Connecting Clinical Capacity and Intervention Sustainability in Resource-Variable Pediatric Oncology Centers in Latin America.

Clinical capacity for sustainability, or the clinical resources needed to sustain an evidence-based practice, represent proximal determinants that contribute to intervention sustainment. We examine the relationship between clinical capacity for sustainability and sustainment of PEWS, an evidence-based intervention to improve outcomes for pediatric oncology patients in resource-variable hospitals. We conducted a cross-sectional survey among Latin American pediatric oncology centers participating in Proyecto Escala de Valoración de Alerta Temprana (EVAT), an improvement collaborative to implement Pediatric Early Warning Systems (PEWS). Hospitals were eligible if they had completed PEWS implementation. Clinicians were eligible to participate if they were involved in PEWS implementation or used PEWS in clinical work. The Spanish language survey consisted of 56 close and open-ended questions about the respondent, hospital, participants' assessment of clinical capacity to sustain PEWS using the clinical sustainability assessment tool (CSAT), and perceptions about PEWS and its use as an intervention. Results were analyzed using a multi-level modeling approach to examine the relationship between individual, hospital, intervention, and clinical capacity determinants to PEWS sustainment. A total of 797 responses from 37 centers in 13 countries were included in the analysis. Eighty-seven percent of participants reported PEWS sustainment. After controlling for individual, hospital, and intervention factors, clinical capacity was significantly associated with PEWS sustainment (OR 3.27, p < .01). Marginal effects from the final model indicate that an increasing capacity score has a positive influence (11% for every additional CSAT point) of predicting PEWS sustainment. PEWS is a sustainable intervention and clinical capacity to sustain PEWS contributes meaningfully to PEWS sustainment.

Improving Delivery and Use of HIV Pre-Exposure Prophylaxis in the US: A Systematic Review of Implementation Strategies and Adjunctive Interventions.

Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States. To date, the literature has focused on identifying determinants of PrEP use, with a lesser focus on developing and testing change methods to improve PrEP implementation. Moreover, the change methods available for improving the uptake and sustained use of PrEP have not been systematically categorized. To summarize the state of the literature, we conducted a systematic review of the implementation strategies used to improve PrEP implementation among delivery systems and providers, as well as the adjunctive interventions used to improve the uptake and persistent adherence to PrEP among patients. Between November 2020 and January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer reviewed articles. We identified 44 change methods (18 implementation strategies and 26 adjunctive interventions) across a variety of clinical and community-based service settings. We coded implementation strategies and adjunctive interventions in accordance with established taxonomies and reporting guidelines. Most studies focused on improving patient adherence to PrEP and most conducted pilot trials. Just over one-third of included studies demonstrated a positive effect on outcomes. In order to end the human immunodeficiency virus (HIV) epidemic in the U.S., future, large scale HIV prevention research is needed that develops and evaluates implementation strategies and adjunctive interventions for target populations disproportionately affected by HIV.

Establishing Evidence Criteria for Implementation Strategies: A Delphi Study for HIV Services.

Background: There are no criteria specifically for evaluating the quality of implementation research and recommend implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Rubric, a set of criteria to evaluate the evidence supporting implementation strategies, in the context of HIV. Methods: We developed the Best Practices Rubric from 2022-2023 in three phases. (1) We purposively selected and recruited by email participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. We developed a draft rubric and criteria based on a literature review and key informant interviews. (2) The rubric was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate, and the rubric and criteria were revised. (3) We then applied the rubric to a set of research studies assessing 18 implementation strategies designed to promote the adoption and uptake of pre-exposure prophylaxis, an HIV prevention medication, to assess reliable application of the rubric and criteria. Results: Our initial literature review yielded existing rubrics and criteria for evaluating intervention-level evidence. For a strategy-level rubric, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best practice, promising practice, more evidence needed, and harmful practices. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies. Conclusions: We developed a rubric to evaluate the evidence supporting implementation strategies for HIV services. Although the rubric is specific to HIV, this tool is adaptable for evaluating strategies in other health areas.

Sustainability determinants of an intervention to identify clinical deterioration and improve childhood cancer survival in Latin American hospitals: the INSPIRE study protocol.

BACKGROUND: More than 90% of children with cancer live in low-resourced settings, where survival is only 20%. Sustainable evidence-based (EB) interventions yielding ongoing beneficial patient outcomes are critical to improve childhood cancer survival. A better understanding of factors promoting intervention sustainability in these settings is urgently needed. The aim of this study is to provide an empirical understanding of how clinical capacity for sustainability, or the resources needed to sustain an intervention, impacts the sustainment of Pediatric Early Warning System (PEWS), an EB intervention that improves pediatric oncology outcomes in low-resource hospitals by detecting clinical deterioration and preventing the need for more intense treatment. METHODS: We will conduct a prospective, longitudinal study of approximately 100 resource-variable hospitals implementing and sustaining PEWS participating in Proyecto EVAT, a quality improvement collaborative of Latin American pediatric oncology centers. Aim 1: We will evaluate how clinical capacity for sustainability changes over time through 5 to 9 prospective measurements of capacity via survey of clinical staff using PEWS (approximately n = 13 per center) during the phases of PEWS adoption, implementation, and sustainability using the Clinical Sustainability Assessment Tool (CSAT). Aim 2: We will determine the relationship between capacity and a) PEWS sustainment and b) clinical deterioration mortality among pediatric oncology patients at centers sustaining PEWS for 2 to 10 years using chart review and an existing patient outcomes registry. Aim 3: We will develop novel strategies to promote sustainability by gaining a deeper understanding of perceived challenges to building capacity and PEWS sustainment. In combination with quantitative outcomes, we will conduct 24 focus groups with staff (doctors, nurses, and administrators) from hospitals with both high (n = 4) and low capacity (n = 4). We will then use implementation mapping to generate theoretically driven, empirically-supported sustainability strategies. DISCUSSION: This study will advance implementation science by providing a theoretically driven, foundational understanding of factors that predict sustainability among a large, diverse cohort of hospitals. We will then use this knowledge to develop sustainability evidence-informed strategies that optimize capacity and promote long-term sustainment of PEWS and improvements in patient outcomes, thus promoting equity in childhood cancer care globally.

Adapting an Electronic STI Risk Assessment Program for Use in Pediatric Primary Care.

OBJECTIVES: Sexually transmitted infections (STIs) are an ongoing public health issue in adolescents. the Centers for Disease Control and Prevention and American Academy of Pediatrics have and continue to recommend STI screening in at-risk adolescents, however screening and testing continues to lag behind the need. We previously designed and implemented an electronic risk assessment tool to support STI testing in our pediatric emergency department. Pediatric primary care clinics may be better positioned for STI risk assessments, as they can offer greater privacy and confidentiality, a lower stress environment, and greater opportunity for longitudinal care. STI risk assessment and testing continues to be a challenge in this setting. The goal of this work was to evaluate the usability of our electronic tool to support adaptation and implementation in pediatric primary care practices. METHODS: We conducted qualitative interviews of pediatricians, clinic staff, and adolescents from 4 pediatric practices as part of a study whose goal is to ultimately implement STI screening in pediatric primary care. The goal of the interviews were (1) to understand contextual factors related to STI screening in primary care, which we have reported previously, and (2) to obtain feedback on our electronic platform, the questionnaire content, and their perspective on implementing it in primary care settings, which we report here. We received quantitative feedback using the System Usability Scale (SUS). The SUS is a validated, reliable tool to measure the usability of hardware, software, websites, and applications. SUS scores range from a score of 0 to 100, with a score of 68 or higher indicating above average usability. We additionally obtained qualitative feedback via interviews and used inductive analysis to identify common themes. RESULTS: We recruited 14 physicians, 9 clinic staff, and 12 adolescents. Participants rated the tool highly using the SUS, with a median score of 92.5 (threshold for average usability is 68) and an interquartile range of 82.5 to 100. Thematically, all participants perceived a need for such a screening program and indicated the format would encourage more honest responses on the topic adolescents. We used these results to modify the questionnaire prior to implementing it into participating practices. CONCLUSION: We demonstrated that our electronic STI risk assessment tool had a high level of usability and could be adapted for use in pediatric primary care.

Beyond implementation: Uncovering the parallels between de-implementation and antimicrobial stewardship.

De-implementation is defined as the process of discontinuing, removing, reducing, or replacing a harmful, ineffective, or low-value clinical practice or intervention. The goal of de-implementation strategies is to minimize patient harm, maximize use of resources, and reduce healthcare costs and inequities. Both antibiotic and diagnostic stewardship programs focus on reducing low-value interventions (tests or antimicrobials). Stewardship interventions commonly involve de-implementation and deprescribing strategies. This commentary explores unique aspects of deimplementing low-value testing and unnecessary antimicrobial use, similarities between de-implementation and stewardship approaches, multilevel factors that impact de-implementation, and opportunities for future research.

The COVID-19 Pandemic's impact on sustainability and expansion of a Pediatric Early Warning System in resource-limited hospitals.

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.

Categorising implementation determinants and strategies within the US HIV implementation literature: a systematic review protocol.

INTRODUCTION: Despite decreased rates of new infections, HIV/AIDS continues to impact certain US populations. In order to achieve the goals laid out in the Ending the HIV Epidemic (EHE) in the US initiative, implementation science is needed to expand the sustained use of effective prevention and treatment interventions, particularly among priority populations at risk for and living with HIV/AIDS. Over 200 HIV-related implementation studies have been funded by the US National Institutes of Health. Therefore, a comprehensive review of the literature identifying implementation determinants (barriers and facilitators) and categorising implementation strategies across the continuum of HIV prevention and care in the USA is appropriate and needed to enhance current knowledge and help achieve the goals laid out in the EHE national strategic plan. METHODS AND ANALYSIS: This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Between November 2020 and January 2022, a broad database search strategy of Ovid MEDLINE, PsycINFO and Web of Science was conducted to capture implementation-related studies along the HIV prevention and care continuum. Articles were eligible for inclusion if they were: conducted in the USA, published after the year 2000, written in English, related to HIV/AIDS, focused on outcomes related to dissemination and implementation (ie, did not test/evaluate/explore implementation determinants or strategies) and were behavioural studies (ie, not basic science). We plan to conduct three systematic reviews to identify and categorise determinants and strategies associated with three HIV focus areas: pre-exposure prophylaxis, testing/diagnosing and linkage to care, and treatment. Determinants will be coded according to an adapted Consolidated Framework for Implementation Research 2.0. Implementation strategies and outcomes will be categorised in accordance with existing taxonomies and frameworks. ETHICS AND DISSEMINATION: Ethics approval is not applicable. No original data will be collected. Results will be disseminated through peer-reviewed publications, conference presentations and via online tools. PROSPERO REGISTRATION NUMBER: CRD42021233089.

Provider and Practice Factors Associated With On-Time HPV Vaccination in Primary Care.

BACKGROUND: In 2018, only one third of girls and boys completed the 2-dose series of the human papillomavirus vaccine by their 13th birthday, the target for on-time vaccination. The study objective was to identify key patient, provider and practice-level factors associated with on-time vaccination in the primary care setting. METHODS: We examined data from 20 primary care pediatric practices (89 providers) in St. Louis including: the percentage of eligible patients with on-time vaccination assessed from medical records; providers' knowledge, attitudes and behaviors regarding on-time vaccination assessed with a survey; and practice-level strategies used to optimize vaccine delivery assessed with a 19-item vaccine delivery system score (VDSS). Factors that increased on-time vaccination were identified using logistic regression, controlling for clustering within providers. RESULTS: Completion of on-time vaccination occurred in 1347/3125 (43.10%) of patients (95% confidence interval [CI], 41.36%-44.86%) and varied among practices (7.39%-64.24%) and among providers (2.63%-82.50%). Independent predictors for higher completion of on-time vaccination included more frequent use by providers of the announcement style for vaccine recommendation (odds ratio [OR] 1.18, 95% CI, 1.04, 1.35), higher provider self-efficacy to deliver the vaccine according to guideline recommendations if parents were hesitant (OR 1.21, 95% CI, 1.05, 1.40), and higher VDSS (OR 1.20, 95% CI, 1.10, 1.31). CONCLUSIONS: Provider and practice-level factors were identified that may represent modifiable targets for improvement in on-time vaccine uptake. Future research is needed to test interventions built on these findings.

High Impact for Whom? A Qualitative Analysis of Organization Concerns About the Transition to High-Impact Prevention Policy.

HIV represents a significant health burden in the United States. In 2012, the Centers for Disease Control and Prevention (CDC) stopped recommending many once-promoted interventions as part of a shift from one HIV intervention policy, Diffusion of Effective Behavioral Interventions (DEBI), to another, High Impact Prevention (HIP). Twenty-nine staff members from 10 organizations were interviewed to explore how organizations reacted to this shift. Three major themes emerged: (1) Personal experience, community assessment, and epidemiological evidence influenced organizations' perceptions of efficacy and preference for earlier interventions. (2) Organizations were concerned that HIP interventions were not a good fit for their priority populations. (3) Organizations were frustrated with the top-down approach by the CDC prioritizing HIP interventions over earlier interventions. These results indicate that organizations continue to see value in and provide DEBI interventions. In addition, a more participatory process incorporating qualitative evidence and organizations' experiences may be necessary to achieve widespread de-implementation of DEBI interventions.

Dissemination and implementation science and antimicrobial stewardship in solid organ transplantation: A perspective.

BACKGROUND: Recipients of solid organ transplants (SOTs) have unique risks for infections, but providers are often hesitant to apply the principles of antimicrobial stewardship to this patient population due to perceived excess risk. The methods of implementation science may move the field forward to simultaneously improve patient outcomes and patient safety. METHODS: Perspective piece on implementation science in SOT patients. RESULTS: Herein, we provide explanation of implementation science as it relates to SOT patients. In addition, we provide examples of how implementation science can be applied to antimicrobial stewardship in SOT patients. CONCLUSION: Implementation science may offer insights and solutions to the challenges of implementing evidence-based antimicrobial stewardship interventions in patients with SOT, including uptake of new practices and the de-implementation of outdated or low-value practices.

Public Health Information Seeking, Trust, and COVID-19 Prevention Behaviors: Cross-sectional Study.

BACKGROUND: Preventative health measures such as shelter in place and mask wearing have been widely encouraged to curb the spread of the COVID-19 disease. People's attitudes toward preventative behaviors may be dependent on their sources of information and trust in the information. OBJECTIVE: The aim of this study was to understand the relationship between trusting in COVID-19 information and preventative behaviors in a racially and politically diverse metropolitan area in the United States. METHODS: We conducted a web-based cross-sectional survey of residents in St. Louis City and County in Missouri. Individuals aged ≥18 years were eligible to participate. Participants were recruited using a convenience sampling approach through social media and email. The Health Belief Model and the Socioecological Model informed instrument development, as well as COVID-19-related questions from the Centers for Disease Control and Prevention. We performed an ordinary least squares linear regression model to estimate social distancing practices, perceptions, and trust in COVID-19 information sources. RESULTS: Of the 1650 eligible participants, the majority (n=1381, 83.7%) had sought or received COVID-19-related information from a public health agency, the Centers for Disease Control and Prevention, or both. Regression analysis showed a 1% increase in preventative behaviors for every 12% increase in trust in governmental health agencies. At their lowest levels of trust, women were 68% more likely to engage in preventative behaviors than men. Overall, those aged 18-45 years without vulnerable medical conditions were the least likely to engage in preventative behaviors. CONCLUSIONS: Trust in COVID-19 information increases an individual's likelihood of practicing preventative behaviors. Effective health communication strategies should be used to effectively disseminate health information during disease outbreaks.

Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America.

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.

The Use of the Consolidated Framework for Implementation Research to Understand Facilitators and Barriers to Sexually Transmitted Infection Screening in Primary Care.

BACKGROUND: Adolescents bear a disproportionate burden of sexually transmitted infections (STIs) and the sequelae of delayed treatment, yet STI screening is infrequently performed in pediatric primary care clinics with many of those at-risk not administered testing. This study aims to understand contextual factors influencing STI screening and testing among adolescents in pediatric primary care. METHODS: We used the Consolidated Framework for Implementation Research (CFIR) as part of a stepwise approach to facilitate a deep understanding the pediatric primary care environment. We conducted semistructured interviews of physicians, nurses, and patient-parent dyads from 4 pediatric primary care practices in the St. Louis metropolitan area about STI screening practices and common concerns regarding STI screening. Qualitative analysis was conducted using a categorical coding technique informed by the CFIR followed by a thematic coding technique. RESULTS: We interviewed 23 physicians/nurses and 12 patient-parent dyads. Individual-level barriers to STI screening and testing included wide variability in clinicians' practice patterns and their perception of STI risk in the patient population. Structural barriers included a lack of capacity to perform testing in clinic and time constraints during patient visits. Confidentiality issues also created significant barriers to screening and testing on both individual and structural levels. Adopting confidential methods for testing and educating providers on patients' recommendations for STI testing were discussed as ways to potentially improve STI care in pediatric patients. CONCLUSIONS: Our use of the CFIR facilitated a systematic approach to identify gaps in STI care for adolescents and identified opportunities to close those gaps. An integrated, systematic approach that enhances patient confidentiality and improves clinicians' knowledge could address gaps in STI care in pediatric primary care settings.

Transition for Adolescents and Young Adults With Sickle Cell Disease in a US Midwest Urban Center: A Multilevel Perspective on Barriers, Facilitators, and Future Directions.

BACKGROUND: Sickle cell disease (SCD), an inherited red blood cell disorder, primarily affects African Americans in the United States. Adolescents and young adults with SCD (AYA-SCD) are at risk of high morbidity and mortality when transitioning from pediatric to adult care. The goal of this qualitative study was to understand factors associated with optimal implementation of the AYA-SCD transition. METHODS: Participants were recruited from a large hospital system and the community. Interview guides included topics on access to primary and specialized care, beliefs and practices related to pain control, transition from pediatric to adult care, and patient experiences in the emergency department. Data were coded and analyzed using an inductive thematic coding approach in combination with a deductive coding approach using domains from the Consolidated Framework for Implementation Research (CFIR). RESULTS: Fifty-nine participants, including 21 AYA-SCD from both the pediatric and adult clinics, 17 caregivers, 9 pediatric SCD providers, 6 adult SCD providers, and 6 emergency department providers, completed 11 focus groups and 5 semistructured interviews. Results identified multiple factors within the domains of CFIR including the outer setting, inner setting, individual characteristics, and intervention characteristics. Results were incorporated into a transition framework to inform local practice improvement. CONCLUSION: Our study highlights the importance of multilevel barriers and facilitators for AYA-SCD transition from pediatric to adult care. Future studies could use implementation science frameworks to understand local context and identify strategies and intervention characteristics to improve transition programming. These efforts will ultimately reduce health disparities and ensure health equity.

Using Implementation Science to Guide the Process of Adapting a Patient Engagement Intervention for Inpatient Spinal Cord Injury/Disorder Rehabilitation.

OBJECTIVES: This study aimed to describe the process of adapting an evidence-based patient engagement intervention, enhanced medical rehabilitation (E-MR), for inpatient spinal cord injury/disease (SCI/D) rehabilitation using an implementation science framework. DESIGN: We applied the collaborative intervention planning framework and included a community advisory board (CAB) in an intervention mapping process. SETTING: A rehabilitation hospital. PARTICIPANTS: Stakeholders from inpatient SCI/D rehabilitation (N=7) serving as a CAB and working with the research team (N=7) to co-adapt E-MR. INTERVENTIONS: E-MR. MAIN OUTCOME MEASURES: Logic model and matrices of change used in CAB meetings to identify areas of intervention adaptation. RESULTS: The CAB and research team implemented adaptations to E-MR, including (1) identifying factors influencing patient engagement in SCI/D rehabilitation (eg, therapist training); (2) revising intervention materials to meet SCI/D rehabilitation needs (eg, modified personal goals interview and therapy trackers to match SCI needs); (3) incorporating E-MR into the rehabilitation hospital's operations (eg, research team coordinated with CAB to store therapy trackers in the hospital system); and (4) retaining fidelity to the original intervention while best meeting the needs of SCI/D rehabilitation (eg, maintained core E-MR principles while adapting). CONCLUSIONS: This study demonstrated that structured processes guided by an implementation science framework can help researchers and clinicians identify adaptation targets and modify the E-MR program for inpatient SCI/D rehabilitation.

Tailoring dissemination of evidence to preferences of tobacco control partners: results from an academic-community partnership.

BACKGROUND: Tobacco control program leaders and their partners, who often present evidence to policymakers, can increase the use of evidence in program and policy development. However, up-to-date evidence from the scientific community about what works is slow to reach leaders. We describe efforts to understand and utilize tobacco control leaders' preferences for receiving evidence and report on resulting dissemination strategies, translational products, and outcomes. METHODS: This work is part of the Advancing Science and Practice in the Retail Environment (ASPiRE) Center, an interdisciplinary research center focused on understanding and evaluating tobacco retail policy. Participants were members of the ASPiRE Community Advisory Board (CAB), comprised of tobacco control leaders from 30 metropolitan areas representing all regions of the US plus nine representatives from leading national tobacco control organizations (N = 39). During meetings in February 2019 and October 2020, all CAB members were invited to participate in live polls consisting of six survey questions each. Questions addressed preferences for receiving scientific evidence and their anticipated use of ASPiRE translational products. Responses were analyzed descriptively and informed translational product development and communications with ASPiRE contact list members (N = 125). ASPiRE email and website interactions were tracked from March 2019 to May 2021 as a complementary indication of content use. RESULTS: Response rates for 2019 and 2020 CAB meetings were 66% (n = 26) and 59% (n = 23), respectively. CAB members indicated preferences for email communication (33%) and webinars (31%), communications once per month (46%), and short-format documents (28%). In response, the team developed translational short-format products including case studies, fact sheets, and research briefs. On average, 52% (SD = 14%) of recipients opened the newsletter and 17% (SD = 9%) clicked a link within the newsletter. Overall, 95% of responding CAB members found the products useful and all responding CAB members reported using them to communicate evidence to policymakers, staff, and coalition members. CONCLUSIONS: Our successful dissemination approach to making evidence more accessible and useable for tobacco control leaders could be adapted by researchers working with community partners to assess and respond to stakeholders' preferences for receiving evidence in other areas of health policy.

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

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.

Sustainability in pediatric hospitals: An exploration at the intersection of quality improvement and implementation science.

Background: Although new evidence-based practices are frequently implemented in clinical settings, many are not sustained, limiting the intended impact. Within implementation science, there is a gap in understanding sustainability. Pediatric healthcare settings have a robust history of quality improvement (QI), which includes a focus on continuation of change efforts. QI capability and sustainability capacity, therefore, serve as a useful concept for connecting the broader fields of QI and implementation science to provide insights on improving care. This study addresses these gaps in understanding of sustainability in pediatric settings and its relationship to QI. Methods: This is a cross-sectional observational study conducted within pediatric academic medical centers in the United States. Clinicians surveyed worked with one of three evidence-based clinical programs: perioperative antimicrobial stewardship prescribing, early mobility in the intensive care unit, and massive blood transfusion administration. Participants completed two assessments: (1) the Clinical Sustainability Assessment Tool (CSAT) and (2) a 19-question assessment that included demographics and validation questions, specifically a subset of questions from the Change Process Capability Questionnaire, a QI scale. Initial descriptive and bivariate analyses were conducted prior to building mixed-effects models relating perceived QI to clinical sustainability capacity. Results: A total of 181 individuals from three different programs and 30 sites were included in the final analyses. QI capability scores were assessed as a single construct (5-point Likert scale), with an average response of 4.16 (higher scores indicate greater QI capability). The overall CSAT score (7-point Likert scale) was the highest for massive transfusion programs (5.51, SD = 0.91), followed by early mobility (5.25, SD = 0.92) and perioperative antibiotic prescribing (4.91, SD = 1.07). Mixed-effects modeling illustrated that after controlling for person and setting level variables, higher perceptions of QI capabilities were significantly related to overall clinical sustainability. Conclusion: Organizations and programs with higher QI capabilities had a higher sustainability capacity, even when controlling for differences at the individual and intervention levels. Organizational factors that enable evidence-based interventions should be further studied, especially as they relate to sustainability. Issues to be considered by practitioners when planning for sustainability include bedside provider perceptions, intervention achievability, frequency of delivery, and organizational influences.