Browsing by Author "Ferrara, Gia"

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    Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings
    (2022) Agulnik, Asya; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz, Rosdali; Hernandez, Cinthia; Juárez Tobias, Susana; de Jesus Loeza, Jose; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Graetz, Dylan E
    Importance: Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. Objective: To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. Design, setting, and participants: In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. Main outcomes and measures: Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. Results: Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. Conclusions and relevance: To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.
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    Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals
    (2022) 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, Jose de Jesus; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Agulnik, Asya
    Background: Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods: We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results: PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions: In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes. Keywords: Latin America; Pediatric Early Warning System (PEWS); global health; pediatric critical care; pediatric oncology; quality improvement; resource-limited. Copyright © 2022 Mirochnick, Graetz, Ferrara, Puerto-Torres, Gillipelli, Elish, Muniz-Talavera, Gonzalez-Ruiz, Armenta, Barra, Diaz-Coronado, Hernandez, Juarez, Loeza, Mendez, Montalvo, Penafiel, Pineda and Agulnik.
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    Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource‐limited pediatric oncology centers
    (2023) Woo, Marisa Cristin; 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; Mendez, Alejandra; Montalvo, Erika; Peñafiel, Eulalia; Pineda, Estuardo; Graetz, Dylan E; Kortz, Teresa; Agulnik, Asya
    Background Pediatric 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. Methods At 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. Results Participants 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. Conclusion This 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. Keywords: behavioral science, clinical cancer research, clinical management, implementation science, pediatric cancer, Pediatric Early Warning Systems, resource‐limited, stages of change, transtheoretical model
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    The COVID‐19 Pandemic's impact on sustainability and expansion of a Pediatric Early Warning System in resource‐limited hospitals
    (2023) Wiphatphumiprates, Parima P; Graetz, Dylan E; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Carpio, Zulma; Hernandez, Cinthia; Juarez, Susana; de Jesus Loeza, Jose; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; McKay, Virginia; Agulnik, Asya
    Background: The COVID-19 pandemic impacted healthcare delivery worldwide, including pediatric cancer care, with a disproportionate effect in resource-limited settings. This study evaluates its impact on existing quality improvement (QI) programs. Methods: We conducted 71 semi-structured interviews of key stakeholders at five resource-limited pediatric oncology centers participating in a collaborative to implement Pediatric Early Warning System (PEWS). Interviews were conducted virtually using a structured interview guide, recorded, transcribed, and translated into English. Two coders developed a codebook of a priori and inductive codes and independently coded all transcripts, achieving a kappa of 0.8-0.9. Thematic analysis explored the impact of the pandemic on PEWS. Results: All hospitals reported limitations in material resources, reduction in staffing, and impacts on patient care due to the pandemic. However, the impact on PEWS varied across centers. Identified factors that promoted or limited ongoing PEWS use included the availability of material resources needed for PEWS, staff turnover, PEWS training for staff, and the willingness of staff and hospital leaders to prioritize PEWS. Consequently, some hospitals were able to sustain PEWS; others halted or reduced PEWS use to prioritize other work. Similarly, the pandemic delayed plans at all hospitals to expand PEWS to other units. Several participants were hopeful for future expansion of PEWS post-pandemic. Conclusion: The COVID-19 pandemic created challenges for sustainability and scale of PEWS, an ongoing QI program, in these resource-limited pediatric oncology centers. Several factors mitigated these challenges and promoted ongoing PEWS use. These results can guide strategies to sustain effective QI interventions during future health crises. Keywords: COVID-19; Latin America; PEWS; implementation science; pediatric early warning system; pediatric oncology; quality improvement collaborative; resource-limited.