Challenges and Opportunities for Implementing Pediatric Early Warning Systems in Low- and Middle-Income Countries—Using Resources Wisely

The capacity for intensive care and continuous monitoring in low and middle-income countries is often outstripped by demand due to the high burden of critical illness.¹ Early warning scores developed in resource-rich settings are being adopted in resource-limited settings to identify patients whose conditions are deteriorating and require escalation of care. Pediatric early warning systems (PEWS) are designed to trigger an algorithm-based response depending on a risk score derived from clinical symptoms and signs.²

Agulnik et al³ report on the findings of a qualitative study exploring barriers and facilitators to PEWS implementation in 5 resource-limited pediatric oncology centers in Latin America. Using the Consolidated Framework for Implementation Research, the authors identified that the factors crucial to PEWS implementation cut across all the 5 domains and barriers to implementation in one setting or at one stage can be enablers in another setting or transform over the implementation process.⁴

Enablers of PEWS implementation included characteristics of the intervention, support from an established collaborative network, simplicity of the intervention, the perceived strength of evidence, and the availability of funding to support implementation. Examples of barriers identified in the study include hesitation from clinical staff and leaders, a medical culture that discouraged interdisciplinary collaboration, and delayed stakeholders' involvement. Many of the enablers and barriers identified could serve as the foundation for a priori assessment of the suitability of PEWS implementation or similar interventions in a similar resource-limited context.

An organization's culture and readiness for improvement help overcome traditional barriers toward implementation projects by ensuring a framework that aligns the roles of staff with the larger organization's quality goal. Equally important, supportive leadership, including champions advocating the use of the intervention, is necessary to actualize that institutional mission for improvement. Ensuring that adequate resources are available and providing sufficient evidence for an intervention's benefit to skeptical staff will be useful for implementing new care pathways. Starting at a system and process level rather than via individuals may ensure that the delivery of an intervention is not wholly dependent on individual staff characteristics. Teamwork is also a vital implementation principle that harnesses different individuals' knowledge, skills, experience, and perspectives to make sustainable improvements. A collaborative approach that brings together teams from various institutions to address common health challenges may increase the likelihood of success, shorten the time required to implement a project, and maximize its larger outcomes.⁵

This study raises important implementation questions for consideration in future studies. How does early warning system implementation align strategically with the local health system priorities when resources are strained? Are the benefits of early warning systems worthy of the human and material resources required for implementation in all resource-limited contexts? If not, in which contexts are early warning systems most appropriate and useful? Although the included participants self-identified as working in a resource-limited setting, all hospitals had intensive care units and specialized pediatric oncology services. The importance of some of the identified barriers to early warning system implementation in settings with greater resource limitations remains unknown, and resource tradeoffs will need to be considered. In some resource-limited settings, human and material resource constraints (including lack of staff training, high staff turnover, or inadequate functional monitoring equipment) and dysfunctional supply chain processes hinder the basic vital sign monitoring required for these scores and place strain on available nursing staff. In these environments, these barriers would potentially be prohibitive to PEWS implementation, necessitating adaptations that further reduce the workload required. In slightly better-resourced settings where routine monitoring is feasible, early warning score calculation and trigger algorithms might be easily integrated into regular clinical care without the need for additional resources. Implementation of the early warning system might be challenged by the availability of personnel for the response arm and capacity to escalate care once a trigger is activated. In addition, as the authors identify, sustainability of the intervention beyond the research setting and without external funding or equipment sources remains uncertain.⁶ These are pivotal issues that should become commonplace in evaluating all interventions in resource-limited settings moving forward.

This study reminds us that the success of an intervention relies on the complementary roles of the science of discovery that identifies efficacious interventions and the science of delivery that ensures that everyone who requires the intervention receives it. This study sheds light on the complexity of PEWS implementation in less-resourced settings and gives voice to the broader health care team directly affected by its use. This work must be carried forward to better understand whether and how tools such as PEWS can adapt to varied contexts to meet the needs of the local population and improve the care of critically ill children.

Published: March 9, 2022. doi:10.1001/jamanetworkopen.2022.1553

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Nyandat J et al. JAMA Network Open.

Corresponding Author: Srinivas Murthy, MD, CM, MHSc, Faculty of Medicine, Department of Pediatrics, University of British Columbia, 4500 Oak St, Vancouver, BC V6H 3V4, Canada (srinivas.murthy@cw.bc.ca).

Conflict of Interest Disclosures: Dr Murthy reported receiving grants from Innovative Medicines Canada, Health Research Foundation, Canadian Institutes of Health Research, and Wellcome Trust outside the submitted work. No other disclosures were reported.