A qualitative study of the reimplementation of a standardised paediatric early warning system pilot in England

Efforts to improve healthcare quality and safety and optimise resource use are increasingly focused on deimplementation-the reduction or cessation of existing practice. Reimplementation, a common form of deimplementation, involving the reintroduction of an existing intervention with some degree of modification, is under-researched, particularly in the context of standardising clinical tools. Recent initiatives, such as the national rollout of a standardised paediatric early warning system (PEWS) in England, highlight the need to understand the processes and challenges of substitution, especially from nursing and paediatric perspectives.

This qualitative study employed a comparative case study design across four diverse hospital sites. Data collection (June 2023-November 2024) included semi-structured interviews with staff (n = 29), site-specific workshops and a final stakeholder workshop. Thematic analysis, informed by the Theoretical Domains Framework, was used to analyse interview and workshop data, with cross-case comparisons to identify influences on the reimplementation of PEWS.

Buy-in and firm commitment (purchase) was identified as a central influence on the reimplementation effort and was in turn influenced by factors falling into four key categories: product and process (characteristics of, familiarity with and confidence using the system being reimplemented - connected to specific training needs and gaps); people (the people involved in or providing support for reimplementation - having strong leadership across roles and seniority, ward champions and peer support); purpose and promise (belief in the value of the reimplementation); and practice (practical and contextual influences on reimplementation efforts - staffing pressures, removal of the previous system, and acknowledgement that the change would require an initial adjustment period).

The considerations identified in this study provide a simple '5P' framework to help understand and support reimplementation, which maps to and is grounded in existing theory. Those considering reimplementation efforts should consider (1) the people, (2) the product and process, (3) the purpose and promise, and (4) the practical influences when reimplementing systems or initiatives. These factors greatly influence (5) purchase - buy-in and commitment - and, we suggest, ultimate success. This will be important in the wider roll-out of a national PEWS as well as other standardisation efforts in the NHS.