evidenced that the time from referral to death was 4.4 months(38). Highlighting children are still not being referred to PC until mere days before death, not in line with recommendations from the WHO and other organizations(39) that recommend PPC to be provided after diagnosis of life-threatening diseases, which in turn could result in less aggressive care and better outcomes at the end-of-life(40). The global trend is to promote death at home with patient-family comfort and support measures(41); however, in pediatrics, multiple difficulties arise when trying to promote this measure, and the hospital scenario is the most frequent place of death(42). Our team recognized the same difficulty, and most of our patients (74%) died in the hospital. Some of the barriers identified in favoring end-of-life care at home were related to fear from parents or caregivers to face the death of their child alone, the high attention needs of a patient at the end-of-life, the lack of home care programs with PC training, and the absence of pediatric hospices in the country, similar to what is described in the literature(41–43). However, some families were able to care for their children at home during their final days. Finally, family support during bereavement is an essential biopsychosocial need for the family’s well-being after the loss of a child(44). Our program does follow-up to support parents in grief: however, bereavement workshop attendance has been low (25%). We consider it an important aspect to improve by increasing coverage and offering more family services. Future goals, achievable through My Child Matters grant, include improving inclusion and access by benefitting more than 500 children in the region, accompanying 1000 families and relatives, and educating more than 1500 healthcare professionals. We also seek to make the enlarged program sustainable. LIMITATIONS This study shows the implementation of a PPC program in a teaching, general hospital in Cali, Colombia. This is a descriptive study, and the data were retrospectively collected, which implies that selection and information bias could be introduced during its development. To mitigate this situation, our databases were crossed with different sources of institutional information to improve the quality of information. On the other hand, our institution is a specialized reference center for patients with highly complex diseases; therefore, the reported number of patients who benefit from the program is high when compared with other institutions. Additionally, the Colombian healthcare system is based on universal coverage provided by several insurance companies, and as such, patients are often transferred to other institutions due to individual insurance preferences or administrative limitations, making it hard to keep track of all PPC patients. Likewise, there was no guarantee that all the patients with cancer and life-threatening conditions received outpatient care and completed follow-up through the TCY program because patients often need difficult-to-obtain authorization from their health entity to receive specialized care, such as PPC. Despite these limitations, our implementation model could be an example to mitigate gaps in the PPC service for Latin America and the Caribbean, where availability and access to a PPC team are scarce. Conclusions The creation of a specialized PPC service increases patient referrals and favors a comprehensive approach to patients with life-threatening and limiting conditions in a general hospital. Institutional support, philanthropic support, awareness, and education are essential for the viability and impact of PPC programs. There are still many opportunities for improvement, such as the referral time and death of patients, the creation of a pediatric hospice, and improving the bereaved follow up, among others. The implementation of a PPC program in Colombia is a difficult but not impossible task to accomplish. With this paper, we hope that other PPC programs can be strengthened or new ones can be created in Latin America and the Caribbean. List Of Abbreviation “Taking Care of You” (TCY), Pediatric Palliative Care (PPC), Palliative Care (PC), American Academy of Pediatrics (AAP), The Institute of Medicine (IoM), International Meeting for Palliative Care in Children’s Trento (IMPaCCT), Children Cancer Care Units (CCCU) or Children Cancer Units (CCU), National Hospice and Palliative Care Organization ( NHPCO), pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), Asociacion de Cuidados Paliativos de Colombia (ASOCUPAC), The World Health Organization (WHO), Human immunodeficiency virus (HIV). Declarations Ethics approval and consent to participate This study is retrospective, no clinical chart review took place and does not contain any individual persons data, therefore no patient consent to participate was needed, and no administrative permissions were required to access raw data. Nonetheless the article was approved by the IRB and ethics committee, Comite de Etica en Investigacion Biomedica of Fundacion Valle del Lili protocol Number 1658 . Consent for publication Not applicable Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Completing interests The authors declared no potential conflicts of interest concerning the research, authorship and/or publication of this article Funding The program is funded in part by My Child Matters grant, given by Sanofi Espoir Foundation in 2019, to reduce health inequality for children with cancer in low and middle-income-countries, and includes support for PPC programs as an essential element of healthcare for children with oncological conditions, non the less the present paper received no funding from the grant. Authors´ contributions XGQ (PI) was the person that conceived and designed the program TCY in collaboration with MICS(Co-PI), who helped conceive the program and create the database. LGPL provided knowledge with his writing expertise and was the leader of the investigation group, he additionally helped through his biostatistics expertise. ACH provided the in-hospital setting research expertise, filled the database and contributed in the methodology and writing of the paper. WGG provided perspectives from PC settings in the Caribbean. FD provided expertise with disadvantaged populations, NAC provided broad expertise in palliative care. We certify that all individuals listed as authors of this manuscript, 1) have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) have been involved in drafting the manuscript or revising it critically for important intellectual content; 3) have given final approval of the version to be published, and 4) agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Acknowledgments The authors wish to thank all the children and the families that have been or are part of our program, you’ve made it a marvelous journey that inspires us to keep going. We also want to thank our adult and pediatric PC family: Dr. Arno Bromet, Dr. Carlos Chavarro, Dr. Elsa Tejada, Dr. Maria E. Giraldo, Dr. Oscar Cifuentes, Isabel C. Correa, Clara Reyes, Jennifer Tovar, Tatiana Pineda, Vilma K. Suarez, Alba L. 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Hubble RA, Ward-Smith P, Christenson K, Hutto CJ, Korphage RM, Hubble CL. Implementation of a palliative care team in a pediatric hospital. J Pediatr Health Care. 2009;23(2):126–31. Kiman R, Varela, Requena. Establishing a Pediatric Palliative care team in an Argentinian Hospital. Eur J Palliat Care. 2011 Jan 1;18:40–5. Lyons-Warren A. Update on Palliative Care for Pediatric Neurology. Am J Hosp Palliat Med. 2018 Jul 11;36:104990911878695. Lyons-Warren AM, Stowe RC, Emrick L, Jarrell JA. Early Identification of Pediatric Neurology Patients With Palliative Care Needs: A Pilot Study. Am J Hosp Palliat Med [Internet]. 2019 Apr 23;36(11):959–66. Available from: https://doi.org/10.1177/1049909119844519 Thrane SE, Maurer SH, Cohen SM, May C, Sereika SM. Pediatric Palliative Care: A Five-Year Retrospective Chart Review Study. J Palliat Med. 2017;20(10):1104–11. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care 4 th edition Publisher: National Coalition for Hospice and Palliative Care Clinical Practice Guidelines for Quality Palliative Care, 4 th edition [Internet]. 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018 [cited 2020 Mar 9]. 1–190 p. Available from: https://www.nationalcoalitionhpc.org/ncp Cuervo-Suarez MI, Claros-Hulbert A, Manzano-Nunez R, Muñoz M, García X. Pediatric Palliative Care During End of Life: A Privilege of a Few in a Tertiary Referral Hospital From Colombia. Am J Hosp Palliat Med. 2020; Villanueva G, Murphy MS, Vickers D, Harrop E, Dworzynski K. End of life care for infants, children and young people with life limiting conditions: summary of NICE guidance. BMJ. 2016 Dec;355:i6385. Widger K, Seow H, Rapoport A, Chalifoux M, Tanuseputro P. Children’s end-of-life health care use and cost. Pediatrics. 2017;139(4). Gao W, Verne J, Peacock J, Stiller C, Wells C, Greenough A, et al. Place of death in children and young people with cancer and implications for end of life care: A population-based study in England, 1993-2014. BMC Cancer [Internet]. 2016;16(1):1–15. Available from: http://dx.doi.org/10.1186/s12885-016-2695-1 Donovan LA, Wakefield CE, Russell V, Cohn RJ. Hospital-based bereavement services following the death of a child: a mixed study review. Palliat Med. 2015 Mar;29(3):193–210. Tables Table 1. Eight-step implementation strategy Strategies Objective Setting Deliverable Education Inform healthcare providers, families, health care professionals in order to raise awareness Hospitalization, emergency, PICU, NICU, CCU Educational discussion meetings, conferences for caregivers, patients, and families. Institutional Support To establish collaborative support between board directors/decision-makers and PPC program leader Board of directors Education committee Management committee Reports and meetings that showed the enhancement of humanized care, improvement in patient experience and healthcare personnel experience, health outcomes, and finally resource optimization. Academic Support To educate HCW in PPC and its impact in the healthcare services All HCW from hospitalization, PICU, NICU, CCU, BMTU Meetings Conferences Workshops Educational material Advocacy With Other Actors In The Health System To promote PPC with healthcare authorities, scientific societies, the academic community, and stakeholders health insurance, scientific associations, patient associations, national palliative care scientific associations, territorial health entities Boards Meetings Conferences, Diplomacy Capacity Building To train and educate the TCY program team in PPC Postgraduate education: -Universidad Internacional de La Rioja Continued education: -Harvard Medical School courses Master´s degree Palliative care education and practice course Multidisciplinary Team To organize a multidisciplinary team in PPC that guarantees a comprehensive and holistic approach for the patient and their family needs FVL Inclusion of different healthcare workers including a psychologist, social worker, nurse, and spiritual counselor Specialized Pediatric Team Leader To guarantee a comprehensive approach to the pediatric medical conditions in PC FVL, Pediatrician leader, Department of Palliative Care A physician with specific training in pediatrics and PPC Research To create an information system that characterizes the population and identifies clinical, economic, and social problems that may contribute to solving scientific gaps and support multilevel decision-making. FVL PPC research group Support of research assistant Bone Marrow Transplant Unit (BMTU), Healthcare Workers (HCW), Pediatric Palliative Care (PPC), Children Cancer Units (CCU), Pediatric Intensive Care Unit (PICU), Neonatal Intensive Care Unit (NICU), “Taking Care of You” (TCY), Fundacion Valle del Lili (FVL) Table 2. Effective Practice and Organisation of Care (EPOC) Taxonomy “Implementation Strategies” and “Financial Arrangements” Fitting the “Taking Care of You” (TCY) Program Strategy and Objectives Implementation Strategies Interventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals or the use of health services by healthcare recipients Category: Interventions targeted at healthcare workers Subcategory TCY strategy Strategy objective A. Communities of Practice Local advocacy to convene capacity building Train a specialized PPC team through graduate programs abroad B. Educational Materials Design and create written, and online evidence-based information material Supply healthcare professionals with key objective topics and information on PPC C. Educational Meetings Local, and national educational courses and workshops Create a successful method to favor mass training and raising awareness on PPC approach and principles for healthcare professionals D. Interprofessional Education Coach national multidisciplinary courses and participation in postgraduate university courses Increase national multidisciplinary knowledge on palliative philosophy E. Patient-Mediated Interventions Medical, psychological and social work evaluation of the patient and family to discuss as part of multidisciplinary medical board meetings Provide a psychosocial and medical perspective of the patient and family prior to multidisciplinary decision-making meetings Financial Arrangements Changes in how funds are collected, insurance schemes, how services are purchased, and the use of targeted financial incentives or disincentives Category: Collection of funds Subcategory TCY Strategy Strategy objective F. External Funding Apply for funding through a research grant Promote and sustain pediatric palliative care in a middle-income country Category: Insurance schemes Subcategory TCY strategy Strategy objective G. Community-Based Health Insurance Held Advocacy Reunions with health care providers locally Lower access barriers for patients and families of MIC Category: Mechanisms for the payment of health services Subcategory TCY strategy Strategy Objective H. Payment Methods for Health Workers Reunions with the board of directors and decision-makers emphasizing the added value of PPC, based on enhancing patient and family satisfaction, patient experience, health humanization, and resource optimization Obtain institutional support to consolidate the team and decrease the access barrier Delivery Arrangements Changes in how, when, and where healthcare is organized and delivered, and who delivers healthcare. Category: Where care is provided and changes to the healthcare environment Subcategory TCY strategy Strategy Objective I. Site of service delivery Promote patient attention in the outpatient scenario through medical order Since most of the patients are referred to the program from hospitalization, we make sure they can continue attention in the outpatient ward Category: Who provides care and how the healthcare workforce is managed Subcategory TCY strategy Strategy objective J. Role expansion or task shifting Coached local interdisciplinary team meetings, educational meetings among the general PC group. Guide the conformation of the Pediatric Palliative Care team Category: Coordination of care and management of care processes Subcategory TCY strategy Strategy objective K. Care pathways Held institutional multidisciplinary meetings with local health care providers Contextualize life-limiting-and-threatening disease L. Case management Participated in multidisciplinary board meetings with treating specialist and several homecare services Coordinate and guarantee an integrative followup to improve patients care M. Communication between providers Coached local interdisciplinary team meetings, support for clinical improvement plans of the team and regional educational meetings Facilitating and establishing communication and developing an improved dialogue. N. Continuity of care While in hospitalization we hold medical board meetings with interdisciplinary teams and promote continuity through outpatient setting followup Ensuring the responsibility of care and bereavement followup O. Disease management Coached educational team meetings, regional meetings with health care professionals and healthcare providers Promote adequate quality of life during the health-disease-attention process P. Patient-initiated appointment systems Providing phone advisory 24 hours 7 days a week Around-the-clock availability for care consultation to direction the family and bereavement care Q. Referral systems Coached educational sessions with the hospital's pediatric departments Educating about the importance of involving comprehensive care and patients with complex chronic diseases who are candidates for referral to the PPC team R. Shared decision-making Meetings and constant communication is held with TCYteam, treating specialist and the family Establish individualized management goals S. Teams Coached local interdisciplinary team meetings, support for clinical improvement plans, and regional educational meetings Establishing a multidisciplinary team that provides organizational status, coordinated care, and capability based on individualized relevance and effectivity T. Transition of Care Interdisciplinary meetings between treating specialist, our team and the family Provide objective information to the family when a patient's treatment changes from curative to palliative Pediatric Palliative Care (PPC), Middle Income Country (MIC), “Taking Care of You” (TCY), Middle-Income countries (MIC) Table 3. Pediatric Patient Referral by Departments Pediatric Patient Referral by Departments Department 2017 2018 2019 Total n % n % n % n % Hospitalization 4 40.0% 398 50.0% 634 52.5% 1036 52.7% Pediatric ICU - - 192 19.5% 266 14.6% 458 23% Pediatric Emergency room 5 50.0% 126 15.6% 150 12.7% 281 14.3% Neonatal ICU 1 10.0% 61 7.7% 87 7.5% 149 7.6% Bone Marrow Transplant - - 13 1.6% 28 2.4% 41 2.1% Total general 10 100% 790 100% 1165 100% 1965 100% ICU Intensive Care Unit Table 4. Place of death and bereavement workshop attendance comparison per year Place of death Total n=288 2017* n=57 2018** n=111 2019 n=120 Emergency 24 2 11 11 Hospitalization 215 39 83 93 Another health institution 14 3 1 10 Home 35 13 16 6 Attendance to bereavement workshop 79 6 12 61 *General PC program **Start of the PPC program Supplementary Files AdditionalFile1.docx Additional File 1: Title: Appendix 1. Colombian legal framework related to palliative care Description: Provide a summary of the Colombian laws and legislations that support Pediatric Palliative Care and promote quality of life for children with life-limiting and threatening diseases AdditionalFile2.docx Additional File 2: Title: Appendix 2. Program approach strategy Description: The team developed a question-based strategy to address institutional education and awareness in PPC AdditionalFile3.docx Additional File 3: Title: Appendix 3 Institutional Satisfaction Survey Description: Online institutional questionnaire applied to healthcare professionals through the pediatric departments, to quantify satisfaction and referral motives Cite Share Download PDF Status: Published Journal Publication published 06 Nov, 2020 Read the published version in BMC Palliative Care → Version 3 posted Submission checks completed at journal 18 Oct, 2020 Editorial decision: Accept 16 Oct, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-39336","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3611384,"identity":"924c0669-206b-407b-9c22-112835bbb70d","order_by":0,"name":"Ximena Garcia-Quintero","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYDACZiT2AYYKOQY+ErWcMWZgI81KxjYitBgc5058XFDDYNc/+/DDAz/nGSS2MTAf+/iFwU4OlxbJZt7NxjOOMSTPOJdmcLB3G0gLW/JsGYZkY1xa+Jl5t0nzsDEkM5zhYTjAu+2PMRsDjzGzBMOBxAYcWtiYebf/5vnHkCwP1HLw7xwDwlpAtjDztjHYGQC1HOZtMJADaWH8gEcLyC/SvH0SCYZn2AwOyxwDamFmS2ZmMMDtF4PzZzd+5vlmYy93hvnxxzc1Bjz87M2HGX9U4A4xKJBAcgYwcpl5DAhoAAJ7FB7jD8I6RsEoGAWjYOQAAGKmR5yLYvF/AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1416-544X","institution":"Fundacion Valle del Lili","correspondingAuthor":true,"prefix":"","firstName":"Ximena","middleName":"","lastName":"Garcia-Quintero","suffix":""},{"id":3611385,"identity":"0a1f3018-ce1b-434c-bc15-5ef9179a2139","order_by":1,"name":"Luis Gabriel Parra-Lara","email":"","orcid":"","institution":"Universidad Icesi","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Gabriel","lastName":"Parra-Lara","suffix":""},{"id":3611386,"identity":"66830679-1d07-43d3-a8fb-ee558979e8d3","order_by":2,"name":"Angelica Claros-Hulbert","email":"","orcid":"","institution":"Fundacion Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Angelica","middleName":"","lastName":"Claros-Hulbert","suffix":""},{"id":3611387,"identity":"1bac3944-74af-480d-a3f5-7beab92ccb98","order_by":3,"name":"Maria Isabel Cuervo-Suarez","email":"","orcid":"","institution":"Fundacion Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Isabel","lastName":"Cuervo-Suarez","suffix":""},{"id":3611388,"identity":"6f2abae7-15b7-4d6e-996b-1f94091b049b","order_by":4,"name":"Wendy Gomez-Garcia","email":"","orcid":"","institution":"Hospital Infantil Robert Reid Cabral","correspondingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Gomez-Garcia","suffix":""},{"id":3611389,"identity":"64a3ba05-8578-4509-95db-74b8c4989123","order_by":5,"name":"Francois Desbrandes","email":"","orcid":"","institution":"Fondation Sanofi Espoir","correspondingAuthor":false,"prefix":"","firstName":"Francois","middleName":"","lastName":"Desbrandes","suffix":""},{"id":3611390,"identity":"b3c07d20-651a-46a8-9469-1014e46ada1b","order_by":6,"name":"Natalia Arias-Casais","email":"","orcid":"","institution":"Universidad de Navarra","correspondingAuthor":false,"prefix":"","firstName":"Natalia","middleName":"","lastName":"Arias-Casais","suffix":""}],"badges":[],"createdAt":"2020-07-01 12:21:44","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-39336/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-39336/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-020-00674-2","type":"published","date":"2020-11-06T15:01:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3116483,"identity":"57d26993-1208-41ea-b3b5-501cc88137eb","added_by":"auto","created_at":"2020-10-21 20:10:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":245649,"visible":true,"origin":"","legend":"Comparison of the number of patients assessed by the PPC program in the outpatient setting between 2017-2019. \nPCC Pediatric Palliative Care\n","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/9ad282fe226a2b6c3345394d.png"},{"id":3116484,"identity":"e4323d7a-9ea8-400a-9a43-277a3fb7a69d","added_by":"auto","created_at":"2020-10-21 20:10:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43423,"visible":true,"origin":"","legend":"Comparison of the number of Inpatients referred to the program from 2017 - 2019. \nPPC Pediatric Palliative Care\n","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/69c520dbebc156679d775863.png"},{"id":3116487,"identity":"02e55b08-e54e-40a3-b5cc-dfe2cb3531b4","added_by":"auto","created_at":"2020-10-21 20:10:26","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":228925,"visible":true,"origin":"","legend":"Integration of the EPOC categories “Implementation Strategy”, “Financial Arrangements ”, “Delivery Arrangements” in the matrix of targeted “levels of organization” and “Domains of implementation” \nNote EPOC: Effective Practice and Organisation of Care\n","description":"","filename":"Fig3.JPG","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/60a8ca3596c70e337bbeed02.JPG"},{"id":13604525,"identity":"33ad09fd-2e53-42f7-b6c6-82d340021b45","added_by":"auto","created_at":"2021-09-17 06:00:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1270921,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/a9b12507-1ec1-4fd6-be7e-208ed4cc30d8.pdf"},{"id":3116482,"identity":"441dc9aa-c26d-43a8-b15d-92544080083e","added_by":"auto","created_at":"2020-10-21 20:10:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15757,"visible":true,"origin":"","legend":"Additional File 1: \nTitle: Appendix 1. Colombian legal framework related to palliative care\nDescription: Provide a summary of the Colombian laws and legislations that support Pediatric Palliative Care and promote quality of life for children with life-limiting and threatening diseases\n","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/36c72b2b25dd0487b3bee05f.docx"},{"id":3116485,"identity":"cf5208cb-459e-4597-8c80-1d8870597f37","added_by":"auto","created_at":"2020-10-21 20:10:25","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13518,"visible":true,"origin":"","legend":"Additional File 2: \nTitle: Appendix 2. Program approach strategy \nDescription: The team developed a question-based strategy to address institutional education and awareness in PPC\n","description":"","filename":"AdditionalFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/f4c97a7b09e171d20b49b1a7.docx"},{"id":3116486,"identity":"ec3982de-aae2-4bc1-9ef1-70050aceb61b","added_by":"auto","created_at":"2020-10-21 20:10:26","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18523,"visible":true,"origin":"","legend":"Additional File 3: \nTitle: Appendix 3 Institutional Satisfaction Survey\nDescription: Online institutional questionnaire applied to healthcare professionals through the pediatric departments, to quantify satisfaction and referral motives \n","description":"","filename":"AdditionalFile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-39336/v3/46b61b867a68a612dcf11764.docx"}],"financialInterests":"","formattedTitle":"Advancing Pediatric Palliative Care In a Low-Middle Income Country: An Implementation Study, A challenging but not impossible task","fulltext":[{"header":"Background","content":"\u003cp\u003eThe prevalence of complex life-threatening diseases in children has increased significantly worldwide(1,2). In the United Kingdom, the prevalence of limiting and life-threatening diseases increased from 12 per 10,000 population in 2003 to 16 per 10,000 by 2007(3,4). The prevalence of these diseases in Latin America is still to be determined since there is still a lack of information. The World Health Organization (WHO) stated that such conditions could benefit from the palliative care (PC) approach(5). In this light, the burden of these diseases and thus the need for PC becomes a growing necessity for healthcare systems worldwide and a moral imperative(6).\u003c/p\u003e\n\u003cp\u003eA recent regional study assessing the development of pediatric palliative care (PPC) in Europe estimated that approximately 150,000 children need PPC every year(7). The region offers a total of 680 services to address the need, of which 133 are hospices, 385 are home-care services and 162 are hospital services(7). The statistics about PC need are expected to be larger in Latin America due to the health inequalities that the region faces. The Lancet Commission on Palliative Care reported an unaddressed lack of access to PC and pain relief worldwide which mainly affects low- and middle-income countries (LMICs) where the provision for PPC and pain relief are estimated to be neglected(8). A systematic review reported that 66.7% of the countries in South America did not have any PPC activity until 2011, when the first integrated PPC service was documented(9). The field of PC has continued to develop and become an active area of research and advocacy. Even though a new definition of the concept is available, the generalized provision of healthcare in Latin America has focused on improving access to specialized adult services(10). This results in an untrained health workforce in the field of pediatrics and a lack of PPC services to address the current need(11).\u003c/p\u003e\n\u003cp\u003eThe 2012 Atlas of Palliative Care in Latin America reported Colombia as having four hospice-type residencies, only one second-level service, and 13 tertiary care units that serve both adults and children(12). There are still no available data regarding the national need for PC; however, according to the Childhood Cancer Outcomes Surveillance System (VIGICANCER),\u0026nbsp; the\u0026nbsp; incident rate of pediatric cancer from 1977 to 2011 is comparable with affluent countries.(13)\u003c/p\u003e\n\u003cp\u003eTo date, national PC services are estimated to have grown almost 500% in the past 5 years. However, developing PPC in Colombia requires overcoming even greater barriers than for adults, mainly due to the absence of PC academic training programs for pediatricians and the lack of related educational objectives for other healthcare professionals(9,14).\u003c/p\u003e\n\u003cp\u003eIn light of the pressing need to promote PPC in Latin America and considering the characteristics of PPC in Colombia based on the recommendations from the \u003cem\u003eAmerican Academy of Pediatrics\u003c/em\u003e (AAP), the \u003cem\u003eInstitute of Medicine\u003c/em\u003e (IoM), and the \u003cem\u003eInternational Meeting for Palliative Care in Children\u0026rsquo;s\u003c/em\u003e \u003cem\u003eTrento\u003c/em\u003e (IMPaCCT) for the introduction of PPC teams(12,15,16), the objective of this paper is to report the process of implementing the PPC program \u003cem\u003e\u0026ldquo;Taking Care \u003c/em\u003eof You\u0026rdquo; (\u003cem\u003eTCY\u003c/em\u003e) in the city of Cali in Colombia. As with other LMIC health inequalities and a lack of scientific literature on the subject, Cali represents a context where promoting PPC might seem to be an impossible task. This article reflects on the strategies attempted for developing a multidisciplinary program that could provide coordinated care and symptom management to children with life-threatening and limiting conditions, geared toward reducing suffering and improving patients and families\u0026rsquo; quality of life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONTEXTUAL FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeographic and demographic context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eColombia has a population of 48,258,494 inhabitants, 51.2% of the population is female, and 22.6% are between 0 and 14 years of age(17). Cali is a city with 2.5 million inhabitants(18). There is limited data available regarding the number of pediatric patients with a need for\u0026nbsp; PC or PPC services available in the country; however, the age-standardized annual incidence rate of childhood cancer in Cali from 1977 to 2011 was 141 cases per million. (13,19).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eColombian legal framework for PC regulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince 2014, the country has passed relevant measures related to PPC regulation. Important milestones include the regulation of services in the country, including those aimed at the pediatric population(20), guidelines for inclusive care in PC, differentiating attention for adults and children(21), specific standards for Children Cancer Care Units (CCCU) where PC and pain treatment must be guaranteed from the beginning of treatment(22), a cancer control plan with a mention of PC(23), and regulating the process of dignifying death for children and adolescents, allowing euthanasia(24). (Colombian regulatory framework is summarized in \u003cstrong\u003eAppendix 1\u003c/strong\u003e under supplementary data)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe program \u0026ldquo;Taking Care of You\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe program operates in the Fundaci\u0026oacute;n Valle del Lili, a nonprofit, teaching hospital that functions as a referral center for the southwestern region of Colombia. It has 177 pediatric beds and cares for approximately 50,000 children annually.\u003c/p\u003e\n\u003cp\u003eOur institution has a general PC program that has operated since 2007 and is led by family medicine physicians with a multidisciplinary team. The general PC program had served the entire population including children until late 2017, when the specialized PC program for pediatric patients called Taking Care of You (\u003cem\u003eTCY) \u003c/em\u003ewas launched.\u0026nbsp; TCY is led by a pediatrician with a team that includes a family medicine physician, a nurse, a social worker, and a psychologist.\u003c/p\u003e\n\u003cp\u003eThe main objective of the program is to provide coordinated, multidisciplinary and humanized care to promote quality of life for patients under the age of 18 with life-threatening and limiting conditions in any hospital care service [emergency room, hospital room, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and outpatient setting]. Patients are treated through an inter-consultation or first-time assessment by the multidisciplinary PPC team.\u003c/p\u003e\n\u003cp\u003eThis multidisciplinary team is designed to provide coordination\u0026nbsp; of care, support in clinical decision-making, facilitated communication, pain and other symptom management, advanced care planning, end of life care, and bereavement follow up(25), among others that will be described later.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProgram strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo fulfill the baseline program goals and objectives, an eight-step strategy was implemented. This included education and awareness in PPC (a question-based strategy, summarized in \u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003eppendix 2 \u003c/strong\u003eunder supplementary data), institutional support, the participation of the PPC team in academic and healthcare activities, advocacy with other actors in the healthcare system, capacity building in PPC, the formation of a multidisciplinary team led by a pediatrician with training in PPC, and research that is described in \u003cstrong\u003eTable 1.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTwo approaches were followed to describe the outcomes of the program. First, a categorization of the strategies was conducted to assist with its implementation, and second, descriptive statistics were used to describe the program\u0026rsquo;s outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMapping implementation strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA theory-based method was applied to describe the implementation process of our program. The approach was based on the Poot et al. article(26) where a matrix was retrospectively developed from descriptive frameworks. To analyze and display the strategies implemented, a matrix exercise was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrategies of the Program\u0026nbsp;\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eTCY\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;in the matrix:\u0026nbsp;\u003c/strong\u003eThe strategies were categorized retrospectively with the Cochrane Effective Practice and Organization of Care(EPOC)(27,28), Review Group Taxonomy 2015(28), and grouped into the categories and subcategories: Implementation Strategies, Financial arrangements and Delivery arrangements \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe matrix combines two frameworks: first, levels of organization influenced by the implementation(29), and second, the domains of implementation(30) to provide a comprehensive matrix where defined project activities can be positioned according to their intended target domain and level, facilitating a structured description of the project(26,29). The matrix displays the implementation strategies,\u0026nbsp; Financial arrangements, and delivery arrangements.\u0026nbsp; Different sources of information were cross-referenced in a database to improve the quality of the information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProgram outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA descriptive analysis of the variables was performed using the program\u0026acute;s administrative registry, no clinical chart review took place, nonetheless, this study was submitted to the Institutional Research Board (IRB) and Ethical Committee.\u0026nbsp; The results were reported using measures of central tendency and dispersion, according to data distribution. Categorical variables were summarized as percentages. The variables analyzed included a detailed analysis of the children served and the referral service, type of pathologies (i.e., oncologic vs nononcologic), and place of death per year. All analyses were performed using Microsoft Excel 2016\u003cstrong\u003e. \u003c/strong\u003eInformation from referral motive was gathered as part of an internal administrative process through an online survey (\u003cstrong\u003eAppendix 3\u003c/strong\u003e provided in supplementary data). No literature search took place, but it did undergo IRB and Ethical Committee review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were continuous educational activities in the pediatric units that emphasized on the importance and health benefits from the early referral of children with limiting and life-threatening conditions to PPC, advancing to the progressive growth of the program. Educational activities include PPC and pain management workshops, communication role play games, printed materials, PPC subjects in the grand rounds, clinical case discussions, among others.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eCoverage\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince the beginning of the program in 2017, a total of 1,965 children have been referred. In 2017, before the specific PPC program was created, 146 pediatric patients were assessed by the general PC team, whereas in 2019, one year after the start of the \u0026ldquo;Taking Care of You\u0026rdquo; program, 771 children were assessed in the pediatric inpatient services and 324 new patients were assessed in the outpatient setting of the hospital. This represents an 81% and 93% increase PPC demand in the inpatient and outpatient services, respectively (\u003cstrong\u003esee Figures 1 and 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eA relevant aspect in the program development was making a strategic alliance with the PICU and the pediatric oncology unit, which favored early integration of the PPC team in the unit\u0026rsquo;s activities and allowed support in decision-making to promote patient quality of life. This also allows continuity of care, interdisciplinary communication, and therapeutic adherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisease prevalence at the moment of referral to the program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients referred to the program were classified as oncological and non-oncological. We found a similar proportion in both categories, including inpatient and outpatient care. In our institution, the most frequent oncological clinical conditions were central nervous system tumors (53%) (mainly medulloblastoma and low- and high-grade gliomas), followed by bone tumors (26%) (Osteosarcoma and Ewing\u0026rsquo;s sarcoma). On the other hand, non-oncological conditions were mainly related to severe neurological compromise in 38% of the cases (including congenital malformations and chromosomal abnormalities, such as trisomy\u0026rsquo;s, microcephaly, cerebral palsy), followed by inherited muscle disorders and rare diseases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCause of referral\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main causes for referral in outpatient and inpatient setting was support during therapeutic withholding and withdrawal of a treatment that was already established (89%), followed by end-of-life care (86%), Communication support (70%), Pain and symptom control (69%), Psychosocial support (67%), Decision-making support (63%), and Health Care coordination (57%). The most frequent reasons for referral to the PPC program by departments are summarized in\u0026nbsp;\u003cstrong\u003eTable 3, the majority came from t\u003c/strong\u003ehe pediatric inpatient ward (52%) and the PICU(23%).\u0026nbsp; The median time from referral to death was 12 days, with an interquartile range of 2 to 61 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlace of death and bereavement follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe place of death of most of the patients was the hospital \u003cstrong\u003eTable 4\u003c/strong\u003e. Eleven percent of the relatives attended the bereavement workshops in the 2017-2018 time period and 25% in the 2018-2019 time period. \u0026nbsp;The \u003cem\u003eTCY\u003c/em\u003e program accompanied bereavement of parents and families through, follow-up calls, sending condolence letters, and bereavement support groups, with a symbolic butterfly release in addition to psychological interventions.\u003c/p\u003e\n\u003cp\u003eThe program has had around-the-clock availability, it received 81 phone calls in 2018 and 244 phone calls in 2019, related to symptom management (58%) and care coordination (42%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3\u003c/strong\u003e shows the integration of the EPOC categories on a single matrix displaying the categorization for the domains: implementation strategies, financial arrangements, and delivery arrangements. The program has focused on advancing in educational and professional interaction, through promoting communication between interdisciplinary teams. Second, it aimed on developing organizational change by task shifting, promoting incentives and resources and pursuing change in social, political and legal frameworks. The program has not stressed change at a policy level, though small changes have been reported at generating specific roles for the program, determining the site of services and providing disease management specifically from a PPC perspective.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe program has focused on an unaddressed gap, the provision of PPC for children in Cali. It has improved referral times, coordination of care, availability of compassionate/holistic care to children with limiting and life-threatening diseases, and end-of-life care. The implementation of this program has required the onset of specific strategies and arrangements to promote awareness and education, which has been a difficult task. With this implementation experience, we intend to contribute to the PC philosophy in pediatric patients\u0026rsquo; care and hope it serves as a model for other regions and countries.\u003c/p\u003e\n\u003cp\u003eEstablishing a PC team with skills, training, and exclusive activity assistance for the pediatric population was a crucial element to expand PPC demand for children with complex chronic diseases and to increase the program demand a three-fold compared with the previous year. As described in the Children\u0026rsquo;s Hospital of Eastern Ontario, Ottawa, a significant increase in patient referrals was associated with the inclusion of social work resources and experienced PC physicians(31). Additionally, Education was key for the progressive growth of the program(32) and could be a strategy to lower resistance from healthcare professionals, since this has been described to be a barrier(33).\u003c/p\u003e\n\u003cp\u003eWhen using the theory-based method description applied to our TCY program implementation, we recognized the program has focused on advancing individual professional and groups of professionals in their capacities and competencies and on generating organizational change to find a niche within the hospital without influencing policy. Small changes at the policy level can be accounted for by the definition of specific PPC roles and settings for patient care.\u003c/p\u003e\n\u003cp\u003eDisease prevalence at the moment of referral to the program displayed the most frequent diagnoses in oncological and non-oncological groups were neurological, similar to other implementation studies carried out worldwide(34). We corroborate that children with neurological conditions, even if not progressive, experience high distress due to symptom control difficulties(32,35), the high burden associated with care(36,37), and potential complications that could cause premature death(32,34)\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003epointing out the important role a PC team plays in the multidisciplinary management of these patients.\u003c/p\u003e\n\u003cp\u003eReferral causes regarding our PPC program were associated with supporting decisions around withholding or withdrawing treatment, and end-of-life care, especially in the NICU and the PICU\u0026nbsp; services, with an average time from referral until death of 12 days.\u0026nbsp; This underlines late integration of PPC in the wide and varied conditions susceptible to the service. In the largest retrospective medical record review for a PPC population in the US by Thrane et al., they evidenced that the time from referral to death was 4.4 months(38). Highlighting children are still not being referred to PC until mere days before death, not in line with recommendations from the WHO and other organizations(39) that recommend PPC to be provided after diagnosis of life-threatening diseases, which in turn could result in less aggressive care and better outcomes at the end-of-life(40).\u003c/p\u003e\n\u003cp\u003eThe global trend is to promote death at home with patient-family comfort and support measures(41); however, in pediatrics, multiple difficulties arise when trying to promote this measure, and the hospital scenario is the most frequent place of death(42). Our team recognized the same difficulty, and most of our patients (74%) died in the hospital. Some of the barriers identified in favoring end-of-life care at home were related to fear from parents or caregivers to face the death of their child alone, the high attention needs of a patient at the end-of-life, the lack of home care programs with PC training, and the absence of pediatric hospices in the country, similar to what is described in the literature(41\u0026ndash;43). However, some families were able to care for their children at home during their final days.\u003c/p\u003e\n\u003cp\u003eFinally, family support during bereavement is an essential biopsychosocial need for the family\u0026rsquo;s well-being after the loss of a child(44). Our program does follow-up to support parents in grief: however, bereavement workshop attendance has been low (25%). We consider it an important aspect to improve by increasing coverage and offering more family services. Future goals, achievable through My Child Matters grant, include improving inclusion and access by benefitting more than 500 children in the region, accompanying 1000 families and relatives, and educating more than 1500 healthcare professionals. We also seek to make the enlarged program sustainable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study shows the implementation of a PPC program in a teaching, general hospital in Cali, Colombia. This is a descriptive study, and the data were retrospectively collected, which implies that selection and information bias could be introduced during its development. To mitigate this situation, our databases were crossed with different sources of institutional information to improve the quality of information. On the other hand, our institution is a specialized reference center for patients with highly complex diseases; therefore, the reported number of patients who benefit from the program is high when compared with other institutions. Additionally, the Colombian healthcare system is based on universal coverage provided by several insurance companies, and as such, patients are often transferred to other institutions due to individual insurance preferences or administrative limitations, making it hard to keep track of all PPC patients. Likewise, there was no guarantee that all the patients with cancer and life-threatening conditions received outpatient care and completed follow-up through the \u003cem\u003eTCY\u003c/em\u003e program because patients often need difficult-to-obtain authorization from their health entity to receive specialized care, such as PPC.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, our implementation model could be an example to mitigate gaps in the PPC service for Latin America and the Caribbean, where availability and access to a PPC team are scarce.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe creation of a specialized PPC service increases patient referrals and favors a comprehensive approach to patients with life-threatening and limiting conditions in a general hospital. Institutional support, philanthropic support, awareness, and education are essential for the viability and impact of PPC programs. There are still many opportunities for improvement, such as the referral time and death of patients, the creation of a pediatric hospice, and improving the bereaved follow up, among others. The implementation of a PPC program in Colombia is a difficult but not impossible task to accomplish. With this paper, we hope that other PPC programs can be strengthened or new ones can be created in Latin America and the Caribbean.\u003c/p\u003e"},{"header":"List Of Abbreviation","content":"\u003cp\u003e\u003cem\u003e\u0026ldquo;Taking Care of You\u0026rdquo; \u003c/em\u003e(TCY), Pediatric Palliative Care (PPC), Palliative Care (PC), \u003cem\u003eAmerican Academy of Pediatrics\u003c/em\u003e (AAP), The \u003cem\u003eInstitute of Medicine\u003c/em\u003e (IoM),\u0026nbsp; \u003cem\u003eInternational Meeting for Palliative Care in Children\u0026rsquo;s\u003c/em\u003e \u003cem\u003eTrento \u003c/em\u003e(IMPaCCT), Children Cancer Care Units (CCCU) or Children Cancer Units (CCU), \u003cem\u003eNational Hospice and Palliative Care Organization\u003c/em\u003e (\u003cem\u003eNHPCO),\u003c/em\u003e pediatric intensive care unit (PICU), neonatal intensive care unit (NICU),\u003cem\u003e Asociacion de Cuidados Paliativos de Colombia \u003c/em\u003e(ASOCUPAC), The World Health Organization (WHO), Human immunodeficiency virus (HIV).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is retrospective, no clinical chart review took place and does not contain any individual persons data, therefore no patient consent to participate was needed, and no administrative permissions were required to access raw data. Nonetheless the article was approved by the IRB and ethics committee, \u003cem\u003eComite de Etica en Investigacion Biomedica \u003c/em\u003eof Fundacion Valle del Lili protocol Number 1658 .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp; \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompleting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest concerning the research, authorship and/or publication of this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe program is funded in part by My Child Matters grant, given by Sanofi Espoir Foundation in 2019, to reduce health inequality for children with cancer in low and middle-income-countries, and includes support for PPC programs as an essential element of healthcare for children with oncological conditions, non the less the present paper received no funding from the grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026acute; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXGQ (PI) was the person that conceived and designed the program \u003cem\u003eTCY\u003c/em\u003e in collaboration with MICS(Co-PI), who helped conceive the program and create the database. LGPL provided knowledge with his writing expertise and was the leader of the investigation group, he additionally helped through his biostatistics expertise. ACH provided the in-hospital setting research expertise, filled the database and contributed in the methodology and writing of the paper. WGG provided perspectives from PC settings in the Caribbean. FD provided expertise with disadvantaged populations, NAC provided broad expertise in palliative care. We certify that all individuals listed as authors of this manuscript, 1) have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) have been involved in drafting the manuscript or revising it critically for important intellectual content; 3) have given final approval of the version to be published, and 4) agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all the children and the families that have been or are part of our program, you\u0026rsquo;ve made it a marvelous journey that inspires us to keep going. We also want to thank our adult and pediatric PC family: Dr. Arno Bromet, Dr. Carlos Chavarro, Dr. Elsa Tejada, Dr. Maria E. Giraldo, Dr. Oscar Cifuentes, Isabel C. Correa, Clara Reyes, Jennifer Tovar, Tatiana Pineda, Vilma K. Suarez, Alba L. Vargas, and Dra. Ximena Condines. We also thank Andres Gempeler for his comments and Fundacion Valle Del Lili for their unconditional support. We are grateful to My Child Matters of Sanofi Espoir Foundation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBogetz JF, Ullrich CK, Berry JG. Pediatric hospital care for children with life-threatening illness and the role of palliative care. Vol. 61, Pediatric Clinics of North America. W.B. Saunders; 2014. p. 719\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eDowning J, Birtar D, Chambers L, Drake R, Gelb B, Kiman R. Children\u0026rsquo;s palliative care: A global concern. Int J Palliat Nurs. 2012;18(3):109\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eFraser LK, Miller M, Hain R, Norman P, Aldridge J, McKinney PA, et al. Rising national prevalence of life-limiting conditions in children in England. Pediatrics. 2012;129(4).\u003c/li\u003e\n\u003cli\u003eTogether for Short Lives. Making and impact: moments that count [Internet]. 2018-2019. [cited 2020 Apr 22]. Available from: https://www.togetherforshortlives.org.uk/about-us/making-an-impact/impact-reports/\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Integrating Palliative Care and Symptom Relief into Pediatrics: A WHO guide for health planners, implementers and managers,. Geneva: World Health Organization; 2018. 1\u0026ndash;87 p.\u003c/li\u003e\n\u003cli\u003eStevenson M, Achille M, Lugasi T. Pediatric palliative care in Canada and the United States: A qualitative metasummary of the needs of patients and families. J Palliat Med [Internet]. 2013 May 1 [cited 2020 Mar 9];16(5):566\u0026ndash;77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23556988\u003c/li\u003e\n\u003cli\u003eArias-Casais N, Garralda E, Rhee JY, Lima L de, Pons JJ, Clark D, et al. EAPC Atlas of Palliative Care in Europe 2019 [Internet]. 2019. 1\u0026ndash;197 p. Available from: https://dadun.unav.edu/handle/10171/56787%0Ahttp://dadun.unav.edu/handle/10171/56787\u003c/li\u003e\n\u003cli\u003eKnaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, et al. Alleviating the access abyss in palliative care and pain relief\u0026mdash;an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018;391(10128):1391\u0026ndash;454.\u003c/li\u003e\n\u003cli\u003eFlorez SP, Tovar MB, Leon MX, Villegas K, Villamizar D del P, Granados CE. Caracterizaci\u0026oacute;n del conocimiento en cuidado paliativo pedi\u0026aacute;trico y percepci\u0026oacute;n debarreras por parte de los pediatras y residentes de pediatr\u0026iacute;a. Med Paliativa. 2015;22(4):127\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eRadbruch L, Lima L De, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining Palliative Care \u0026ndash; a New Consensus-based Definition. J Pain Symptom Manage [Internet]. 2020; Available from: https://doi.org/10.1016/j.jpainsymman.2020.04.027\u003c/li\u003e\n\u003cli\u003eObservatorio Colombiano de Cuidados Paliativos, Universidad El Bosque. Anuario del Observatorio Colombiano De Cuidados Paliativos. 1st ed. Bogot\u0026aacute; D.C.: Editorial Universidad El Bosque; 2016. 1\u0026ndash;114 p.\u003c/li\u003e\n\u003cli\u003eFamilies I of M (US) C on P and E-LC for C and T, Field MJ, Behrman RE. Institute of Medicine (US) Committee on Palliative and End-of-Life Care for Children and Their Families. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families [Internet]. Field MJ, Behrman RE, editors. National Academies Press; 2003 [cited 2020 Mar 9]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25057608\u003c/li\u003e\n\u003cli\u003eBravo LE, Garc\u0026iacute;a LS, Collazos P, Aristizabal P, Ramirez O. Descriptive epidemiology of childhood cancer in Cali, Colombia 1977-2011. Colomb Med [Internet]. 2013 Sep 30 [cited 2020 Sep 10];44(3):155\u0026ndash;64. Available from: https://doi.org/10.1016/j.phoj.2019.01.001\u003c/li\u003e\n\u003cli\u003eOspina ML, Huertas JA, Monta\u0026ntilde;o JI, Rivillas JC. Observatorio Nacional de C\u0026aacute;ncer Colombia. Rev Fac Nac Salud P\u0026uacute;blica [Internet]. 2015 [cited 2019 Nov 25];33(2). Available from: http://dx.doi.org/10.17533/udea.rfnsp.v33n2a\u003c/li\u003e\n\u003cli\u003eNelson RM, Botkin JR, Kodish ED, Levetown M, Truman JT, Wilfond BS. Palliative care for children. Vol. 106, Pediatrics. American Academy of Pediatrics; 2000. p. 351\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eCraig F, Abu-Saad Huijer H, Benini F, Kuttner L, Wood C, Feraris PC, et al. IMPaCCT: Standards p\u0026auml;diatrischer Palliativversorgung in Europa. Der Schmerz [Internet]. 2008;22(4):401\u0026ndash;8. Available from: https://doi.org/10.1007/s00482-008-0690-4\u003c/li\u003e\n\u003cli\u003eCenso Nacional de Poblaci\u0026oacute;n y Vivienda 2018 [Internet]. [cited 2020 Mar 9]. Available from: https://www.dane.gov.co/index.php/estadisticas-por-tema/demografia-y-poblacion/censo-nacional-de-poblacion-y-vivenda-2018\u003c/li\u003e\n\u003cli\u003eDepartamento Administrativo Nacional de Estad\u0026iacute;stica. Proyecciones de poblaci\u0026oacute;n municipales por \u0026aacute;rea. Censo general 2005 [Internet]. 2005 [cited 2020 Mar 9]. Available from: https://www.dane.gov.co/index.php/estadisticas-por-tema/demografia-y-poblacion/censo-general-2005-1\u003c/li\u003e\n\u003cli\u003eRamirez O, Aristizabal P, Zaidi A, Gagnepain-Lacheteau A, Ribeiro RC, Bravo LE. Childhood cancer survival disparities in a universalized health system in Cali, Colombia. Pediatr Hematol Oncol J [Internet]. 2018 Dec [cited 2020 Sep 10];3(4):79\u0026ndash;87. Available from: https://doi.org/10.1016/j.phoj.2019.01.001\u003c/li\u003e\n\u003cli\u003eEl Congreso de Colombia. Ley No 1733 Consuelo Devis Saavedra [Internet]. Bogota D.C; 2014 [cited 2020 Feb 24]. Available from: http://wsp.presidencia.gov.co/Normativa/Leyes/Documents/LEY 1733 DEL 08 DE SEPTIEMBRE DE 2014.pdf\u003c/li\u003e\n\u003cli\u003eMinisterio de Salud y Protecci\u0026oacute;n Social. Ley 1733 (septiembre 8). Bogot\u0026aacute; D.C.: Ministerio de Salud y Protecci\u0026oacute;n Social; 2014. p. 1\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eMinisterio de Salud y Protecci\u0026oacute;n Social. Resoluci\u0026oacute;n 1477 (abril 22) [Internet]. Bogot\u0026aacute; D.C. 2016 [cited 2020 Mar 9]. p. 1\u0026ndash;30. Available from: https://www.minsalud.gov.co/Normatividad_Nuevo/Resoluci\u0026oacute;n 1477 de 2016.pdf\u003c/li\u003e\n\u003cli\u003eMinisterio de Salud y Protecci\u0026oacute;n Social, Instituto Nacional de Cancerolog\u0026iacute;a E.S.E. Plan Nacional para el control del c\u0026aacute;ncer en Colombia, 2012-2021. [Internet]. Bogot\u0026aacute; D.C. 2012 [cited 2020 Mar 9]. p. 1\u0026ndash;85. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/IA/INCA/plan-nacional-control-cancer-2012-2020.pdf\u003c/li\u003e\n\u003cli\u003eMinisterio de Salud y Protecci\u0026oacute;n Social. Resoluci\u0026oacute;n 825 (marzo 9) [Internet]. Bogot\u0026aacute; D.C. 2018 [cited 2020 Mar 9]. p. 1\u0026ndash;16. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/resolucion-825-de-2018.pdf\u003c/li\u003e\n\u003cli\u003eVerberne L, Kars M, Schepers S, Schouten-van Meeteren A, Grootenhuis M, Delden J. Barriers and facilitators to the implementation of a paediatric palliative care team. BMC Palliat Care. 2018 Dec 1;17.\u003c/li\u003e\n\u003cli\u003ePoot AJ, de Waard CS, Wind AW, Caljouw MAA, Gussekloo J. A structured process description of a pragmatic implementation project: Improving integrated care for older persons in residential care homes. Inq (United States). 2017;54.\u003c/li\u003e\n\u003cli\u003eProctor EK, Powell BJ, McMillen JC. Implementation strategies: Recommendations for specifying and reporting. Implement Sci. 2013;8(1):1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eArrangements D. EPOC Taxonomy \u0026ndash; topics list. 2015;1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eFlottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8(1).\u003c/li\u003e\n\u003cli\u003eShortell SM. Increasing value: A research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States. Med Care Res Rev. 2004;61(3 SUPPL.):12\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eVadeboncoeur CM, Splinter WM, Rattray M, Johnston DL, Coulombe L. A paediatric palliative care programme in development: Trends in referral and location of death. Arch Dis Child. 2010 Sep;95(9):686\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003evan Dyck PC, Kogan MD, McPherson MG, Weissman GR, Newacheck PW. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med. 2004 Sep;158(9):884\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eKeele L, Keenan HT, Sheetz J, Bratton SL. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHubble RA, Ward-Smith P, Christenson K, Hutto CJ, Korphage RM, Hubble CL. Implementation of a palliative care team in a pediatric hospital. J Pediatr Health Care. 2009;23(2):126\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eKiman R, Varela, Requena. Establishing a Pediatric Palliative care team in an Argentinian Hospital. Eur J Palliat Care. 2011 Jan 1;18:40\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eLyons-Warren A. Update on Palliative Care for Pediatric Neurology. Am J Hosp Palliat Med. 2018 Jul 11;36:104990911878695.\u003c/li\u003e\n\u003cli\u003eLyons-Warren AM, Stowe RC, Emrick L, Jarrell JA. Early Identification of Pediatric Neurology Patients With Palliative Care Needs: A Pilot Study. Am J Hosp Palliat Med [Internet]. 2019 Apr 23;36(11):959\u0026ndash;66. Available from: https://doi.org/10.1177/1049909119844519\u003c/li\u003e\n\u003cli\u003eThrane SE, Maurer SH, Cohen SM, May C, Sereika SM. Pediatric Palliative Care: A Five-Year Retrospective Chart Review Study. J Palliat Med. 2017;20(10):1104\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eNational Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care 4 th edition Publisher: National Coalition for Hospice and Palliative Care Clinical Practice Guidelines for Quality Palliative Care, 4 th edition [Internet]. 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018 [cited 2020 Mar 9]. 1\u0026ndash;190 p. Available from: https://www.nationalcoalitionhpc.org/ncp\u003c/li\u003e\n\u003cli\u003eCuervo-Suarez MI, Claros-Hulbert A, Manzano-Nunez R, Mu\u0026ntilde;oz M, Garc\u0026iacute;a X. Pediatric Palliative Care During End of Life: A Privilege of a Few in a Tertiary Referral Hospital From Colombia. Am J Hosp Palliat Med. 2020;\u003c/li\u003e\n\u003cli\u003eVillanueva G, Murphy MS, Vickers D, Harrop E, Dworzynski K. End of life care for infants, children and young people with life limiting conditions: summary of NICE guidance. BMJ. 2016 Dec;355:i6385.\u003c/li\u003e\n\u003cli\u003eWidger K, Seow H, Rapoport A, Chalifoux M, Tanuseputro P. Children\u0026rsquo;s end-of-life health care use and cost. Pediatrics. 2017;139(4).\u003c/li\u003e\n\u003cli\u003eGao W, Verne J, Peacock J, Stiller C, Wells C, Greenough A, et al. Place of death in children and young people with cancer and implications for end of life care: A population-based study in England, 1993-2014. BMC Cancer [Internet]. 2016;16(1):1\u0026ndash;15. Available from: http://dx.doi.org/10.1186/s12885-016-2695-1\u003c/li\u003e\n\u003cli\u003eDonovan LA, Wakefield CE, Russell V, Cohn RJ. Hospital-based bereavement services following the death of a child: a mixed study review. Palliat Med. 2015 Mar;29(3):193\u0026ndash;210.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Eight-step implementation strategy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse; border: none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eStrategies\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eObjective\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eSetting\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eDeliverable\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eEducation\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eInform healthcare providers, families, health care professionals in order to raise awareness\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eHospitalization, emergency, PICU, NICU, CCU\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eEducational discussion meetings,\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003econferences for caregivers, patients, and families.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eInstitutional Support\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo establish collaborative support between board directors/decision-makers and PPC program leader\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eBoard of directors\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eEducation committee\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eManagement committee\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eReports and meetings that showed the enhancement of humanized care, improvement in patient experience and healthcare personnel experience, health outcomes, and finally resource optimization.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eAcademic Support\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo educate HCW in PPC and its impact in the healthcare services\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eAll HCW from hospitalization, PICU, NICU, CCU, BMTU\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eMeetings\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eConferences\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eWorkshops\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eEducational material\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eAdvocacy With Other Actors In The Health System\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo promote PPC with healthcare authorities, scientific societies, the academic community, and stakeholders\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ehealth insurance, scientific associations, patient associations, national palliative care scientific associations, territorial health entities\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eBoards\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eMeetings\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eConferences,\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eDiplomacy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eCapacity Building\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo train and educate the TCY program team in PPC\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ePostgraduate education:\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e-Universidad Internacional de La Rioja\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eContinued education:\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e-Harvard Medical School courses\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eMaster\u0026acute;s degree\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ePalliative care education and practice course\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eMultidisciplinary Team\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo organize a multidisciplinary team in PPC that guarantees a comprehensive and holistic approach for the patient and their family needs\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eFVL\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eInclusion of different healthcare workers including a psychologist, social worker, nurse, and spiritual counselor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eSpecialized Pediatric Team Leader\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo guarantee a comprehensive approach to the pediatric medical conditions in PC\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eFVL, Pediatrician leader, Department of Palliative Care\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eA physician with specific training in pediatrics and PPC\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eResearch\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTo create an information system that characterizes the population and identifies clinical, economic, and social problems that may contribute to solving scientific gaps and support multilevel decision-making.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eFVL\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\"\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ePPC research group\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eSupport of research assistant\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin-bottom: 10.0pt; text-align: justify; line-height: 200%; background: white;\"\u003eBone Marrow Transplant Unit (BMTU), Healthcare Workers (HCW), Pediatric Palliative Care (PPC), Children Cancer Units (CCU), Pediatric Intensive Care Unit (PICU), Neonatal Intensive Care Unit (NICU), \u0026ldquo;Taking Care of You\u0026rdquo; (TCY), Fundacion Valle del Lili (FVL)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Effective Practice and Organisation of Care (EPOC) Taxonomy \u0026ldquo;Implementation Strategies\u0026rdquo; and \u0026ldquo;Financial Arrangements\u0026rdquo; Fitting the \u0026ldquo;Taking Care of You\u0026rdquo; (TCY) \u0026nbsp;Program Strategy and Objectives\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;\" width=\"105%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eImplementation Strategies\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eInterventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals or the use of health services by healthcare recipients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e Interventions targeted at healthcare workers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eTCY strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eStrategy objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eA.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eCommunities of Practice\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eLocal advocacy to convene capacity building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eTrain a specialized PPC team through graduate programs abroad\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eB.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eEducational Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eDesign and create written, and online evidence-based information material\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eSupply healthcare professionals with key objective topics and information on PPC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 67.9pt;\"\u003e\n \u003ctd style=\"width: 29.3%; padding: 0in 5.75pt 0in 5.75pt; height: 67.9pt;\" width=\"29%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eC.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eEducational Meetings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; padding: 0in 5.75pt 0in 5.75pt; height: 67.9pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eLocal, and national educational courses and workshops\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; padding: 0in 5.75pt 0in 5.75pt; height: 67.9pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCreate a successful method to favor mass training and raising awareness on PPC approach and principles for healthcare professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eD.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eInterprofessional Education\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoach national multidisciplinary courses and participation in \u0026nbsp;postgraduate university courses\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eIncrease national multidisciplinary knowledge on palliative philosophy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eE.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003ePatient-Mediated Interventions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eMedical, psychological and social work evaluation of the patient and family to discuss as part of multidisciplinary medical board meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eProvide a psychosocial and medical perspective of the patient and family prior to multidisciplinary decision-making meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eFinancial Arrangements\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eChanges in how funds are collected, insurance schemes, how services are purchased, and the use of targeted financial incentives or disincentives\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 18.1pt;\"\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 18.1pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e\u0026nbsp; Collection of \u0026nbsp;funds \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in 0in 0in -5.75pt;\"\u003e\u003cstrong\u003eTCY Strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Strategy objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eF.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eExternal Funding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eApply for funding through a research grant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003ePromote and sustain pediatric palliative care in a middle-income country\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 16.1pt;\"\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 16.1pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e Insurance schemes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003ctable style=\"border-collapse: collapse;\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 14.65pt;\"\u003e\n \u003ctd style=\"width: 134.7pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 14.65pt;\" width=\"180\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170.1pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 14.65pt;\" width=\"227\"\u003e\n \u003cp style=\"margin: 0in 0in 0in -5.75pt;\"\u003e\u003cstrong\u003eTCY strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163.0pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 14.65pt;\" width=\"217\"\u003e\n \u003cp style=\"margin: 0in 0in 0in -5.75pt;\"\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Strategy objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eG.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eCommunity-Based Health Insurance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eHeld Advocacy Reunions with health care providers locally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eLower access barriers for patients and families of MIC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e Mechanisms for the payment of health services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eTCY strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11pt;\"\u003eStrategy Objective\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.3%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"29%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eH.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003ePayment Methods for Health Workers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.48%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eReunions with the board of directors and decision-makers emphasizing the added value of PPC, based on enhancing patient and family satisfaction, patient experience, health humanization, and \u0026nbsp;resource optimization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.22%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"35%\"\u003e\n \u003cp style=\"margin: 0in 0in 0in 11.9pt;\"\u003eObtain institutional \u0026nbsp;support to consolidate the team and decrease the access barrier\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eDelivery Arrangements\u003c/strong\u003e\u003c/p\u003e\n \u003ctable style=\"border-collapse: collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 4.95pt;\"\u003e\n \u003ctd style=\"width: 441.9pt; padding: 0in 5.75pt 0in 5.75pt; height: 4.95pt;\" width=\"589\"\u003e\n \u003cp style=\"margin: 0in 0in 0in -5.4pt;\"\u003eChanges in how, when, and where healthcare is organized and delivered, and who delivers healthcare.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003ctable style=\"border-collapse: collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 5.5pt;\"\u003e\n \u003ctd style=\"width: 388.35pt; padding: 0in 5.75pt 0in 5.75pt; height: 5.5pt;\" width=\"518\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e Where care is provided and changes to the healthcare environment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eTCY strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11pt;\"\u003eStrategy Objective\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable style=\"border-collapse: collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 4.95pt;\"\u003e\n \u003ctd style=\"width: 151.8pt; padding: 0in 5.75pt 0in 5.75pt; height: 4.95pt;\" width=\"202\"\u003e\n \u003cp style=\"text-indent: -.5in; tab-stops: list 8.45pt; vertical-align: baseline; margin: 0in 0in 0in 29.7pt;\"\u003e\u003cstrong\u003eI.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eSite of service delivery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003ePromote patient attention in the outpatient scenario through medical order\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eSince most of the patients are referred to the program from hospitalization, we make sure they can continue attention in the outpatient ward\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e Who provides care and how the healthcare workforce is managed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eTCY strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eStrategy objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eJ.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eRole expansion or task shifting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoached local interdisciplinary\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eteam meetings, educational meetings among the general PC group.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eGuide the conformation of the Pediatric Palliative Care team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 100.0%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eCategory:\u003c/strong\u003e Coordination of care and management of care processes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eTCY strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003e\u003cstrong\u003eStrategy objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 50.45pt;\"\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; padding: 0in 5.75pt 0in 5.75pt; height: 50.45pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eK.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eCare pathways\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; padding: 0in 5.75pt 0in 5.75pt; height: 50.45pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eHeld institutional \u0026nbsp;multidisciplinary meetings with local health care providers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; padding: 0in 5.75pt 0in 5.75pt; height: 50.45pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eContextualize life-limiting-and-threatening disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eL.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eCase management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eParticipated in multidisciplinary board meetings with treating specialist and several homecare services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoordinate and guarantee an integrative followup to improve patients care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eM.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eCommunication between providers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoached local interdisciplinary\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eteam meetings, support for clinical improvement plans\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eof the team and regional\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eeducational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eFacilitating and establishing communication and developing an\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eimproved dialogue.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 71.55pt;\"\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt; height: 71.55pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eN.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eContinuity of care\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt; height: 71.55pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eWhile in hospitalization we hold medical board meetings with interdisciplinary teams and promote continuity through \u0026nbsp;outpatient setting followup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt; height: 71.55pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eEnsuring the responsibility of care and \u0026nbsp;bereavement followup\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eO.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eDisease management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoached educational team meetings, regional meetings with health care professionals and healthcare providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003ePromote adequate quality of life during the health-disease-attention process\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eP.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003ePatient-initiated appointment systems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eProviding phone advisory 24 hours 7 days a week \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eAround-the-clock availability for care consultation to direction the family \u0026nbsp;and bereavement care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 100.15pt;\"\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt; height: 100.15pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eQ.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eReferral systems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt; height: 100.15pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoached educational sessions with the hospital\u0026apos;s pediatric departments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt; height: 100.15pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eEducating about the importance of involving comprehensive care and patients with complex chronic diseases \u0026nbsp;who are candidates for referral to the PPC team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eR.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eShared decision-making\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eMeetings and constant communication is held with TCYteam, treating specialist and the family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eEstablish \u0026nbsp;individualized management goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 111.75pt;\"\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; padding: 0in 5.75pt 0in 5.75pt; height: 111.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eS.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eTeams\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; padding: 0in 5.75pt 0in 5.75pt; height: 111.75pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eCoached local interdisciplinary\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eteam meetings, support for\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eclinical improvement plans, and regional\u003c/p\u003e\n \u003cp style=\"margin: 0in;\"\u003eeducational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; padding: 0in 5.75pt 0in 5.75pt; height: 111.75pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eEstablishing a multidisciplinary team that provides organizational status, coordinated care, and capability based on individualized relevance and effectivity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 78.45pt;\"\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.54%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 78.45pt;\" width=\"31%\"\u003e\n \u003cp style=\"text-indent: -.25in; tab-stops: list .5in; vertical-align: baseline; margin: 0in 0in 0in .5in;\"\u003e\u003cstrong\u003eT.\u003cspan style=\"font: 7.0pt 'Times New Roman';\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eTransition of Care\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 37.02%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 78.45pt;\" width=\"37%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eInterdisciplinary meetings between treating specialist, our team and the family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.44%; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.75pt 0in 5.75pt; height: 78.45pt;\" width=\"31%\"\u003e\n \u003cp style=\"margin: 0in;\"\u003eProvide objective information to the family when a patient\u0026apos;s treatment changes from curative to palliative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border: none;\" width=\"219\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"border: none;\" width=\"17\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"border: none;\" width=\"249\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"border: none;\" width=\"28\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"border: none;\" width=\"235\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin: 0in;\"\u003ePediatric Palliative Care (PPC), Middle Income Country (MIC), \u0026ldquo;Taking Care of You\u0026rdquo; (TCY), Middle-Income countries (MIC)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTable 3. Pediatric Patient Referral by Departments\u003cspan style=\"color:black;background:white;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"width:544.65pt;margin-left:-50.3pt;border-collapse:collapse;border: none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width:544.65pt;border-top:solid black 1.0pt;border-left:none;border-bottom:solid black 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:33.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003ePediatric Patient Referral by Departments\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:88.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eDepartment\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:112.95pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e2017\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:113.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e2018\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:114.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e2019\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:114.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eTotal\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:55.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:88.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eHospitalization\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e40.0%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e398\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e50.0%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e634\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e52.5%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e1036\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e52.7%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:88.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003ePediatric ICU\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e192\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e19.5%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e266\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e14.6%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e458\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:28.85pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e23%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:88.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003ePediatric Emergency room\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e50.0%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e126\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e15.6%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e150\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e12.7%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e281\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:49.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e14.3%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:88.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eNeonatal ICU\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e10.0%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e61\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e7.7%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e87\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e7.5%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e149\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:20.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e7.6%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:88.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eBone Marrow Transplant\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e13\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e1.6%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e28\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e2.4%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height: 115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e41\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e2.1%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:88.85pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eTotal general\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.05pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e10\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e100%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:55.85pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e790\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e100%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e1165\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e100%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:56.65pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family: \"Times New Roman\",serif;color:black;background:white;'\u003e1965\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:57.9pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.05pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003e100%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:white;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;background:white;'\u003eICU Intensive Care Unit\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"line-height: 200%; border: none;\"\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Place of death and bereavement workshop attendance comparison per year\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse; border: none;\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103.5pt; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"138\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003ePlace of death\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78.45pt; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"105\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003eTotal\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003en=288\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003e2017*\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003en=57\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.95pt; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"124\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003e2018**\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003en=111\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border-top: solid black 1.0pt; border-left: none; border-bottom: solid black 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003e2019\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"background: white;\"\u003en=120\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103.5pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"138\"\u003e\n \u003cp style=\"line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003eEmergency\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"105\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e24\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.95pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"124\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103.5pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"138\"\u003e\n \u003cp style=\"line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003eHospitalization\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"105\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e215\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e39\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.95pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"124\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e83\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e93\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 44.95pt;\"\u003e\n \u003ctd style=\"width: 103.5pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 44.95pt;\" width=\"138\"\u003e\n \u003cp style=\"line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003eAnother health institution\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 44.95pt;\" width=\"105\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 44.95pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.95pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 44.95pt;\" width=\"124\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 44.95pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e10\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103.5pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"138\"\u003e\n \u003cp style=\"line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003eHome\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78.45pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"105\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e35\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e13\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.95pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"124\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e16\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 60.55pt;\"\u003e\n \u003ctd style=\"width: 103.5pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 60.55pt;\" width=\"138\"\u003e\n \u003cp style=\"margin-right: 7.65pt; line-height: 200%; border: none;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 200%; background: white;\"\u003eAttendance to bereavement workshop\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78.45pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 60.55pt;\" width=\"105\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e79\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 60.55pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.95pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 60.55pt;\" width=\"124\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88.9pt; border: none; border-bottom: solid black 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 60.55pt;\" width=\"119\"\u003e\n \u003cp style=\"text-align: center; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white;\"\u003e61\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white none repeat scroll 0% 0%;\"\u003e*General PC program\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; border: none;\"\u003e\u003cspan style=\"background: white none repeat scroll 0% 0%;\"\u003e**Start of the PPC program\u0026nbsp;\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pediatric, pediatric palliative care, program, palliative medicine, implementation, terminal care, Latin America","lastPublishedDoi":"10.21203/rs.3.rs-39336/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-39336/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The disparities in access to pediatric palliative care and pain management in Latin America remains an unaddressed global health issue. Efforts to improve the development of Palliative Care (PC) provision have traditionally targeted services for adults, leaving the pediatric population unaddressed. Examples of such services are scarce and should be portrayed in scientific literature to inform decision-makers and service providers on models of care available to tackle the burden of Pediatric Palliative Care (PPC) in Low-and middle-income countries (LMIC). The purpose of this study is to describe the implementation of a pediatric palliative care program, “Taking Care of You ” (TCY) , in a tertiary care, university hospital in Cali, Colombia. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A program’s database was built with children between 0 to 18 years old and their families, from year 2017 to 2019. Descriptive analysis was carried out to evaluate the impact of the program and service delivery. A theory-based method was directed to describe the PPC program, according to the implementation of self-designed taxonomy, mapping theoretical levels and domains. Clinical outcomes in patients were included in the analysis. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Since 2017 the program has provided PPC services to 1.965 children. Most of them had an oncologic diagnosis and were referred from hospitalization services (53%). The number of ambulatory patients increased by 80% every trimester between 2017-2018. A 50% increase was reported in hospitalization, emergency, and intensive care units during the same time period. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The program addressed a gap in the provision of PPC to children in Cali. It shows effective strategies used to implement a PPC program and how the referral times, coordination of care, communication with other hospital services were improved while providing compassionate/holistic care to children with life-limiting and threatening diseases and in end-of-life. The implementation of this program has required the onset of specific strategies and arrangements to promote awareness and education proving it a hard task, yet not impossible. \u003c/p\u003e","manuscriptTitle":"Advancing Pediatric Palliative Care In a Low-Middle Income Country: An Implementation Study, A challenging but not impossible task","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-10-21 20:10:23","doi":"10.21203/rs.3.rs-39336/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2020-10-18T12:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2020-10-16T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-10-13 16:35:41","doi":"10.21203/rs.3.rs-39336/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-10-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-29T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-28T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-23 13:39:34","doi":"10.21203/rs.3.rs-39336/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-08-25T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-20T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nComments after review of the article: PCAR-D-20-00208R1\n\n1) Type of study:\n\nGenerally we do not mention the type of study as 'Descriptive implementation study\". May be verified and modified.\n\n2) Incidence:\n\nIncidence is the number of new cases in a given period in a specified population. In the article, the duration is from 1986 to 2005 which is significantly long and is a period fifteen years back, and there is no information regarding the illness after that. Since the article is written in the year 2020, a more recent data is preferable.\n\n3) Methods:\n\nThe methodology is not clear and needs to be more descriptive and precise. They have written as \" Theory based method was applied. The approach is explained in detail elsewhere\" Methodology should be described in detail under the heading \"Methodology\".\n\n4) Program outcomes:\n\nAuthors have written as \"no administrative sanction was required to access the data\". They have not mentioned the reasons for not needing the sanction. All research studies need permission from the \"Institutional research Committee and the Institutional Ethical Committee\". Otherwise, specific reason should be given\n\n5) Online Questionnaire:\n\nIt is stated that \" information for referrals was gathered through an online institutional questionnaire applied to multidisciplinary pediatric departments\". How did they prepare the questionnaire ? Was it obtained from any literature search? If so, reference is to be given. If they prepared the questionnaire by themselves, was it validated. Did they get approval from the Institutional Research and Ethical Committee ?\n\nThe term' multidisciplinary pediatric department' should be described in detail as they themselves stated that such facilities are negligible in the region.\n\n6) Results:\n\nA more detailed analysis of the children referred is preferable. Number of children attended by the team as out-patient, in-patient, in intensive care and in newborn\n\nintensive care may be shown separately. The diagnosis of the child, their needs and the service provided may also be given.\n\na) Disease prevalence:\n\n\"Spino muscular atrophy\" is given as a neurodegenerative disease and \" immune deficiency and metabolic disorder\" as orphan disease. We group spino muscular atrophy as an inherited muscle disorder and not a neuro-degenerative disease. Generally we do not use the terminology 'orphan disease' nowadays. Hence may be modified.\n\nb) Cause of referral:\n\nThe most important cause of referral is noted as \" support during therapeutic effort limitation\". This point may be clarified further for better understanding. The same person may be referred for multiple reasons, which is not looked into. Hence the analysis is incomplete.\n\nc) Education:\n\nDetails of the methods of spreading the concept of palliative care is given here. However, such details should be ideally under the heading 'methodology' and only the results of such measures need to be given here.\n\n7) Discussion:\n\nRepetitions to be avoided and hence can be made short.\n\n8) Declarations:\n\nIt is stated that \"no administrative sanction was needed since it was a retrospective analysis and also, no need of consent for publication. Both points need retrospection.\n\n9) Tables:\n\nAll the tables especially \"table. No. 2 is significantly lengthy which may be edited.\n\nTable No.3 to be modified. Please refer \"cause of referral\".\n\n10) General comments:\n\na) Needs improvement of the language including correction of grammar and spell check.\n\nb) Word count also need to be done depending on the specifications of the journal.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **'I declare that I have no competing interests'.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **No**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-31T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThis is a well written and detailed article that describes the process of setting up a new Pediatric Palliative Care program.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2020-07-24T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-24T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-24T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-07-22T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-07-21T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-07-21T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9b331fe-f295-4c5b-a67d-20d84d39aa5f","owner":[],"postedDate":"October 21st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":769930,"name":"Anesthesiology \u0026 Pain Medicine"},{"id":769931,"name":"Pediatrics"}],"tags":[],"updatedAt":"2020-11-08T15:02:45+00:00","versionOfRecord":{"articleIdentity":"rs-39336","link":"https://doi.org/10.1186/s12904-020-00674-2","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2020-11-06 15:01:30","publishedOnDateReadable":"November 6th, 2020"},"versionCreatedAt":"2020-10-21 20:10:23","video":"","vorDoi":"10.1186/s12904-020-00674-2","vorDoiUrl":"https://doi.org/10.1186/s12904-020-00674-2","workflowStages":[]},"version":"v3","identity":"rs-39336","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-39336","identity":"rs-39336","version":["v3"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}