Background
Bronchial Asthma (BA) is one of the most common chronic diseases worldwide. Epidemiological studies showed high prevalence of asthma in children in many countries all over the globe [
1] and the disease is associated with considerable morbidity and a significant economical burden for many countries [
2]. In Saudi Arabia asthma is one of the most common chronic diseases, affecting more than 2 million people [
3]. The prevalence of childhood BA in Saudi Arabia has increased in less than a decade from 8% to 23% [
4,
5]. The impact of childhood asthma, as a public health problem for communities and the continuing innovations in its management, led to the development of evidence based clinical practice guidelines and protocols for its management. However, unless these guidelines and protocols are successfully implemented [
6], translation of evidence into practice and improvement in patient care will not be achieved [
7,
8].
Clinical practice guidelines (CPG) are “systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances” [
9]. Despite the expected positive impact of the implementation of CPG on the health of the individuals and the quality of medical care by decreasing inappropriate variation in clinical practice, guidelines are not uniformly adopted [
10].
Many studies investigated the barriers to the implementation of CPG in healthcare and the effective strategies for translating research into practice, however it is recognized that identification of local barriers to change is pivotal to changing practitioners’ behavior towards adoption of guidelines [
11].
In this study we examine the barriers to the adoption of the asthma clinical practice guideline by the healthcare professionals in the pediatrics emergency department (PED), focusing on the guidelines as an innovation and employing the theory of diffusion of innovation to investigate the barriers to implementation.
Diffusion of innovation, as introduced by Rogers et al, is the process by which a new practice (an innovation) is communicated over time among members of a social system [
12]. The process of adoption of innovation develops in 4 stages which are: knowledge or awareness, persuasion, decision and implementation. The concept was further developed by Greenhalgh and her colleagues to include innovation in health services organizations [
13]. They suggested that diffusion of innovation is influenced by factors related to the attribute of the innovation, the adopters’ characteristics, the context or the environment where the innovation is implemented and the dissemination efforts [
13].
In this study we considered the Pediatric Asthma Management Protocol (PAMP) as the innovations, the healthcare professionals working in the emergency department as adopters and the organization (department and the hospital) is the context or the environment in which the PAMP is implemented. We investigated the barriers for implementations through the lens of the factors which influence innovation adoption, including the characteristics (attributes) of the PAMP, the characteristics of the healthcare professionals (adopters’ characteristics) and the environmental factors (context) which constitutes the complex environment of the department and the hospital as well as the patient as a stakeholder.
Method
The protocol for this study was approved by King Saud University Institutional Review Board and by the PED.
This study is designed in 2 parts; the first part is a patients’ chart review to investigate the compliance of healthcare providers (physicians and nurses) to 8 recommendations of the PAMP and the second part is a focus group interview to elicit the reasons behind non- adherence to the recommendation detected by the chart review. The 8 key recommendations which were deduced from the literature [
14] were considered as indicators for evidence based best practice.
King Khalid University Hospital (KKUH) in Riyadh, one of King Saud University Hospitals, is a tertiary referral center. The hospital has 750 beds and provides services for all major specialties as well as subspecialties such as infertility and plastic surgery. The hospital provides emergency services through the adult and pediatric emergency departments.
During the last 2 years KKUH has witnessed considerable expansion and reform to face the increase in the catchment area covered by its services and to fulfill the requirements for the accreditation.
To unify the quality of healthcare delivery, the hospital accreditation requires implementation of clinical guidelines in all departments with high turnover of patients such as the emergency department. Sheikh Bahamdan Research Chair of Evidence Based Healthcare and Knowledge Translation is commissioned by the Quality Department to outline strategies for effective implementation of Clinical Practice Guidelines (CPG) in high demand areas. The PED is one of the busiest departments in the hospital; there were 42,635 visits to the department in 2009, 5% of which were for BA.
The PED has few protocols to unify the management of certain conditions which are seen frequently in the PED including a protocol for management of acute BA.
The PAMP is based on the recommendations of the Saudi Initiative for Asthma (SINA), which is a national guideline for the management of asthma in adults and children [
3]. SINA was adapted from Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program [
3,
15].
The PAMP was developed by the members of the pulmonology department in KKUH without active contribution from the staff in the PED. The protocol has no reference to the parent guidelines from which it was developed. Implementation of the protocol started in 2005.
The PAMP was introduced to the PED staff during one of the department monthly meetings, which is usually attended by the physicians and the head nurse. Following the meeting the protocol was approved for implementation. The PAMP was not accompanied by an implementation strategy.
Chart review
To investigate the healthcare providers’ adherence to the existing PAMP; the file numbers of the patients seen by the PED with the diagnosis of BA during the period from the 1st of January 2009 to the 31st of March 2009, were extracted from the PED admission registry book, then the patients charts were retrieved for data collection.
Data were extracted from the medical record using a pre-formatted data collection sheet. For the purpose of establishing the percentage of patients with mild and moderate asthma who received Ipratropium, and due to infrequent documentation of asthma severity grading in patients’ records, a retrospective grading was done by the two authors at the time of data collection using the same grading score of the PAMP and the vital signs recorded for each patient which were available for all patients included in this study.
Any feature of moderate asthma led to classification as moderate and any feature of severe asthma led to the classification as severe.
Data collected included the number of healthcare providers complying with the following 8 recommendations which were considered as frequently encountered evidence-practice gaps in the management of acute BA in children [
14]:
1.
Documentation of asthma severity grading by the treating physician and nurse as either mild, moderate or severe.
2.
Administration of Salbutamol using an inhaler via a spacer.
3.
Prescription of systemic corticosteroids to all cases of acute BA.
4.
Documentation of parental education for the home asthma management plan.
5.
Management of all cases of asthma as outpatients unless diagnosed as severe or life threatening asthma.
6.
Prescription of Ipratropium for children with severe asthma only.
7.
Prescription of antibiotics for children with evidence of chest infection only.
8.
Chest x-ray requisition for children with signs of chest infection only.
The cut-off value for each recommendation was extracted from the PAMP recommendations; when the recommendation includes (all patients) we considered the cut-off value to be 100% of patients and this applied to recommendations 1–4. For recommendations 5 and 6 we performed retrospective asthma grading of all patients included in the chart review and we considered the cut-off value as the percentage of children who presented with severe or life threatening asthma. For recommendations 7 and 8 we calculated the cut-off value from the percentage of children with asthma who were febrile when they presented to PED. Cut-off values were rounded to the nearest 10.
The percentage of healthcare providers adhering to each one of the 8 recommendations aforementioned was calculated.
Following the analysis of the focus group interviews, further analysis of the chart review data was performed to explore the adherence of the healthcare providers to the PAMP recommendations stratified by patients’ age group (≤ 3 and >3 years). The analysis was performed to substantiate or refute the claims of the healthcare providers about the difficulties to apply the PAMP recommendations on young children as the reason for non-adherence. Furthermore the charts of the children who re-visited PED within a week of the first visit with asthma were identified from admission registry book and were excluded from the final analysis.
Other data collected included the gender and the age of the child.
Focus group interview
The first part of this study showed that there were 5 recommendations of the PAMP which were not adhered to by the healthcare providers namely; grading of asthma severity, the prescription of Salbutamol nebulizer instead of the inhaler, over-prescription of Ipratropium for mild or moderate asthma, under-prescription of corticosteroids and lack of documentation of parents’ counseling for home treatment plan (Table
1).
Table 1
Recommendations of the PAMP inadequately adhered to by the healthcare providers
Documentation of Asthma severity grading | 100% | 3 (0.4) | 1 (0.3) | 2 (0.6) |
Salbutamol metered-dose inhaler use | 100% | 0.0 | 0.0 | 0.0 |
Ipratropium prescription | ≤ 10% | 316 (48.1) | 149 (45.4) | 167 (50.7) |
Corticosteroid prescription | 100% | 188 (28.6) | 83 (25.3) | 105 (32.0) |
Documented parents’ education | 100% | 2 (0.3) | 1 (0.3) | 1 (0.3) |
We conducted focus group interviews to explore the opinions of the healthcare professional about the reasons behind non-adherence to the aforementioned recommendations of the PAMP. The focus group interview approach was chosen to facilitate fuller expression of the participants’ opinions, capitalizing on the group dynamic and interaction during the discussion [
16,
17].
At the time of data collection for this study, the PED was staffed by 12 physicians who covered 8 hour shifts, and 20 nurses who covered 12 hour shifts. There were 4 consultant physicians, 6 specialists and 2 residents. All physicians are bilingual; speaking both Arabic and English except for 2 who speak English and Urdu. The nursing staff includes one head nurse, 10 senior and 10 junior nurses. All nurses speak Filipino as their first language and English as the language of communication with the other professionals in the department. On joining the department, all nurses were given courses in Arabic language to help communication with the patients.
We used a purposive sampling to recruit nurses and physicians for the focus group. The participants of the focus group were staff who hold substantive posts (locum staff excluded) and who have spent a year or more in the PED. All nurses and physicians working in the PED were invited to participate in the focus group interview; however participation was totally voluntary with the option to withdraw at any time during the interview.
At the start of each focus group the study objectives were explained to the participants, confidentiality was granted and the permission of the participants to tape-record the session was obtained.
During November and December 2009; 2 separate focus group interviews were conducted for 10 physicians and 10 nurses by the authors (RZ, HW), at the PED during a time convenient to the participants.
The questions for the semi-structured interview for focus group, which were developed by the authors, were asked to the participants to start the focus group discussion (Additional file
1).
The participants were encouraged to discuss the barriers for implementation of the 5 recommendations of the PAMP which were not adhered to, quite freely and only when the discussion was out of track, did one of the authors interfere to direct the discussion back to the study topic [
16]. Focus group interviews were conducted in English language (the language for reporting medical findings). At rare occasions Arabic speaking physicians spoke in their first language; at those times one of the facilitators encouraged them to express themselves in English language so as not to disturb the group dynamic for English speaking physicians. At all times one of the two facilitators (RZ and HW) kept field notes while the other facilitator ensured the coverage of all the topics on the topic guide.
To deepen our understanding of the issues raised during the focus group as reasons behind non-compliance to the recommendations, the two authors performed 4 additional individual semi- structured interviews, one with each of the following key personnel; the head of department, the head nurse, the pharmacist responsible for the equipment and drug supply to the PED and the most senior physician in the department. The head of the department and the pharmacist did not attend the large focus group interview while the senior nurse and the senior physician did. The purpose of the interviews was to further explore the reasons raised by the focus groups to be behind non-adherence to the PAMP.
Focus group data analysis
The interviews were tape-recorded, transcribed verbatim and independently checked for accuracy by the two authors. Transcribed interviews were read and text which appears to describe a barrier to the implementation of the asthma protocol was highlighted. Subsequently all the highlighted text was coded using the predetermined themes applying a directed qualitative content analysis as described by Hsieh et al. [
18]. For this method of content analysis and to determine the main themes of the study, we draw on the conceptual model of the innovation diffusion theory [
12] and its application in healthcare organizations [
13]. The following themes were derived from the theory; perceived characteristics of the innovation (PAMP), characteristics of the adopters (healthcare professionals), and the context (organizational factor). The sub-themes emerged from the interviews. According to the codes, quotes were sorted into themes and sub-themes. Analysis was conducted by the two authors and disagreement was resolved by discussion.
Discussion
Protocols are tools for translating evidence into practice; they are intended to integrate evidence based guidelines into healthcare provision and to improve the quality of patient care. Nevertheless implementation of evidence into practice is not a linear or passive process and that it entails both organizational and individual behavioral changes [
19]. Addressing barriers to implementation of evidence based guidelines is a pivotal process which is integrated in many knowledge translation models [
20‐
22]
In this study the 3 themes suggested in the theoretical framework covered all the perceived barriers expressed by healthcare professionals in the PED, which shows that the framework is suitable for the evaluation of implementation of guidelines as an innovation (Table
5).
Many of the perceived attributes of the protocol impeded its adoption by the healthcare professionals, such as the lack of participation of the target group of users (physicians, nurses and patients) in the development of the protocol, which is a known barrier for implementation of guidance [
23], and the fact that the original guidelines from which the protocol was developed was not known, affecting its credibility by some of the interviewed physicians.
Developing the protocol and introducing it to the department in the general meeting was the only dissemination effort made by the department to translate asthma guidelines into practice. Simplifying the recommendations of the guidelines into a format of a protocol, or a clinical pathway, overcomes a known barrier for implementation of evidence and wit, the complexity of some guidelines [
23]. However, a single implementation strategy may not be as effective as a multifaceted approach to ensure the awareness of the healthcare professionals of the existence of the guideline, to increase their familiarity with its recommendations and to detect and address barriers to the implementation of these recommendations [
24,
25]. Some of the PAMP recommendations were perceived by the healthcare professionals not to be applicable to a large number of the patients attending the PED. Nearly 50% of the patients who attended the PED during the study period were 0–3 years old (Table
2). According to most of the interviewed physicians, applying some of the recommendations of the PAMP such as staging of asthma severity is not easy in this age group. Patients’ characteristics, such as co-morbidity, was found by other investigators to affect the adoption of guidelines by healthcare professionals [
26]. Providing guidance for a special group of people defined by co-morbidity or physiological characteristics is suggested to provide evidence based management for these special groups of patients [
27]. Moreover a number of guideline developers are providing special guidance for patients with certain physiological characteristics such as pregnancy as well as for specific age groups [
28]. However in this study we did not find evidence from the quantitative data to support the claims that adherence to the asthma protocol is influenced by the patient age (Table
1).
The characteristics of the healthcare professionals in this study were found to influence the adoption of guideline recommendations. Lack of awareness of the existence of the protocol, which represents the lack of knowledge about the innovation, an essential first step in Rogers et al theoretical frame for the innovation diffusion process [
12], and the disagreement with some of its recommendations, such as the use of corticosteroids for mild asthma were factors behind non- adherence of some professionals to the recommendations. Similar characteristics of healthcare professionals were found by other studies [
26,
29]. However a unique finding in this study is the language barrier between the nurses and the patient’s parents due to the fact that Arabic is not the first language for most of the nurses in the Saudi health settings.
Organizational or contextual barriers such as limited time and personnel in addition to the lack of some equipment and devices were raised repeatedly by the focus group and were considered among the most important barriers for implementation of the asthma protocol. Similar barriers were recognized by other investigators [
26,
30]. A unique finding to this study is the impact of the defective system for patients’ referral to outpatient services, thereby increasing the load on the emergency department by increasing the revisit rate and affecting the continuity of care for the patients. Almost 20% of the patients who presented to the PED and were diagnosed as asthmatic were not in the acute stage of the disease; nevertheless they will create confusion about the consistent use of the PAMP in the department and difficulty in the interpretation of any audits designed to evaluate implementation.
This study reflects the efforts of exploring the barriers to the implementation of good medical practice by applying a theoretical framework to establish a tailored implementation strategy in the future.
The results of the study has many implications to practice in the PED setting and in similar setting in Saudi Arabia including the importance of designing an effective dissemination and implementation strategy for clinical guidelines and protocols, in addition effective policies should be implemented to improve communication between medical and nursing staff and the patients or their parents including addressing language barriers. Since the introduction of the PAMP in 2005, the department did not conduct an audit to assess the success of implementation, which might have contributed to the current state of non-adherence to most of the recommendations. Regular audit and redesign of the strategies of implementation should be an integral part of any future plans for evidence translation.
The strength of this study comes from the iterative employment of both the quantitative and the qualitative design to explore the barriers to the adherence to the asthma guidance in PED.
We are aware of the limitations of this study including that it investigated barriers to evidence-based clinical practice without linkage to the patients’ outcome, such as the number of revisits. However parental education, which one of the main factors for improving revisit rate, was provided to only 2 patients, which invalidate the value of linking outcome to adherence. It is worth noting that this study investigated the adherence of the healthcare professionals to the PAMP recommendations during winter (3 months), when most of the BA patients present; however the results might not reflect the adherence during the rest of the year when the demand for the service is not as high. Another limitation is that the focus group did not include all the staff working in the PED and it may have missed some important opinions.
Competing interest
The authors declare that they have no competing interests.
Authors’ contributions
HW and RZ conceived the idea of the research; RZ collected data for the quantitative part of the study and HW and RZ conducted and analyzed the focus group interviews, HW written the manuscript and RZ reviewed it.