Project Summary Background and Goal: Nearly 90% children with cancer live in low- and middle-income countries, where survival is as low as 20%. Children undergoing cancer treatment frequently develop critical illness, however, low-resource hospitals face multiple challenges delivering high-quality pediatric onco-critical care (POCC), including limited material and human resources. Additionally, hospitals in these settings face challenges implementing and sustaining evidence-based interventions that improve outcomes for children undergoing cancer treatment. Pediatric Early Warning Systems (PEWS) are evidence-based interventions that aid in early identification of critical illness in children with cancer, resulting in improved survival. Although sustaining interventions like PEWS is essential for ongoing impact on childhood cancer outcomes, little is known about how resource limitations impact their ongoing use and sustainability. The goal of the proposed diversity supplement is to investigate how POCC resources impact PEWS sustainability in resource-limited hospitals. Aims and Methods: We will conduct an observational cross-sectional study of 36 resource-limited centers participating in Proyecto EVAT, a collaborative of hospitals in Latin America implementing and sustaining PEWS, and evaluate how POCC resources affect PEWS sustainability. We will measure POCC resources through PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe care), a consensus derived tool to assess the quality and capacity for POCC in resource-limited hospitals. During Aim 1: We will identify common gaps in POCC resources among Proyecto EVAT centers and their perceived impact on PEWS sustainability. During Aim 2: We will evaluate the relationship between POCC resources, clinical capacity for sustainability, ongoing PEWS use, and patient outcomes. Innovation and Impact: Determinants of sustainability for evidence-based interventions, including the role of resources, are poorly understood. This study will advance the field of implementation science by enhancing our understanding of how resources promote ongoing use of intervention like PEWS in low-resource settings by leveraging a new measure (PROACTIVE). This work will contribute to the overall aim of the parent award (R37CA276215-01, MPIs: Agulnik/McKay) to identify determinants of PEWS sustainability in these low-resource hospitals and inform development of sustainability strategies suitable to a hospital’s resources. Findings from this study will also assist hospitals to advocate for resources that promote sustainability of interventions that outcomes for children with cancer in low-resource settings.