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

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.

Keywords: global health; implementation science (MeSH); pediatric early warning systems (PEWS); pediatric oncology; resource-limited settings (RLS); sustainability.

Figure 1

Modified clinical capacity sustainability framework (CCS) describing identified themes. The seven domains of clinical capacity for sustainability are represented in dark purple. Our conceptual model posits that clinical capacity for sustainability is initially developed during the implementation process to better support use of the evidence-based intervention, a Pediatric Early Warning System (PEWS). During this time, PEWS may also be adapted to fit existing capacity. Following implementation, clinical capacity for sustainability impacts ongoing use of PEWS (sustainment), ultimately determining the long-term impact on patient outcomes. The blue boxes represent identified sustainability determinant themes as they map to the domains of the CCS. The COVID-19 pandemic was also identified as an external factor that disrupted clinical capacity, ultimately impacting PEWS sustainability at some centers.