Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings

Abstract

IMPORTANCE Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. OBJECTIVE To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. DESIGN, SETTING, AND PARTICIPANTSIn this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR).Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. MAIN OUTCOMES AND MEASURES Thematic analysis was conducted based on CFIR domains(inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. RESULTSSeventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%).Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast-and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. CONCLUSIONS AND RELEVANCETo date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the (continued) Key Points Question What barriers and enablers to pediatric early warning systems (PEWS) implementation in resource-limited hospitals are reported by health care professionals? Findings In this qualitative study including 5 resource-limited pediatric oncology centers in 4 countries in Latin America, ma...

Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals

“…Implementation and improvement research is important in resource-limited settings where contextual and infrastructural challenges make implementing evidence-based practices more difficult ( 14 ). Correct use of any evidence-based practice is integral to assuring impact, and quality of use must be measured and iteratively improved over time.…”

“…This is a secondary analysis of a study designed to identify barriers and enablers to PEWS implementation, and study methods have been previously described in detail ( 14 ). The study was approved by the St. Jude institutional review board as a minimal risk and thereby exempt study.…”

“…An interview guide ( Supplemental Figure 1 ) was designed to identify barriers and enablers to PEWS implementation at participating centers ( 14 ). The guide was translated to Spanish, iteratively revised for relevance and clarity, pilot tested with three individuals from hospitals not participating in this study but demonstrative of the target population, and modified based on feedback.…”

Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America

“…To maintain effectiveness, fidelity with no changes is recommended to the validated components of the PEWS tool or how it is used in patient care 17 . Centers, however, are encouraged to adapt other elements of PEWS to their setting, including adjusting the wording of the PEWS tool to match local medical Spanish and the details of the PEWS algorithm to better fit with available resources and processes for care escalation in hospitalized children 34 . Centers are taught a standard strategy to train staff on PEWS use; however, they also adapt these core materials using education techniques, such as visual platforms (e.g., videos, documentaries) and hands‐on learning (e.g., interactive digital games, patient simulations) based on local needs.…”

Paediatric early warning systems in low‐income settings—Putting the pieces together

“…However, a multitude of simultaneous interventions need to be implemented if outcomes are to improve. In addition to much needed financial resources, several factors are required to improve the quality of care of sick children, including improved management routines, empowering of nurses, local governance and advocacy, better staff communication and team training and, not least, an overall belief that the work is adding value 10 . Although developing a risk score to identify those at risk is only part of the puzzle, it is a welcome contribution to increasing the efforts to improve the management of children at risk.…”