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

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, many barriers to PEWS implementation were identified, including inadequate resources and staff resistance to change. Most barriers were successfully converted to enablers during implementation through strategies such as early stakeholder engagement, adapting PEWS to the local context, and changing the hospital setting to support use of PEWS. Meaning The findings of this study suggest that barriers to implementation of evidence-based interventions in resource-limited settings are not immutable and can be converted to enablers through targeted implementation strategies.


eFigure: Interview Guide (Back-translated to English)
We are conducting a qualitative research study to evaluate the barriers and facilitators in the implementation of the Early Warning Assessment Scale. This study will allow for evaluating the factors that contribute to the successful implementation of PEWS in the centers that participate in the multicenter PEWS project, with the goal of identifying strategies to improve the implementation process in new centers. We are interviewing leaders of PEWS and directors of the hospital.
You are cordially invited to voluntarily participate in this study. Your participation will help us identify ways to improve the implementation of quality improvement programs at a global level. The study consists of conducting individual interviews that will take approximately 30-45 minutes to complete. The interviews are completely confidential, will be recorded as part of the study, and will be transcribed anonymously and deidentified. The purpose of participating in this interview is to improve our understanding of the process of implementation of PEWS and nothing that you say will be associated with your name and it won't affect your employment. Your work relationship with any member of the study team or with St. Jude Children's Research Hospital will not be affected by participating in this study. Although participation in this study is of great help, you have the option to not participate or to stop the interview at any moment. In completing this interview, you agree to participate in this research study.
If you have any questions with respect to this study, please contact the principal investigator, Dr. Asya Agulnik.
To start off, we'd like to know a little more about you with demographic information: • What's your profession?
• How many years have you been working in this center/hospital/institution?
• What role do you currently have in the center/hospital/institution?
• What is your role in Project PEWS? (during PEWS's implementation in your center) Thanks, now we'd like to start with the interview questions; we're going to talk about quality improvement in your center and questions related to the implementation of PEWS: 1. In general, how would you describe the culture of the personnel in your hospital with regard to patient safety? (how does your institution address patient safety) a. To what extent are new ideas adopted or used to bring about improvements in your hospital? b. How do you believe that stakeholders, meaning the authorities and influential leaders, respond to initiatives proposed for quality improvement in your hospital? c. Before PEWS, did other quality improvement projects exist in your hospital?
i. Have you ever participated in a quality improvement project before PEWS? d. Before PEWS, had your hospital participated in collaborative projects with other centers? i. Have you participated in collaborative projects with other centers before PEWS?
2. We're going to talk about the implementation of PEWS in your center. Don't worry if you can't answer some questions. Why did your hospital decide to implement PEWS? Any description of the hospital including organization, type of funding, size, age, etc. Includes description of the pediatric hematology-oncology unit vs other units, general mentions of staffing and workload (if not related to PEWS). Does not include mention of organizations culture (code as "Culture").

Available Material Resources
The level of resources dedicated to implementation and ongoing use of PEWS, including money, physical space, and materials. This includes monitors and other vital sign equipment as well as PEWS guides or tools, patient boards. Includes mention of how resources were obtained, if mentioning specific resources delegated for this. If the reference is unclear for material vs human resources, code both.

Available Human Resources
The level of human resources dedicated to implementation and ongoing use of PEWS, including personnel and time, or having enough time dedicated for PEWS training (including providing paid time to attend trainings). If the reference is unclear for material vs human resources, code both.

Staff Turnover
Any mention of staff turnover, including ration nurses, residents, fellows, physicians, or entry of new staff to the unit. Also includes turn-over of leadership in the hospital. Includes mentions of lack of turnover (staff permanence). If mention of training new staff, double code with "PEWS Training".

Why PEWS
Why the hospital decided to implement PEWS, including the reason behind the perceived need for this intervention at the center, or how the current situation is intolerable. Frequently involves statements such as "before PEWS (something bad happened to patients)" or "we needed PEWS to improve... in our hospital". Do not double code with "Goals".

Culture
The approach (norms, values, and basic assumptions) of personnel in the hospital to patient safety and quality, including the desire to do what's best for the patient and provide high-quality patient-centered care, and other elements of the hospital's general culture. Includes mentions employees feeling valued, essential, and psychologically safe to try new methods, including how new ideas for improvements are approached and adopted and how leadership generally respond to new suggestions for improvements. Includes general mentions of how decisions are made and hierarchies.

Role of Hospital Leaders
Commitment, involvement, and accountability of leaders and managers with implementation and use of PEWS, including their role in PEWS. Includes statements like "the leadership was supportive" and giving mandates to do XYZ with PEWS and general awareness about PEWS.

Characteristics of Individuals Stage of Change
Willingness, or lack of willingness of individuals or authorities in the hospital to gain new skills, accept change, or show interest/enthusiasm for PEWS. Includes mentions of resistance to or embracing using PEWS as part of routine patient care, comments about how useful PEWS is/isn't to patient care and other beliefs about the value of PEWS, perceptions of whether PEWS does/does not increase workload, and recommendations to implement PEWS in other centers. Should only be coded when referring to perceptions or actions of individuals in the organization. May be double coded with 'Sustainability' if mentions both individuals and institutional acceptance of PEWS. Does NOT include knowledge or skill on HOW to use PEWS correctly ("skill with PEWS").