Knowledge translation in emergency medical services: a qualitative survey of barriers to guideline implementation

The Influencing Factors of Implementation in Emergency Medical Service Systems - A Scoping Review

OBJECTIVES: Emergency medical services (EMS) provide health care in situations with limited time and resources. Challenges arise when introducing novel medications, treatments, or technologies or modifying existing practices in these settings. Effective implementation strategies are pivotal for their success. This study aims to identify and categorize potential facilitators and barriers in the implementation of prehospital EMS through a review of relevant research articles.METHODS: We searched PubMed and EMbase to identify studies published before December 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for our search strategy and scoping review. We included original articles written in English that report on the factors that influence the implementation in prehospital settings. We extracted and categorized the factors into different themes.RESULTS: Out of the 371 retrieved papers, we selected 19 (5%) for inclusion in this review. We extracted 46 influencing factors from the selected articles and categorized them into ten themes: (1) Outer system, (2) Inner system, (3) Practitioner characteristics, (4) Resources, (5) Communication and collaboration, (6) Patient factors, (7) Intervention characteristics, (8) De-implementation of prior practices, (9) Logistical issues, and (10) Quality improvement.CONCLUSIONS: This study examined the literature on EMS implementation factors and proposed a 10-theme EMS model framework. Key factors include training/education, equipment/tools, communication with hospitals, and practitioners' attitudes.

Applying Crew Resource Management tools in Emergency Response Driving and patient transport-Finding consensus through a modified Delphi study

BACKGROUND

Emergency Response Driving (ERD) comprises a significant risk to safety in Emergency Medical Services (EMS). Crew Resource Management (CRM) tools play a major role in securing actions in high-risk procedures. The aim of this study was to find consensus on the important factors to consider when applying CRM tools in ERD and patient transport.

METHODS

ERD experts (n = 50) were recruited for a modified three-round Delphi study. Round 1 was based on previous research. The experts evaluated the items as important, neutral, or not important. The predetermined level of consensus was set at ≥ 80%. Answers given to the open-ended questions were analyzed using inductive content analysis.

RESULTS

Predetermined consensus was reached on 64 of 86 presented items (74.4 %). The mean values of items reaching consensus varied between 3.81 and 4.86 on a five-point Likert scale. The items where consensus was reached were rated as "important" on a trichotomized scale.

CONCLUSION

Multiple important factors to consider when applying CRM tools to ERD and patient transport were highlighted. This study provides valuable information to consider regarding EMS safety improvements. Further scientific research is needed to develop comprehensive recommendations.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport

OBJECTIVES

Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol.

METHODS

We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight.

CONCLUSIONS

EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Emergency Medical Services Clinicians' Pediatric Destination Decision-Making: A Qualitative Study

Objective This study sought to identify factors that influence emergency medical services (EMS) clinicians' destination decision-making for pediatric patients. We also sought EMS clinicians' opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines. Methods Thirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis.  Results EMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals' pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool. Conclusion This study describes specific factors that influence EMS clinicians' transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals' pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.

The Effectiveness of Social Media in the Dissemination of Knowledge About Pain in Dementia

Objectives

Traditional knowledge dissemination methods have been ineffective in leading to timely and widespread changes in clinical practice. Social media have the potential to reach broader audiences than more traditional methods that disseminate research findings. We evaluated the effectiveness of using social media to mobilize knowledge about pain in dementia.

Methods

We developed an online repository of evidence-based content (e.g., guidelines, assessment approaches) and a video about pain in dementia. The video was uploaded to YouTube, a video-sharing platform. We collaborated with stakeholder organizations on a 5-month social media campaign (#SeePainMoreClearly) on Twitter, a social networking site, to disseminate digital content about pain in dementia. The response to our initiatives was evaluated with Web and social media metrics, a video questionnaire, and a comparison of the extent of Twitter discussions about pain in dementia before and during the campaign period.

Results

Web metrics showed a great reach of the initiative: The #SeePainMoreClearly hashtag received more than 5,000,000 impressions and was used in 31 countries. The online repository was viewed by 1,218 individuals from 55 countries, and the video resulted in 51,000 views. Comparisons between the pre-campaign and campaign periods demonstrated a higher number of posts about pain in dementia during the campaign period.

Conclusion

The findings have implications for closing the knowledge-to-practice gap in dementia care through faster mobilization of scientific findings. Our campaign compares favorably with other health information dissemination initiatives. The methodologies used in the study could serve as a framework for the development of social media initiatives in other health disciplines.

Stroke rehabilitation research translation in Australia: a survey of clinical trialists

PURPOSE

Translation of findings from stroke trials into clinical practice remains low. Little is known about planned translation activities from the perspective of trialists who generate the evidence. This study aims to investigate perceptions of Australian stroke clinical trialists' about implementation of their findings into practice, and what translation activities they embedded into trial protocols.

MATERIALS AND METHOD

A descriptive cohort design and electronic survey was conducted. Three databases were searched to identify Australian stroke rehabilitation trials published between 2007 and 2017. Corresponding authors of the included trials were invited to complete an anonymous online survey about implementation of their trial intervention.

RESULTS

Fifty-one trialists were invited to participate and 38 completed the survey (74% response rate). The majority (79%) considered their trial results to be clinically significant and 68% had pre-planned knowledge translation activities. The most common planned translation activities were publication (89%), conference presentation (87%), and feedback of results to target audiences (58%). Mixed opinions were evident regarding when and how to design knowledge translation activities for inclusion in trial protocols. Stroke rehabilitation trialists rely mostly on anecdotal reports about implementation of trial interventions, with few formally measuring uptake.Implications for rehabilitationThe most common knowledge translation activities planned for by researchers are publication of findings in academic journals, and conference presentations.Mixed opinions exist regarding when and how to design for knowledge translation activities in trial protocols.Limited formal measurement of intervention uptake is completed.Further implementation research is required to support and measure effective translation efforts when embedded into trial protocols.

Educational Perspectives: Educational Strategies to Improve Outcomes from Neonatal Resuscitation

Since 1987, the Neonatal Resuscitation Program (NRP) course has taught the cognitive, technical, and behavioral skills required to effectively resuscitate newborns. To remain relevant and effective, the NRP course needs to continually evolve and embrace evidence-based educational strategies proven to improve outcomes from resuscitation. In this Educational Perspectives article, 6 educational strategies that can be applied to neonatal resuscitation education are reviewed. These educational strategies include mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, and innovative educational strategies Then knowledge translation and implementation of these educational strategies through passive and active knowledge translation, change theory, design thinking, performance measurement, deadoption strategies, continuous quality improvement, incentive and penalties, and psychological marketing are explored. Finally, ways to optimize faculty development of NRP instructors, including both initial instructor training and ongoing instructor development, are examined. The goal of this review is to help NRP program developers and instructors use evidence-based educational strategies to improve neonatal resuscitation outcomes.

Emergency Medical Services Traumatic Brain Injury Protocols Do Not Reflect Brain Trauma Foundation Guidelines

OBJECTIVES

Implementation of traumatic brain injury (TBI) guideline recommendations for prehospital care is associated with improved outcomes, but prehospital guideline uptake is frequently delayed. Our objective was to estimate how well TBI guidelines are reflected in a national sample of prehospital TBI protocols in 2012 and 2018, 5 and 11 years after guideline publication. Methods: A purposeful sample of publicly accessible prehospital protocols were obtained in 2012, and updates of those protocols were obtained in 2018. Guideline recommendations were codified into a 23-item tool that was used to dual-abstract each prehospital protocol set. Descriptive statistics and chi-square testing were used to compare differences. Fifty-three sets of protocols representing 25 states and multiple administrative structures were identified. Results: None of the protocols contained all twenty-three elements of the guidelines, and more than one-third (19/53, 35%) did not have a TBI-specific protocol. While some individual items appeared more frequently in 2018 than 2012, more than half of the reviewed protocols do not contain guidance on ventilation or definitions of hypoxemia, hypotension, or pupil asymmetry. Conclusions: Evaluation of a diverse sample of EMS protocols demonstrates a significant deficit in the adoption of TBI guidelines more than a decade after publication.

Tradução do Conhecimento e os desafios contemporâneos na área da saúde: uma revisão de escopo

RESUMO A implementação das melhores evidências científicas nos serviços de saúde ainda não ocorre de forma satisfatória. Diante dessa problemática, o objetivo deste estudo foi investigar os desafios da Tradução do Conhecimento (TC) na área da saúde na atualidade. A metodologia desta revisão foi desenvolvida de acordo com os propósitos da revisão de escopo. Para tanto, as palavras-chave ‘translational medical research’ e ‘knowledge translation’ foram consultadas nos bancos de dados de periódicos da PubMed, Scopus e Web of Science. Foram incluídos os estudos publicados a partir do ano de 2008 até abril de 2018. Entre os 1.677 estudos encontrados, 839 artigos eram duplicados, e 818 não atendiam plenamente ao objetivo desta revisão; assim, 20 estudos foram submetidos à apreciação desse escopo. De acordo com as análises dos estudos, o desafio da TC advém de dois fatores: por um lado, a falta de coesão entre a comunidade científica e os tomadores de decisão em saúde; por outro, a inabilidade dos profissionais em traduzir e aplicar novos conhecimentos, além da omissão de apoio e de incentivos das instituições de saúde. Outrossim, esta revisão aborda um corpo significativo de diversos outros aspectos que limitam e/ou dificultam a TC área da saúde.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study

Background: Seizures have the potential to cause significant morbidity and mortality, and are a common reason emergency medical services (EMS) are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation. Objective: The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems. Methods: This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in 3 different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews. Results: Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability. Conclusions: Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

Differences in implementation strategies of the European Resuscitation Council Guidelines 2015 in Danish hospitals - a nationwide study

Introduction

Guideline implementation is essential to improve survival following cardiac arrest. This study aimed to investigate awareness, expected time frame, and strategy for implementation of the European Resuscitation Council (ERC) Guidelines 2015 in Danish hospitals.

Methods

All public, somatic hospitals with a cardiac arrest team in Denmark were included. A questionnaire was sent to hospital resuscitation committees one week after guideline publication. The questionnaire included questions on awareness of ERC Guidelines 2015 and time frame and strategy for implementation.

Results

In total, 41 hospitals replied (response rate: 87%) between October 22 and December 22, 2015. Overall, 37% hospital resuscitation committees (n=15) were unaware of the guideline content. Most hospitals (80%, n=33) expected completion of guideline implementation within 6 months and 93% hospitals (n=38) expected the staff to act according to the ERC Guidelines 2015 within 6 months. In contrast, 78% hospitals (n=32) expected it would take between 6 months to 3 years for all staff to have completed a resuscitation course based on ERC Guidelines 2015. Overall, 29% hospitals (n=12) planned to have a strategy for implementation later than a month after guideline publication and 10% (n=4) hospitals did not plan to make a strategy.

Conclusion

There are major differences in guideline implementation strategies among Danish hospitals. Many hospital resuscitation committees were unaware of guideline content. Most hospitals expected hospital staff to follow ERC Guidelines 2015 within six months after the publication even though they did not offer information or skill training to all staff members within that time frame.

Educational interventions promoting evidence-based practice among emergency nurses: A systematic review

INTRODUCTION

Emergency nurses are expected to adopt evidence-based practice (EBP). The aim of this systematic review was to describe educational interventions promoting EBP and their outcomes among emergency nurses, compared with no education, to inform clinicians and researchers about effective educational interventions suitable for use in emergency departments (EDs).

METHODS

CINAHL, Cochrane, PubMed and Scopus were systematically searched to identify studies published between January 1, 2006 and October 20, 2016 describing educational interventions designed to promote EBP among emergency nurses. 711 studies were identified and screened; 10 were selected for inclusion and quality assessment. The studies were analyzed using deductive content analysis, and the review's results are presented in accordance with the PRISMA guidelines.

RESULTS

Ten relevant studies on nine different self-developed educational interventions were identified. Eight studies had highly significant or significant results. Interventions involving face-to-face contact led to significant or highly significant effects on patient benefits and emergency nurses' knowledge, skills, and behavior. Interventions using written self-directed learning material led to significant improvements in nurses' knowledge of EBP. All the descriptions of the interventions were incomplete, and the reported details varied considerably between the studies.

CONCLUSIONS

There have been few studies on educational interventions to promote EBP among emergency nurses but the available results are promising.

Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review

OBJECTIVE

As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods.

METHODS

This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported.

RESULTS

The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support).

CONCLUSIONS

While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Challenges and Opportunities to Engaging Emergency Medical Service Providers in Substance Use Research: A Qualitative Study

Introduction Research suggests Emergency Medical Services (EMS) over-use in urban cities is partly due to substance users with limited access to medical/social services. Recent efforts to deliver brief, motivational messages to encourage these individuals to enter treatment have not considered EMS providers. Problem Little research has been done with EMS providers who serve substance-using patients. The EMS providers were interviewed about participating in a pilot program where they would be trained to screen their patients for substance abuse and encourage them to enter drug treatment.

METHODS

Qualitative interviews were conducted with Baltimore City Fire Department (BCFD; Baltimore, Maryland USA) EMS providers (N=22). Topics included EMS misuse, work demands, and views on participating in the pilot program. Interviews were transcribed and analyzed using grounded theory and constant-comparison.

RESULTS

Participants were mostly white (68.1%); male (68.2%); with Advanced Life Skills training (90.9%). Mean age was 37.5 years. Providers described the "frequent flyer problem" (eg, EMS over-use by a few repeat non-emergent cases). Providers expressed disappointment with local health delivery due to resource limitations and being excluded from decision making within their administration, leading to reduced team morale and burnout. Nonetheless, providers acknowledged they are well-positioned to intervene with substance-using patients because they are in direct contact and have built rapport with them. They noted patients might be most receptive to motivational messages immediately after overdose revival, which several called "hitting their bottom." Several stated that involvement with the proposed study would be facilitated by direct incorporation into EMS providers' current workflow. Many recommended that research team members accompany EMS providers while on-call to observe their day-to-day work. Barriers identified by the providers included time constraints to intervene, limited knowledge of substance abuse treatment modalities, and fearing negative repercussions from supervisors and/or patients. Despite reservations, several EMS providers expressed inclination to deliver brief motivational messages to encourage substance-using patients to consider treatment, given adequate training and skill-building.

CONCLUSIONS

Emergency Medical Service providers may have many demands, including difficult case time/resource limitations. Even so, participants recognized their unique position as first responders to deliver motivational, harm-reduction messages to substance-using patients during transport. With incentivized training, implementing this program could be life- and cost-saving, improving emergency and behavioral health services. Findings will inform future efforts to connect substance users with drug treatment, potentially reducing EMS over-use in Baltimore. Maragh-Bass AC , Fields JC , McWilliams J , Knowlton AR . Challenges and opportunities to engaging Emergency Medical Service providers in substance use research: a qualitative study. Prehosp Disaster Med. 2017;32(2):148-155.

Implementing evidence-based practices in an emergency department: contradictions exposed when prioritising a flow culture

Background

An emergency department is typically a place of high activity where practitioners care for unanticipated presentations, which yields a flow culture so that actions that secure available beds are prioritised by the practitioners.

Objectives

How does the flow culture in an emergency department influence nurses’ use of a research‐based clinical guideline and a nutrition screening routine.

Methods

Ethnographic fieldwork was carried out over three months. The first author followed nurses, medical secretaries and doctors in the emergency department. Data were also collected by means of semi‐structured interviews. An activity system analysis, as described in the Cultural Historical Activity Theory, was conducted to identify various contradictions that could exist between different parts of the activity system.

Results

The main contradiction identified was that guidelines and screening routines provided a flow stop. Four associated contradictions were identified: insufficient time to implement guidelines; guilty conscience due to perceived nonadherence to evidence‐based practices; newcomers having different priorities; and conflicting views of what constituted being a professional.

Conclusion

We found that research‐supported guidelines and screening routines were not used if they were perceived to stop the patient flow, suggesting that the practice was not fully evidence based.

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making

Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.

Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study

BACKGROUND

The role of infectious diseases (ID) and clinical microbiology (CM) in hospital settings has expanded in response to increasing antimicrobial resistance, leading to widespread development of hospital antimicrobial stewardship (AMS) programmes, the majority of which include antibiotic approval systems. However, inappropriate antibiotic use in hospitals continues, suggesting potential disjunctions between technical advice and the logics of antibiotic use within hospitals.

AIM

To examine the experiences of doctors in a UK hospital with respect to AMS guidance of antibiotic prescribing, and experiences of a verbal postprescription antibiotic approval process.

METHODS

Twenty doctors in a teaching hospital in the UK participated in semi-structured interviews about their experiences of antibiotic use and governance. NVivo10 software was used to conduct a thematic content analysis systematically.

FINDINGS

This study identified three key themes regarding doctors' relationships with ID/CM clinicians that shaped their antibiotic practices: (1) competing hierarchical influences limiting active consultation with ID/CM; (2) non-ID/CM consultants' sense of ownership over clinical decision-making and concerns about challenges to clinical autonomy; and (3) tensions between evidence-based practice and experiential-style learning.

CONCLUSIONS

This study illustrates the importance of examining relations between ID/CM and non-ID/CM clinicians in the hospital context, indicating that AMS models that focus exclusively on delivering advice rather than managing interprofessional relationships may be limited in their capacity to optimize antibiotic use. AMS and, specifically, antibiotic approval systems would likely be more effective if they incorporated time and resources for fostering and maintaining professional relationships.

Post resuscitation care of out-of-hospital cardiac arrest patients in the Nordic countries: a questionnaire study

Background

Aim of this study was to compare post resuscitation care of out-of-hospital cardiac arrest (OHCA) patients in Nordic (Denmark, Finland, Iceland, Norway, Sweden) intensive care units (ICUs).

Methods

An online questionnaire was sent to Nordic ICUs in 2012 and was complemented by an additional one in 2014.

Results

The first questionnaire was sent to 188 and the second one to 184 ICUs. Response rates were 51 % and 46 %. In 2012, 37 % of the ICUs treated all patients resuscitated from OHCA with targeted temperature management (TTM) at 33 °C. All OHCA patients admitted to the ICU were treated with TTM at 33 °C more often in Norway (69 %) compared to Finland (20 %) and Sweden (25 %), p 0.02 and 0.014. In 2014, 63 % of the ICUs still use TTM at 33 °C, but 33 % use TTM at 36 °C. Early coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) was routinely provided for all survivors of OHCA in 39 % of the hospitals in 2012 and in 28 % of the hospitals in 2014. Routine CAG for all actively treated victims of OHCA was performed more frequently in Sweden (51 %) and in Norway (54 %) compared to Finland (13 %), p 0.014 and 0.042.

Conclusions

Since 2012, TTM at 36 °C has been implemented in some ICUs, but TTM at 33 °C is used in majority of the ICUs. TTM at 33 or 36 °C and primary CAG are not routinely provided for all OHCA survivors and the criteria for these and ICU admission are variable. Best practices as a uniform approach to the optimal care of the resuscitated patient should be sought in the Nordic Countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0141-z) contains supplementary material, which is available to authorized users.

The Canadian National EMS Research Agenda: a mixed methods consensus study

Introduction:

Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study.

Methods:

Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as “important” or “very important.”

Results:

Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/ providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n 5 10), strengths/opportunities (n 5 24), and recommendations (n 5 19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda.

Conclusions:

Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.

Variation in prehospital use and uptake of the national Field Triage Decision Scheme

BACKGROUND

The Field Triage Decision Scheme is a national guideline that has been implemented widely for prehospital emergency medical services (EMS) and trauma systems. However, little is known about the uptake, modification, or variation in field application of triage criteria between trauma systems.

OBJECTIVE

To describe and compare the use of field triage criteria by EMS personnel in six regions, including the timing of guideline uptake and the use of nonguideline criteria.

METHODS

This was a retrospective cohort study of injured children and adults transported by 48 EMS agencies to 105 hospitals (trauma centers and non-trauma centers) in six Western U.S. regions from 2006 through 2008. We used probabilistic linkage to match patient-level prehospital information from multiple sources, including EMS records, base-hospital phone communication records, and trauma registry data files. Triage criteria were evaluated individually and grouped by "steps" (physiologic, anatomic, mechanism, and special considerations). We used descriptive statistics to compare the frequency of triage criteria use (overall and between regions) and to evaluate the timing of guideline uptake across multiple versions of the guidelines.

RESULTS

A total of 260,027 injured patients were evaluated and transported by EMS over the three-year study period, of whom 46,414 (18%) met at least one field triage criterion and formed the primary sample for analysis. The three most common criteria cited (of 33 in use) were EMS provider judgment (26%), age <5 or >55 years (10%), and Glasgow Coma Scale (GCS) score <14 (9%). Of the 33 criteria in use, five (15%) were previously retired from the guidelines and seven (21%) were never included in the guidelines. 11,048 (24%) patients had more than one criterion applied (range 1-21). There was large variation in the type and frequency of criteria used between systems, particularly among the nonphysiologic triage steps. Only one of six regions had translated the most recent guidelines into field use within two years after release.

CONCLUSION

There is large variation between regions in the frequency and type of field triage criteria used. Field uptake of guideline revisions appears to be slow and variable, suggesting opportunities for improvement in dissemination and implementation of updated guidelines.

Use of local data to enhance uptake of published recommendations: an example from the diagnostic evaluation of precocious puberty

BACKGROUND

It has been recommended that basal luteinising hormone (LH) levels be used as the initial test to identify cases of central precocious puberty (CPP) in children. However, in clinical practice, gonadotropin-releasing hormone (GnRH) stimulation tests are frequently still used.

OBJECTIVE

To assess the diagnostic utility of a single LH to identify CPP in girls, as a means to safely reduce GnRH stimulation testing rates.

DESIGN

Retrospective analysis of patients referred for GnRH stimulation between August 2007 and December 2010, with prospective 12-month follow-up of GnRH stimulation testing rates post implementation of management algorithm.

PATIENTS

57 girls (6.2 ± 2.1 years) with early signs of puberty.

MAIN OUTCOME MEASURE

Ability of basal LH to predict clinical pubertal progression, 6 months following the GnRH stimulation test.

RESULTS

Pubertal progression occurred in 18 patients. All patients with a basal LH level ≥ 0.3 IU/L had subsequent pubertal progression, while 39 of 41 patients with a basal LH ≤ 0.2 IU/L did not progress, resulting in 100% specificity (95% CI 92% to 100%) and 90.5% sensitivity (69.6% to 98.8%). Using the locally derived algorithm, GnRH stimulation testing was redirected to patients with pubertal progression that was discordant with basal LH data. Post intervention, there was a 75% reduction in GnRH stimulation testing without comprising the rate of diagnosis of CPP.

CONCLUSIONS

Our results confirm the diagnostic utility of basal LH levels in the diagnosis of CPP and demonstrate that dissemination and interpretation of local data may facilitate change in clinical practice, resulting in streamlined patient care and cost savings.

Next generation paramedics, agents of change, or time for curricula renewal?

BACKGROUND

Knowledge translation involves the dissemination and application of scientific research findings into clinical practice. In the health care arena, uptake of evidence-based assessment and intervention strategies is aimed at reducing inefficiencies and ultimately improving patient outcomes. However, numerous studies have purported gaps in knowledge translation in the health care professions. The objective of this study was to classify the traits of undergraduate paramedic students from Monash Univeristy, Australia, using the practice style inventory (PSI).

METHODS

A cross-sectional study of students across all undergraduate years from Emergency Health and Emergency Health/Nursing was completed. Student knowledge translation levels were measured using the 17-item paper-based PSI.

RESULTS

A total of 266 students participated in the study, of which 68.4% were females. The majority of participants were <26 years of age (n=228) and just over half enrolled in second year studies (n=134). Two subscales produced statistically significant differences: evidence versus experience (extent to which scientific evidence rather than authority is perceived as the best source of knowledge) and nonconformity (degree of comfort with clinical practices that are out of step with recommendations of leaders). There was a statistically significant difference between sex on the evidence versus experience subscale (P<0.0001, d =0.51), and between year levels on the nonconformity subscale (P<0.007, d =0.63).

CONCLUSION

This study identified several differences in knowledge translation subscales in the undergraduate paramedic cohorts. Further investigation is warranted in order to better understand barriers and facilitate improved uptake of evidence-based research into clinical practice and, ultimately, improve patient outcomes. Future research using a longitudinal study design to capture changing attitudes to knowledge translation in the postgraduate population may also prove valuable in curricula renewal.

Parental tobacco screening and counseling in the pediatric emergency department: practitioners' attitudes, perceived barriers, and suggestions for implementation and maintenance

INTRODUCTION

The pediatric emergency department (PED) is a venue that underuses parental tobacco screening and brief cessation counseling. We sought to explore PED practitioners' attitudes and perceived barriers regarding the implementation and adoption of tobacco screening/cessation counseling of parental smokers in the PED setting, as well as to solicit suggestions for improving the sustainability and maintenance of such practices.

METHODS

We conducted an exploratory, qualitative study of a convenience sample of PED practitioners using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Individual, focused interviews were conducted to determine factors that would maximize the implementation and maintenance of parental tobacco screening and intervention counseling as standard PED practice.

RESULTS

Thirty interviews were conducted from which relevant data, patterns, and themes were identified. Reach factors included targeting parental smokers with children with respiratory diseases, having adequate training of practitioners, and providing "prearranged" counseling packages. Effectiveness factors included practitioner desire for outcome data about intervention effectiveness (eg, changes in children's secondhand smoke exposure and parental quit rates). Solutions to increase intervention adoption included quick electronic health record prompts and the provision of onsite tobacco cessation experts. Implementation suggestions emphasized the importance of financial support and the alignment of tobacco screening/counseling with strategic plans. Maintenance factors included institutional and technical support, as well as the importance of intervention "champions" in the PED.

DISCUSSION

By highlighting important viewpoints of practitioners regarding tobacco screening and counseling, the findings can help guide and direct the development and evaluation of sustainable interventions to facilitate tobacco use treatment in the PED.

Real-time audiovisual feedback system in a physician-staffed helicopter emergency medical service in Finland: the quality results and barriers to implementation

OBJECTIVES

To evaluate the quality of cardiopulmonary resuscitation (CPR) in a physician staffed helicopter emergency medical service (HEMS) using a monitor-defibrillator with a quality analysis feature. As a post hoc analysis, the potential barriers to implementation were surveyed.

METHODS

The quality of CPR performed by the HEMS from November 2008 to April 2010 was analysed. To evaluate the implementation rate of quality analysis, the HEMS database was screened for all cardiac arrest missions during the study period. As a consequence of the observed low implementation rate, a survey was sent to physicians working in the HEMS to evaluate the possible reasons for not utilizing the automated quality analysis feature.

RESULTS

During the study period, the quality analysis was used for 52 out of 187 patients (28%). In these cases the mean compression depth was < 40 mm in 46% and < 50 mm in 96% of the 1-min analysis intervals, but otherwise CPR quality corresponded with the 2005 resuscitation guidelines. In particular, the no-flow fraction was remarkably low 0.10 (0.07, 0.16). The most common reasons for not using quality-controlled CPR were that the device itself was not taken to the scene, or not applied to the patient, because another EMS unit was already treating the patient with another defibrillator.

CONCLUSIONS

When quality-controlled CPR technology was used, the indicators of good quality CPR as described in the 2005 resuscitation guidelines were mostly achieved albeit with sufficient compression depth. The use of the well-described technology in improving patient care was low. Wider implementation of the automated quality control and feedback feature in defibrillators could further improve the quality of CPR on the field.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT00951704).

Providers' perceptions of the factors influencing the implementation of the New York State mandatory HIV testing law in two Urban academic emergency departments

OBJECTIVES

Of the 1.1 million people in the United States infected with human immunodeficiency virus (HIV), more than 20% are unaware of their infection. To increase early diagnosis and treatment, New York State recently passed legislation mandating that HIV testing be offered to all patients, ages 13 to 64 years, receiving health care services. Implementation of this legislation is complex, especially in the emergency department (ED). This study explores ED providers' perceptions of the factors affecting the implementation of the law.

METHODS

The authors conducted six focus group sessions and three in-depth interviews with ED health care providers from two New York City teaching hospitals. Sessions were audiotaped and transcribed. Data were coded and summarized thematically through an iterative process after each session.

RESULTS

A total of 49 providers participated and data saturation was achieved. Six factors were identified that predispose a provider to offer an HIV test: 1) self-efficacy, 2) behavioral intention, 3) the testing process, 4) provider knowledge of the legislation, 5) type of HIV test, and 6) follow-up procedures. Five factors were identified that enable providers to offer an HIV test: 1) resources related to time, 2) space, 3) staff, 4) type of test, and 5) timing of the offer. Improving access to HIV testing, linkage to care, and public health were all key factors in reinforcing providers' desire to offer HIV tests. Concerns regarding overall cost saving and coverage for the test were indicated as barriers that needed to be resolved to reinforce the providers to offer an HIV test.

CONCLUSIONS

Understanding the factors influencing the practice of ED providers charged with carrying out this mandate is critical. Despite earlier research that indicated that offering HIV testing to ED patients is largely influenced by cost, this study found additional factors that are important to consider to effectively implementing HIV testing in the ED.

A structured educational intervention to improve targeted temperature management utilization after cardiac arrest

PURPOSE

Post-arrest targeted temperature management (TTM) has been shown to dramatically improve outcomes after resuscitation, yet studies have revealed inconsistent and slow adoption. Little is known about barriers to TTM implementation and methods to increase adoption. We hypothesized that a structured educational intervention might increase TTM use.

MATERIALS AND METHODS

Subjects participated in mixed quantitative/qualitative surveys before and after attending a series of TTM educational courses from October 2010 to October 2011, to determine usage and barriers to implementation. A knowledge examination was also administered to participants before and after the course.

RESULTS

Clinicians completed 227 surveys (129 pre-training and 98 post-training) and 343 exams (165 pre-training and 178 post-training). A ranking survey (score range 1-7; 7 as most challenging) found that communication challenges (mean score 4.7 ± 1.5) and lacking adequate education (4.3 ± 1.9) were the 2 most emphasized barriers to implementation. Post-survey results found that 95% (93/98) of respondents felt more confident initiating TTM post-intervention. There was a statistically significant increase in self-reported TTM usage after participation in the program (P < .01).

CONCLUSIONS

A focused TTM program led to increased confidence and usage among participants. Future work will focus on targeted training to address specific barriers and increase TTM utilization.

A qualitative assessment of factors that influence emergency medical services partnerships in prehospital research

OBJECTIVES

  Recent efforts to increase emergency medical services (EMS) prehospital research productivity by focusing on reducing systems-related barriers to research participation have had limited effect. The objective of this study was to explore the barriers and motivators to participating in research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects.

METHODS

  The authors conducted a qualitative exploratory study of EMS personnel using focus group and focused interview methodology. EMS personnel affiliated with the Pediatric Emergency Care Applied Research Network (PECARN) hospitals were selected for participation using a purposive sampling plan. Exploratory questioning identified identified factors that influence participation in research and suggestions for ensuring successful research partnerships. Through iterative coding and analysis, the factors and suggestions that emerged from the data were organized into a behavioral change planning model.

RESULTS

  Fourteen focus groups were conducted, involving 88 EMS prehospital providers from 11 agencies. Thirty-five in-depth interviews with EMS administrators and researchers were also conducted. This sample was representative of prehospital personnel servicing the PECARN catchment area and was sufficient for analytical saturation. From the transcripts, the authors identified 17 barriers and 12 motivators to EMS personnel participation in research. Central to these data were patient safety, clarity of research purpose, benefits, liability, professionalism, research training, communication with the research team, reputation, administrators' support, and organizational culture. Interviewees also made 29 suggestions for increasing EMS personnel participation in research. During data analysis, the PRECEDE/PROCEED planning model was chosen for behavioral change to organize the data. Important to this model, factors and suggestions were mapped into those that predispose (knowledge, attitudes, and beliefs), reinforce (social support and norms), and/or enable (organizational) the participation in prehospital research.

CONCLUSIONS

  This study identified factors that influence the participation of EMS personnel in research and gathered suggestions for improvement. These findings were organized into the PRECEDE/PROCEED planning model that may help researchers successfully plan, implement, and complete prehospital research projects. The authors provide guidance to improve the research process including directly involving EMS providers throughout, a strong theme that emerged from the data. Future work is needed to determine the validity of this model and to assess if these findings are generalizable across prehospital settings other than those affiliated with PECARN.

Cardiac arrest survival did not increase in the Resuscitation Outcomes Consortium after implementation of the 2005 AHA CPR and ECC guidelines

INTRODUCTION

We examined the effect of the 2005 American Heart Association guidelines on survival in the Resuscitation Outcomes Consortium (ROC) Cardiac Arrest Epistry.

METHODS

We surveyed 174 EMS agencies from 8 of 10 ROC sites to determine 2005 AHA guideline implementation, or crossover, date. Two sites with 2005 compatible treatment algorithms prior to guideline release, and agencies that did not adopt the new guidelines during the study period were excluded. Non-traumatic adult cardiac arrests that were not witnessed by EMS, and did not have do not resuscitate orders were included. A linear mixed effects model was applied for survival controlling for time and agency. The "crossover" date was added to the model to determine the effect of the 2005 guidelines.

RESULTS

Of 174 agencies, 85 contributed cases to both cohorts during the 18 month period between 2005/12/01 and 2007/05/31. Of 7779 cases, 5054 occurred during the 13 month (median) interval before crossover and 2725 occurred in the five month (median) interval after crossover. The overall survival rate was 6.1%; 5.8% in the old cohort vs. 6.5%, p=0.23. For VF/VT patients, survival was 14.6% vs. 18.0%, p=0.063. Our model estimated no increase in survival over time (monthly OR 1.014, 95% CI 0.988, 1.041, p=0.28).

CONCLUSION

This study found no significant change in survival rate over time in the early months after implementation. Further longitudinal study is needed to determine the full impact of the guidelines on survival and methods to translate knowledge quickly and effectively in EMS.