O3233: From Setback to Success: Re-Implementation of Pediatric Early Warning Systems in Resource-Variable Hospitals Providing Childhood Cancer Care in Latin America and Spain

Background: Pediatric Early Warning Systems (PEWS) are evidence-based interventions designed to detect early signs of clinical deterioration in hospitalized children, enabling timely intervention and improved outcomes. While prior research has examined barriers during initial PEWS implementation, little is known about re-implementation, the process of reintroducing an intervention after an unsuccessful initial attempt. Understanding re-implementation is especially critical in resource-limited settings, where systemic resource constraints heighten barriers to sustainable implementation of effective clinical interventions. This study evaluates factors contributing to failed initial PEWS implementations and identifies strategies supporting successful re-implementation across pediatric oncology centers in Latin America and Spain.

Methods: We conducted a sequential mixed-methods study involving hospitals participating in Proyecto EVAT, a multinational quality improvement collaborative dedicated to implementing PEWS in pediatric oncology hospitals. Descriptive quantitative analysis was used to compare hospital-level characteristics, including country income level, and hospital funding type, between centers with successful and unsuccessful initial implementation. These findings, along with the Consolidated Framework for Implementation Research (CFIR) and the Quality Implementation Framework (QIF), informed qualitative interview guides that assessed implementation facilitators and failures (CFIR) and corresponding implementation strategies (QIF). Semi-structured interviews were conducted with implementation leaders (individuals involved in the planning, execution, and/or re-implementation of PEWS) at centers with initial implementation failures. Thematic content analysis explored implementation determinants and barriers utilizing the CFIR and identified re-implementation strategies using the QIF.

Results: Since 2017, 124 centers joined Proyecto EVAT. As of March 2025, 54 centers (43.5%) successfully implemented PEWS on their first attempt, 46 centers (37.2%) were actively implementing, and 24 (19.3%) failed initial implementation. Of those 24, 7 (29.2%) later succeeded, 8 (33.3%) are re-implementing, and 9 (37.5%) withdrew. Comparative analysis revealed no statistically significant differences in hospital characteristics between initially successful and unsuccessful sites. We conducted 40 interviews with key stakeholders at sites with initial implementation failure. Common barriers across center types included high staff turnover, lack of protected time, limited material and human resources, bureaucratic delays, and low initial buy-in. However, centers that successfully re-implemented PEWS described intentionally restructuring implementation teams to include more diverse roles, including nurses, physicians, and administrators, which improved communication and clarified implementation responsibilities. They actively engaged hospital leadership to secure buy-in, clearly delegated tasks to enhance accountability, established routine retraining protocols, and embedded PEWS into hospital workflows rather than treating it as a standalone project. These targeted changes marked a shift from their initial implementation approach and were described as critical to re-implementation success.

Conclusion: This study provides new insights into factors contributing to the unsuccessful implementation of evidence-based interventions like PEWS and highlights key strategies supporting effective re-implementation. These findings can guide future efforts to reintegrate evidence-based interventions into pediatric cancer care, especially in resource-limited settings, ultimately improving care delivery and patient outcomes.