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Aim: Implementation of healthcare interventions in resource-limited settings remains challenging. This exploratory qualitative study describes social and institutional factors to consider prior to nasal high flow deployment in a middle-income country.Methods: Researchers conducted eight nursing focus groups and four semi-structured physician interviews at Instituto Nacional de Salud del Niño in Lima, Peru. Participants were identified via purposive sampling. Data were transcribed, translated and coded using a rigorous and iterative process. Pertinent themes were identified using thematic analysis with Dedoose software.Results: Thirty-nine nurses and four physicians participated in focus groups and interviews, respectively. Participants identified five major factors: (i) Adequate training, (ii) Clinician buy-in, (iii) Resource-limited setting, (iv) Local social context and (v) Organizational change management. To create buy-in, physicians and nurses emphasised the need to recognise benefit of the intervention and agree with clinical practice standardization. Physicians and nurses described barriers specific to resource-limited settings, including unreliable supply chain, whereas nurses shared concerns about increasing workload and physician-nurse social hierarchy. Participants recognised the importance of team commitment and ongoing interdisciplinary communication for sustainability.Conclusion: While some factors to consider prior to deployment of healthcare technology are universal, resource-limited settings have unique implementation barriers.

Acute lower respiratory infections are the leading cause of death outside the neonatal period for children less than 5 years of age. Widespread availability of invasive and non-invasive mechanical ventilation in resource-rich settings has reduced mortality rates; however, these technologies are not always available in many low- and middle-income countries due to the high cost and trained personnel required to implement and sustain their use. High flow nasal cannula (HFNC) is a form of non-invasive respiratory support with growing evidence for use in pediatric respiratory failure. Its simple interface makes utilization in resource-limited settings appealing, although widespread implementation in these settings lags behind resource-rich settings. Implementation science is an emerging field dedicated to closing the know-do gap by incorporating evidence-based interventions into routine care, and its principles have guided the scaling up of many global health interventions. In 2016, we introduced HFNC use for respiratory failure in a pediatric intensive care unit in Lima, Peru using implementation science methodology. Here, we review our experience in the context of the principles of implementation science to serve as a guide for others considering HFNC implementation in resource-limited settings.

ObjectiveRespiratory infections remain the leading infectious cause of death in children under 5 and disproportionately affect children in resource-limited settings. Implementing non-invasive respiratory support can reduce respiratory-related mortality. However, maintaining competency after deployment can be difficult. Our objective was to evaluate the effectiveness of a comprehensive multidisciplinary high-flow training programme in a Peruvian paediatric intensive care unit (PICU).DesignQuasi-experimental single group pre–post intervention study design.SettingQuaternary care PICU in a resource-constrained setting in Lima, Peru.ParticipantsAttending physicians, fellows, paediatric residents, registered nurses, respiratory therapists and medical technicians working in the PICU were invited to participate.InterventionsConcurrent with initial high-flow deployment, we implemented a training programme consisting of lectures, case-based discussion and demonstrations with baseline, 3-month and 12-month training sessions. Pre-training and post-training assessment surveys were distributed surrounding all training sessions.Primary and secondary outcome measuresThe primary outcome was achieving minimum competency (median score of 80%) on the high flow training assessment tool. Secondary outcomes included knowledge acquisition (differences in pre-baseline and post-baseline training assessments), short-term retention (differences in post-baseline and pre-3-month refresher training assessments) and long-term retention (differences in post-3-month refresher and pre-12-month refresher training assessments).ResultsEighty participants (50% nurses, 15% ICU physicians and 34% other providers) completed the baseline assessment. Participants showed improvement in overall score and all subtopics except the clinical application of knowledge after baseline training (p<0.001). Participants failed to retain minimum competency at 3-month and 12-month follow-up assessments (70% (IQR: 57–74) and 70% (IQR: 65–74), respectively). After repeat training sessions, overall knowledge continued to improve, exceeding baseline performance (78% (IQR: 70–87), 83% (IQR: 74–87) and 87% (IQR: 83–91) at baseline, 3 and 12 months, respectively).ConclusionThis study suggests the need for repeat training sessions to achieve and maintain competency after the implementation of new technology.

Despite improvements in global child mortality, more than 650 000 children under five die of lower respiratory infections every year. 1 The vast majority of these deaths occur in low-and middle-income countries, due to more restricted access to basic interventions like immunisations, antibiotics and supplemental oxygen. 2-4 Middle-income countries have a high burden of paediatric respiratory disease. They are also in a unique position to reduce respiratory-related mortality, by improving access to advanced respiratory support, such as mechanical ventilation and non-invasive respiratory support. Using mechanical ventilation leads to complications like ventilator-associated pneumonia, ventilator-induced lung injuries, laryngeal trauma and the prolonged use of sedative medications. Given these complications, many