Browsing by Author "Agulnik, A"

Now showing 1 - 8 of 8

Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America
(Frontiers Media S.A., 2022) Agulnik, A; Schmidt-Grimminger, G; Ferrara, G; Puerto-Torres, M; Gillipelli, SR; Elish, P; Muniz-Talavera, H; Gonzalez-Ruiz, A; Armenta, M; Barra, C; Diaz-Coronado, R; Hernandez, C; Juarez, S; Loeza, JJ; Mendez, A; Montalvo, E; Penafiel, E; Pineda, E; Graetz, DE; McKay, V
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. Copyright © 2022 Agulnik, Schmidt-Grimminger, Ferrara, Puerto-Torres, Gillipelli, Elish, Muniz-Talavera, Gonzalez-Ruiz, Armenta, Barra, Diaz-Coronado, Hernandez, Juarez, Loeza, Mendez, Montalvo, Penafiel, Pineda, Graetz and McKay.
Documenting adaptations to an evidence-based intervention in 58 resource-variable pediatric oncology hospitals across implementation phases
(BioMed Central Ltd, 2024) Quesada-Stoner, AC; Islam, S; Siječić, A; Malone, S; Puerto-Torres, MF; Cardenas, A; Prewitt, K; Alfonso, Carreras, Y; Alvarez-Arellano, SY; Argüello-Vargas, D; Ceballo-Batista, GI; Diaz-Coronado, R; Diniz, Borborema, MDC; Toledo, JE; Fing, E; Garay, Z; Hernández-González, CJ; Jimenez-Antolinez, YV; Juárez, Tobías, MS; Lemos, de, Mendonça, e, Fontes, L; Lopez-Facundo, NA; Mijares, Tobias, JM; Miralda-Méndez, ST; Montalvo, E; Cawich, ZN; Portilla, Figueroa, CA; Sahonero, M; Sánchez-Martín, M; Serrano-Landivar, MX; Soledad, García, V; Vasquez, A; Velásquez, Cabrera, DM; Carothers, BJ; Shelton, RC; Graetz, D; Acuña, C; Luke, DA; McKay, VRR; Agulnik, A
Background: Adaptation of evidence-based interventions (EBIs) often occurs when implemented in new local contexts and settings. It is unclear, however, during which phase of implementation adaptations are most frequently made and how these changes may impact the fidelity, effectiveness, and sustainability of the EBI. Pediatric Early Warning Systems (PEWS) are EBIs for early identification of deterioration in hospitalized children with cancer. This study evaluates adaptations of PEWS made among resource-variable pediatric oncology hospitals in Latin America implementing and sustaining PEWS. Methods: We conducted a cross-sectional survey among pediatric oncology centers participating in Proyecto Escala de Valoración de Alerta Temprana (EVAT), a collaborative to implement PEWS. Adaptations to PEWS were assessed via 3 multiple choice and 1 free text question administered as part of a larger study of PEWS sustainability. Descriptive statistics quantitatively described what, when, and why adaptations were made. Qualitative analysis of free text responses applied the Framework for Reporting Adaptations and Modifications Expanded (FRAME) to describe respondent perspectives on PEWS adaptations. Results: We analyzed 2,094 responses from 58 pediatric oncology centers across 19 countries in Latin America. Participants were predominantly female (82.5%), consisting of nurses (57.4%) and physicians (38.2%) who were PEWS implementation leaders (22.1%) or clinical staff (69.1%). Respondents described multiple PEWS adaptations across all implementation phases, with most occurring during the planning and piloting of EBIs. Adaptations included changes to PEWS content (algorithm, scoring tool, terminology, and use frequency) and context (personnel delivering or population). Respondents felt adaptations streamlined monitoring, enhanced effectiveness, improved workflow, increased comprehension, and addressed local resource limitations. Qualitative analysis indicated that most adaptations were categorized as fidelity consistent and planned; fidelity inconsistent adaptations were unplanned responses to unanticipated challenges. Conclusion: Adaptations made to PEWS across implementation phases demonstrate how EBIs are adapted to fit dynamic, real-world clinical settings. This research advances implementation science by highlighting EBI adaptation as a potential strategy to promote widespread implementation and sustainability in hospitals of all resource levels.
Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America
(John Wiley and Sons Inc, 2022) Agulnik, A; Gonzalez-Ruiz, A; Muniz-Talavera, H; Carrillo, AK; Cárdenas, A; Puerto-Torres, MF; Garza, M; Conde, T; Soberanis-Vasquez, DJ; Méndez-Aceituno, A; Acuña-Aguirre, C; Alfonso, Y; Álvarez-Arellano, SY; Argüello Vargas, D; Batista, R; Blasco Arriaga, EE; Chávez Rios, M; Cuencio Rodríguez, ME; Fing Soto, EA; Gómez-García, W; Guillén Villatoro, RH; Gutiérrez Rivera, MDL; Herrera Almanza, M; Jimenez Antolinez, YV; Juárez Tobias, MS; López Facundo, NA; Martínez Soria, RA; Miller, K; Miralda, S; Morales, R; Negroe Ocampo, N; Osuna, A; Pascual Morales, C; Pérez Fermin, CK; Pérez Alvarado, CM; Pineda, E; Andrés Portilla, C; Rios López, LE; Rivera, J; Sagaón Olivares, AS; Saguay Tacuri, MC; Salas-Mendoza, BT; Solano Picado, I; Soto Chávez, V; Tejocote Romero, I; Tatay, D; Teixeira Costa, J; Villanueva, E; Villegas Pacheco, M; McKay, VR; Metzger, ML; Friedrich, P; Rodriguez-Galindo, C
Background: Pediatric early warning systems (PEWS) aid in the early identification of deterioration in hospitalized children with cancer however, they are under-used in resource-limited settings. The authors use the knowledge-to-action framework to describe the implementation strategy for Proyecto Escala de Valoracion de Alerta Temprana (EVAT), a multicenter quality-improvement collaborative, to scale-up PEWS in pediatric oncology centers in Latin America. Methods: Proyecto EVAT mentored participating centers through an adaptable implementation strategy to: (1) monitor clinical deterioration in children with cancer, (2) contextually adapt PEWS, (3) assess barriers to using PEWS, (4) pilot and implement PEWS, (5) monitor the use of PEWS, (6) evaluate outcomes, and (7) sustain PEWS. The implementation outcomes assessed included the quality of PEWS use, the time required for implementation, and global program impact. Results: From April 2017 to October 2021, 36 diverse Proyecto EVAT hospitals from 13 countries in Latin America collectively managing more than 4100 annual new pediatric cancer diagnoses successfully implemented PEWS. The time to complete all program phases varied among centers, averaging 7 months (range, 3–13 months) from PEWS pilot to implementation completion. All centers ultimately implemented PEWS and maintained high-quality PEWS use for up to 18 months after implementation. Across the 36 centers, more than 11,100 clinicians were trained in PEWS, and more than 41,000 pediatric hospital admissions had PEWS used in their care. Conclusions: Evidence-based interventions like PEWS can be successfully scaled-up regionally basis using a systematic approach that includes a collaborative network, an adaptable implementation strategy, and regional mentorship. Lessons learned can guide future programs to promote the widespread adoption of effective interventions and reduce global disparities in childhood cancer outcomes. Lay summary: Pediatric early warning systems (PEWS) are clinical tools used to identify deterioration in hospitalized children with cancer however, implementation challenges limit their use in resource-limited settings. Proyecto EVAT is a multicenter quality-improvement collaborative to implement PEWS in 36 pediatric oncology centers in Latin America. This is the first multicenter, multinational study reporting a successful implementation strategy (Proyecto EVAT) to regionally scale-up PEWS. The lessons learned from Proyecto EVAT can inform future programs to promote the adoption of clinical interventions to globally improve childhood cancer outcomes.
Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals
(Frontiers Media S.A., 2022) Mirochnick, E; Graetz, DE; Ferrara, G; Puerto-Torres, M; Gillipelli, SR; Elish, P; Muniz-Talavera, H; Gonzalez-Ruiz, A; Armenta, M; Barra, C; Diaz-Coronado, R; Hernandez, C; Juarez, S; Loeza, JDJ; Mendez, A; Montalvo, E; Penafiel, E; Pineda, E; Agulnik, A
Background: Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings
Resilient health care in global pediatric oncology during the COVID-19 pandemic
(John Wiley and Sons Inc., 2021) Graetz, DE; Sniderman, E; Villegas, CA; Kaye, EC; Ragab, I; Laptsevich, A; Maliti, B; Naidu, G; Huang, H; Gassant, PY; Nunes Silva, L; Arce, D; Montoya Vasquez, J; Arora, RS; Alcasabas, AP; Rusmawatiningtyas, D; Raza, MR; Velasco, P; Kambugu, J; Vinitsky, A; Rodriguez-Galindo, C; Agulnik, A; Moreira DC; COVIMPACT Study Group
Background: In the face of unprecedented challenges because of coronavirus disease 2019, interdisciplinary pediatric oncology teams have developed strategies to continue providing high-quality cancer care. This study explored factors contributing to health care resilience as perceived by childhood cancer providers in all resource level settings. Methods: This qualitative study consisted of 19 focus groups conducted in 16 countries in 8 languages. Seven factors have been previously defined as important for resilient health care including: 1) in situ practical experience, 2) system design, 3) exposure to diverse views on the patient's situation, 4) protocols and checklists, 5) teamwork, 6) workarounds, and 7) trade-offs. Rapid turn-around analysis focused on these factors. Results: All factors of health care resilience were relevant to groups representing all resource settings. Focus group participants emphasized the importance of teamwork and a flexible and coordinated approach to care. Participants described collaboration within and among institutions, as well as partnerships with governmental, private, and nonprofit organizations. Hierarchies were advantageous to decision-making and information dissemination. Clinicians were inspired by their patients and explained creative trade-offs and workarounds used to maintain high-quality care. Conclusions: Factors previously described as contributing to resilient health care manifested differently in each institution but were described in all resource settings. These insights can guide pediatric oncology teams worldwide as they provide cancer care during the next phases of the pandemic. Understanding these elements of resilience will also help providers respond to inevitable future stressors on health care systems.
Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource-limited pediatric oncology centers
(John Wiley and Sons Inc, 2023) Woo, MC; Ferrara, G; Puerto-Torres, M; Gillipelli, SR; Elish, P; Muniz-Talavera, H; Gonzalez-Ruiz, A; Armenta, M; Barra, C; Diaz-Coronado, R; Hernandez, C; Juarez, S; Loeza, JDJ; Mendez, A; Montalvo, E; Peñafiel, E; Pineda, E; Graetz, DE; Kortz, T; Agulnik, A
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.
The COVID-19 Pandemic's impact on sustainability and expansion of a Pediatric Early Warning System in resource-limited hospitals
(John Wiley and Sons Inc, 2023) Wiphatphumiprates, PP; Graetz, DE; Ferrara, G; Puerto-Torres, M; Gillipelli, SR; Elish, P; Muniz-Talavera, H; Gonzalez-Ruiz, A; Armenta, M; Barra, C; Carpio, Z; Hernandez, C; Juarez, S; de-Jesus-Loeza, J; Mendez, A; Montalvo, E; Penafiel, E; Pineda, E; McKay, V; Agulnik, A
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.
Utilizing Multilingual Methods and Rapid Analysis for Global Qualitative Research During a Pandemic
(SAGE Publications Inc., 2022) Graetz, DE; Sniderman, E; Villegas, C; Ragab, I; Laptsevich, A; Maliti, B; Naidu, G; Zhang, H; Gassant, P; Nunes, L; Arce, D; Vasquez, JM; Arora, RS; Alcasabas, AP; Rusmawatiningtyas, D; Raza, MR; Hamid, SA; Velasco, P; Kambugu, J; Vinitsky, A; Bolous, NS; Haidar, CE; Bihannic, L; Sa da Bandeira, D; Wang, JX; Li, D; Graca, F; Vasilyeva, A; Lesmana, H; Galindo, CR; Agulnik, A; Moreira, DC
Historically, qualitative research has complemented quantitative biologic and epidemiologic studies to provide a more complete understanding of pandemics. The COVID-19 pandemic has generated unique and novel challenges for qualitative researchers, who have embraced creative solutions including virtual focus groups and rapid analyses to continue their work. We present our experience conducting a multilingual global qualitative study of healthcare resilience among teams of pediatric oncology professionals during the COVID-19 pandemic. We provide an in-depth description of our methodology and an analysis of factors we believe contributed to our study’s success including our use of technology, engagement of a large multilingual team, global partnerships, and framework-based rapid analysis. We hope these techniques may be useful to qualitative researchers conducting studies during the current pandemic, as well as for all pediatric oncology studies including multiple languages or geographically disparate subjects.