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

Mirochnick, Emily; Graetz, Dylan E.; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R.; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz-Coronado, Rosdali; Hernandez, Cinthia; Juarez, Susana; Loeza, José de Jesús; Mendez, A Ruiz; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Agulnik, Asya

doi:10.3389/fonc.2022.1018224

Cited by 9 publications

(8 citation statements)

References 21 publications

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“…Proyecto EVAT is a quality improvement collaborative of pediatric oncology centers in Latin America which has supported PEWS implementation in over 40 low-resource hospitals (41), with preliminary results showing improvements in patient outcomes (42)(43)(44)(45)(46)(47). Recent work by our team identified multiple barriers to PEWS implementation among centers participating in Proyecto EVAT, with many of these barriers converted to enablers by local implementation teams during the implementation process (48).…”

Section: Pediatric Early Warning Systems Improve Childhood Cancer Out...mentioning

confidence: 99%

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

et al. 2022

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BackgroundSustainability, 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).MethodsWe 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.ResultsWe 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.ConclusionThis 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.

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Section: Pediatric Early Warning Systems Improve Childhood Cancer Out...mentioning

confidence: 99%

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

et al. 2022

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“…Stakeholder stage of change, influencing the decision to adopt and continue using a new behavior, is important for successful implementation of any evidence‐based practice 13 . In previous work, an important determinant of sustainability and ongoing use of PEWS was hospital staff's perceptions of PEWS' relative importance and impact in patient care 10,19,20 . By using a stages of change framework to understand how stakeholders' perceptions towards PEWS change, this analysis provides further insight into how stakeholders choose to adopt new clinical practices, and how adoption can be promoted through targeted strategies.…”

Section: Discussionmentioning

confidence: 99%

“…This score is associated with an action algorithm that guides the clinical team's response 4 . PEWS have been shown to reduce clinical deterioration events and PICU utilization, improve interdisciplinary and provider‐family communication, enhance perceptions of healthcare quality, support clinician emotions, and result in cost‐savings 4–10 . However, PEWS are rarely used in resources‐limited hospitals, in part due to challenges during implementation 3 …”

Section: Introductionmentioning

confidence: 99%

Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource‐limited pediatric oncology centers

et al. 2023

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BackgroundPediatric Early Warning Systems (PEWS) assist early detection of clinical deterioration in hospitalized children with cancer. Relevant to successful PEWS implementation, the “stages of change” model characterizes stakeholder support for PEWS based on willingness and effort to adopt the new practice.MethodsAt five resource‐limited pediatric oncology centers in Latin America, semi‐structured interviews were conducted with 71 hospital staff involved in PEWS implementation. Purposive sampling was used to select centers requiring variable time to complete PEWS implementation, with low‐barrier centers (3–4 months) and high‐barrier centers (10–11 months). Interviews were conducted in Spanish, professionally transcribed, and translated into English. Thematic content analysis explored “stage of change” with constant comparative analysis across stakeholder types and study sites.ResultsParticipants identified six interventions (training, incentives, participation, evidence, persuasion, and modeling) and two policies (environmental planning and mandates) as effective strategies used by implementation leaders to promote stakeholder progression through stages of change. Key approaches involved presentation of evidence demonstrating PEWS effectiveness, persuasion and incentives addressing specific stakeholder interests, enthusiastic individuals serving as models for others, and policies enforced by hospital directors facilitating habitual PEWS use. Effective engagement targeted hospital directors during early implementation phases to provide programmatic legitimacy for clinical staff.ConclusionThis study identifies strategies to promote adoption and maintained use of PEWS, highlighting the importance of tailoring implementation strategies to the motivations of each stakeholder type. These findings can guide efforts to implement PEWS and other evidence‐based practices that improve childhood cancer outcomes in resource‐limited hospitals.

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“… 12 Multiple studies have noted the effectiveness of quality improvement initiatives to promote proactive identification and management of critical illness, such as Pediatric Early Warning Systems (PEWS), to improve hospital outcomes in children with cancer. 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 Hospital and provider experience managing children with cancer are also important, with high-volume centers typically having lower PICU mortality for these patients. 18 , 29 Finally, strong interdisciplinary (oncology, intensive care, etc.)…”

mentioning

confidence: 99%

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

Cited by 9 publications

References 21 publications

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

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

Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource‐limited pediatric oncology centers

Management of septic shock in children with cancer—Common challenges and research priorities

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