Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America

• Type of Material: Article
• Authors: Asya Agulnik, St. Jude Children's Research Hospital; Gabriella Schmidt-Grimminger, Washington University; Gia Ferrara, St. Jude Children's Research Hospital; Maria Puerto-Torres, St. Jude Children's Research Hospital; Srinithya R Gillipelli, Baylor College of Medicine, Houston; Paul Elish, Emory University; Hilmarie Muniz-Talavera, St. Jude Children's Research Hospital; Alejandra Gonzalez-Ruiz, St. Jude Children's Research Hospital; Miriam Armenta, Hospital General de Tijuana; Camila Barra, Hospital Dr. Luis Calvo Mackenna; Rosdali Diaz-Coronado, Instituto Nacional de Enfermedades Neoplásicas; Cinthia Hernandez, Hospital Infantil Teletón de Oncología; Susana Juarez, Hospital Central Dr. Ignacio Morones Prieto; Jose De Jesus Loeza, Centro Estatal de Cancerología; Alejandra Mendez, Unidad Nacional de Oncología Pediátrica; Erika Montalvo, Hospital Oncológico Solca Núcleo de Quito; Eulalia Penafiel, Instituto del Cáncer SOLCA Cuenca; Estuardo Pineda, Hospital Nacional de Niños Benjamín Bloom; Dylan E Graetz, St. Jude Children's Research Hospital, Memphis; Virginia McKay, Washington University
• Language: English
• Date: 2022-10-31
• Publisher: Lippincott, Williams & Wilkins
• Publication Version: Final Published Version
• Copyright Statement: © 2022 Agulnik, Schmidt-Grimminger, Ferrara, Puerto-Torres, Gillipelli, Elish, Muniz-Talavera, Gonzalez-Ruiz, Armenta, Barra, Diaz-Coronado, Hernandez, Juarez, Loeza, Mendez, Montalvo, Penafiel, Pineda, Graetz and McKay.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.3389/frhs.2022.1004805
• Title of Journal or Parent Work: Frontiers of Health Services Management
• Volume: 2
• Grant/Funding Information: The current work was supported by a pilot award provided by the St. Jude Children's Research Hospital and the American Lebanese Syrian Associated Charities (ALSAC), as well as a pilot award provided by the National Cancer Institute grant number P50CA244431 awarded to Colditz and Brownson. Agulnik was funded by the Conquer Cancer Foundation Global Oncology Young Investigator Award for this work. These funders were not involved in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication
• Keywords: pediatric early warning systems (PEWS); global health; resource-limited settings (RLS); pediatric oncology; implementation science (MeSH); sustainability
• Research Categories: Health Sciences, Oncology

Abstract

Background Sustainability, or continued use of evidence-based interventions for long-term patient benefit, is the least studied aspect of implementation science. In this study, we evaluate sustainability of a Pediatric Early Warning System (PEWS), an evidence-based intervention to improve early identification of clinical deterioration in hospitalized children, in low-resource settings using the Clinical Capacity for Sustainability Framework (CCS). Methods We conducted a secondary analysis of a qualitative study to identify barriers and enablers to PEWS implementation. Semi-structured interviews with PEWS implementation leaders and hospital directors at 5 Latin American pediatric oncology centers sustaining PEWS were conducted virtually in Spanish from June to August 2020. Interviews were recorded, professionally transcribed, and translated into English. Exploratory thematic content analysis yielded staff perceptions on PEWS sustainability. Coded segments were analyzed to identify participant perception about the current state and importance of sustaining PEWS, as well as sustainability successes and challenges. Identified sustainability determinants were mapped to the CCS to evaluate its applicability. Results We interviewed 71 staff including physicians (45%), nurses (45%), and administrators (10%). Participants emphasized the importance of sustaining PEWS for continued patient benefits. Identified sustainability determinants included supportive leadership encouraging ongoing interest in PEWS, beneficial patient outcomes enhancing perceived value of PEWS, integrating PEWS into the routine of patient care, ongoing staff turnover creating training challenges, adequate material resources to promote PEWS use, and the COVID-19 pandemic. While most identified factors mapped to the CCS, COVID-19 emerged as an additional external sustainability challenge. Together, these challenges resulted in multiple impacts on PEWS sustainment, ranging from a small reduction in PEWS quality to complete disruption of PEWS use and subsequent loss of benefits to patients. Participants described several innovative strategies to address identified challenges and promote PEWS sustainability. Conclusion This study describes clinician perspectives on sustainable implementation of evidence-based interventions in low-resource settings, including sustainability determinants and potential sustainability strategies. Identified factors mapped well to the CCS, however, external factors, such as the COVID pandemic, may additionally impact sustainability. This work highlights an urgent need for theoretically-driven, empirically-informed strategies to support sustainable implementation of evidence-based interventions in settings of all resource-levels.