Barriers to and facilitators of the development and utilization of context appropriate evidence based clinical algorithms to optimize clinical care and patient outcomes in the Tikur Anbessa emergency department: a multi-component qualitative study

We aimed to identify barriers and facilitators to implementation and utilization of EBCAs in the TASH-ED. Additional objectives were to assess stakeholder perceptions regarding the need for and perceived priority targets for development and implementation of EBCAs tailored for the TASH-ED practice context and to understand the context and process of care in the TASH-ED to inform implementation planning.

Multi-component qualitative study including: stakeholder interviews, direct observation of the process of care and flow of patients through the TASH- ED, and document review.

Participants were purposefully selected to represent the range of stakeholders from Tikur Anbessa Specialized Hospital clinical, administrative and essential support services staff who had worked in the TASH-ED for at least 1 month, and University of Toronto affiliated hospital emergency physicians who have worked clinically in the Tikur Anbessa Emergency Department as part of the Toronto Addis Ababa Academic collaboration in emergency medicine (TAAAC EM). TAAAC EM is a collaboration between Adds Ababa and Toronto universities to support the development and implementation of the EM residency program at Addis Ababa University, based at TASH, with emergency medicine faculty from University of Toronto affiliated hospitals providing onsite clinical teaching 3 months each year since the programs’ inception.

A list of potential key informants was developed in consultation with local study team members to represent the range of clinical training (staff physician, residents; masters, bachelor and diploma nurse), primary clinical area (emergency medicine, surgery, internal medicine), and essential support services (pharmacy, radiology, laboratory services, ED management). Snow-ball sampling, which involved asking participants to identify individuals who they felt would provide a unique perspective to the discussion, was subsequently used to identify additional key informants based at TASH. Participants were selected from a list of eligible Toronto participants to represent the range of clinical training, usual practice setting, years of EM experience, and number of months worked in the TASH-ED. Participants identified in the initial TASH and Toronto lists were approached in person or by telephone by the principal investigator (LPR) or a trained research assistant (SB) and invited to participate. Participants identified by snow-ball sampling, were given a brief introduction to the study by the referee and then introduced to the study team. Written informed consent was obtained from all participants. Participants received no remuneration for participation.

Data collection in Ethiopia took place over 2 weeks in July, 2015, and included: a document review, key informant interviews and field observation. Prior to introduction of the study to TASH-ED staff, a search of the clinical, administrative and educational areas of the TASH-ED was undertaken by the Toronto study team, to explore required ED documentation; roles, responsibilities and reporting structure; and any EBCAs available for use in the TASH-ED. Identified paper documents were photographed and electronic documents saved to a USB for analysis. Interviews were conducted by the PI or a trained research assistant using a semi-structured interview guide developed based on the theoretical domains framework (TDF) and previous experience in conducting barrier/facilitator assessments [5, 6] (see Additional file 1). Interviews also sought suggestions for clinical presentations they would most value EBCAs tailored to the TASH-ED context developed for. Interviews were conducted in a private location at TASH at a time convenient to participants. Basic demographic data was collected at the start of each interview, including: background training, current position, years of experience, and for Toronto physicians amount of time spent working in the TASH-ED at the time of the interview. Interviews were conducted in English, with a translator available. Interviews were audio-taped and transcribed verbatim. In order to allow for flexibility to accommodate stakeholder schedules and for observations to reflect times with varying patient volumes and department staffing, field observations and interviews took place concurrently. Observations were conducted by the PI, who is a practicing emergency physician with limited exposure to the TASH-ED prior to the field observation. Observations took place on varying days of the week (commonly busy and less busy days), as well as, at variable times of day (day/evening shifts) and days of the week, for a total of 2 full days. Observations were undertaken in 4 h blocks purposively selected to ensure a comprehensive understanding of changes in patient flow, volumes, and staffing during peak and off-peak hours. A first-year resident based at TASH was present throughout observation to answer any contextual, cultural, or language related questions arising. In order to gain an understanding of the process of care and flow of patients through the emergency department observations were made in: patient arrivals/registration, triage, clinical areas of the department (acute/sub-acute/resuscitation/ED admitted patient area), and support service areas such as radiology, laboratory services, and pharmacy. Field notes were taken during observation. Interviews with Toronto-based physicians were conducted by the PI over 6 weeks in July and August 2015and followed the same interview guide and procedures as for TASH staff. With the exception of one interview during which the recorder failed and hand written notes were taken, as above, interviews were audio taped, and transcribed verbatim.

We used directed content analysis [7], with interviews, as the unit of analysis. NVivo 10 (QSR International Inc., Southport, UK) was utilized to code the data. An initial coding framework based on the theoretical domains framework (TDF) and past experience conducting barrier and facilitator assessments [5, 6] was used. The initial coding framework was expanded based on our preliminary analysis of the interviews. Analysis of interview transcripts occurred in two rounds. First, transcripts were read and coded independently by two study team members (LPR/SB). The coding framework was then revised and applied independently by the same two study team members. Discrepancies were resolved through discussion. Data from field notes were analyzed by the observer with findings discussed with local study team members to ensure accuracy and understanding of observations. Too few relevant documents were identified for analysis.

Several methods were employed during data collection and analysis to enhance the trustworthiness of the study findings. Prior to the start of interviews, participants were informed of the importance of their honest views as these would be used to guide future work to improve patient care and outcomes in their setting. In addition, participants were informed as part of the consent process that their names and interview data would not be accessible by the local study team members, and the findings anonymized so that they could not be identified. Member checks were performed during the interview. Data source triangulation was employed with a wide range of respondents representing all key stakeholder groups within the TASH-ED and from departments providing essential support services, as well as, from ED physicians from University of Toronto affiliated hospitals who had worked in the TASH-ED. Finally, method triangulation [8] was employed in which ED observations and identified documents were considered together with the interview findings to provide a comprehensive understanding of EBCA availability and use in the TASH-ED, and potential barriers to and facilitators of implementation and utilization of context appropriate EBCAs in the TASH-ED.

Field observation provided both a more in-depth understanding of barriers to and facilitators of uptake and utilization of EBCAs in the TASH-ED, as well as, identified areas of importance for tailoring EBCAs for context and potential strategies for implementation. Chief among these was an appreciation of the high volume of high acuity patients routinely managed and context of care in the TASH-ED, which was recognized as both a barrier to uptake of EBCAs, and reinforced the perceived need among TASH-ED for context appropriate EBCAs to facilitate prompt evidence based care. It was not uncommon for several critically ill and/or injured patients to arrive simultaneously, challenging the ED’s capacity in terms of both space and human resources to triage and begin urgent resuscitation. Due to the small number of ED faculty at the time of this study, the TASH-ED was predominantly staffed by EM and off-service residents in the early years of their training. This finding highlighted the perceived need for quick reference guides for urgent cases to facilitate prompt investigation and initial management, until the senior EM resident and/or staff physician can be consulted. A second important challenge to implementation of EBCAs in the TASH-ED was the physical layout and lack of space. Large numbers of patients were boarded in the ED for long periods of time, leading to crowding in treatment areas and clustering of patients in central spaces and near doorways, making movement of patients and staff through the department, or out of the department to imaging, laboratory services or to the pharmacy, challenging.

Third, both the costs of and cues to pay for laboratory and imaging tests, and medications and supplies, are barriers to utilization of standard EBCAs in the TASH-ED. Opportunities to reduce delays in procuring necessary tests and supplies are important to successful implementation of EBCAs in this context. An example work around implemented in the resuscitation room, where urgent medications and supplies are stored for immediate use and later replaced by the patients family, have been highly successful in reducing delays and suggests opportunities for this approach for other time sensitive conditions. Finally, additional context and process of care issues were also identified as important considerations in selection of strategies for EBCA implementation. Patient charts are paper based and include paper orders/results on non-standard sized forms, making comprehensive test and treat ED order sets inconsistent with standard practice and may represent a challenge to this approach. Visible wall space is limited due to curtains and/or partitions making use of reminder posters less feasible in some areas, and suggests a need for a more readily available reminder formats such as pocket cards, chart attachments or formats for use on personal phones. Computer and internet access are limited within the ED, making computer based formats/application less feasible.

As noted above, despite an extensive search too few relevant documents were identified to allow for qualitative analysis. Nursing staff roles, responsibilities, and reporting structure were well documented and made available to staff. Standard operating procedures (SOPs) for common ED nursing procedures were also well documented, with nursing staff required to read and sign off on SOPs, when changed or when new SOPs were developed. No EBCAs were found to be available in TASH-ED clinical areas. ACLS, ATLS and a neonatal resuscitation guideline were posted in the ED education center classroom (not within the ED), and a small number of EBCAs and non-evidence based ED, critical care, and general medical guidelines were saved to computers in the ED computer lab. It was unclear whether these were saved for reference during clinical work as the computer lab is attached to the ED or whether these documents had been downloaded by residents while preparing presentations as appeared to be the case for some guidelines.

Combined barrier and facilitator findings are presented within TDF domains with representative quotes, in Table 2. Although access to and experience with EBCAs was limited, there was a high degree of perceived need for context appropriate EBCAs to improve patient care and outcomes for high burden clinical conditions in TASH-ED. Shortage of human and material resources were identified as the main barriers to EBCAs being used in the TASH-ED. Other reported and observed barriers include high turnover of trainees rotating through the emergency department, lack of physical space making movement within and through the ED challenging, and issues with process of care with respect to accessing medications and supplies, lack of access to and fit of published EBCAs with the TASH-ED context and resistance to use of EBCAs from consultant services. In terms of facilitators, wide engagement of both TASH-ED staff and consultant services were felt essential to successful implementation of EBCAs in the TASH-ED. Other facilitators include strong leadership in the ED, and interest in and a recognized need for EBCAs to standardize and support evidence based care for common urgent clinical conditions treated in the TASH-ED.

Interview participants include the range of both training and experience of staff regularly working in and/or providing essential services to the TASH-ED, allowing for identification of barriers/facilitators from a range of perspectives improving overall understanding of key factors to address in EBCA development and implementation planning, and potential approaches to doing so. Use of multiple data sources including interviews with practicing Toronto ED physicians with experience in working with EBCAs in a variety of clinical contexts and direct observation, provides a comprehensive understanding of identified barriers, facilitators & considerations for EBCA and implementation that would not have been identified through the more common approach to barrier/facilitator assessment employing interviews or surveys alone.

Due to the relatively unique nature of the TASH-ED as the location of the first EM training site and leaders in the development of EM in Ethiopia, the findings from the present study are relatively less generalizable to settings with less developed EM services both within Ethiopia and in other LMICs. In addition, recent improvements in the TASH-ED structure and changes to both structure and function of the ED once the department relocates to the new ED currently under construction, will require reassessment of the structural and process barriers identified in the present study.