Background
Methods
Study design and setting
Study participants
Development of interview protocol
Data collection
Qualitative data analysis
Validation and reliability
Ethics
Results
Hospital characteristics | No. (%) of hospitalsa
|
---|---|
(n = 11) | |
Type of hospital | |
Teaching | 7 (63.6) |
Non-teaching | 4 (36.4) |
Facilities | |
PCI | 2 (18.2) |
PCI and CABG | 3 (27.3) |
No revascularization facilities | 6 (54.5) |
Participant characteristics
|
No. (%) of participants
a
|
(n = 31)
| |
Gender | |
Male | 21 (67.7) |
Age (years) | |
Mean (SD)/Range | 38.9 (9.4)/26-61 |
Type and years in professionb
| |
Cardiologists | 16 (51.6) |
<5 | 5 (31.25) |
5-10 | 5 (31.25) |
>10 | 6 (37.5) |
Medical resident | 7 (22.6) |
<5 | 6 (85.7) |
5-10 | 1 (14.3) |
> 10 | n.a. |
Medical intern | 4 (12.9) |
< 5 | 3 (75) |
5-10 | 1 (25) |
> 10 | n.a. |
Nurse specialist | 3 (9.7) |
< 5 | 1 (33.3) |
5-10 | 2 (66.7) |
> 10 | n.a. |
Emergency physician | 1 (3.2) |
< 5 | n.a. |
5-10 | 1 (100) |
> 10 | n.a. |
Length of interview (minutes) | |
Median (IQR) | 28.2 (25.6) |
< 15 | 9 (29) |
15-30 | 8 (25.8) |
30-45 | 10 (32.3) |
45-60 | 3 (9.7) |
>60 | 1 (3.2) |
PGF dimensionsab
| Category | Description | Concepts |
---|---|---|---|
WHY context | Intrinsic motivations | Personal beliefs of health care practitioners that leads to the implementation | Uniformity problem |
I. Stimuli for implementing cardiac risk scores | Educational support | ||
Research purposes | |||
Extrinsic motivations | Environmental and organizational pressure that leads to the implementation | (Inter) national guideline recommendations | |
Governmental pressure and regulatory demands: quality improvement program, recommendations of Dutch association of cardiology, audits of health care inspectorate | |||
Pressure hospital board | |||
Assessments by health care insurance companies | |||
HOW process | Implementation strategies | Interventions used to enhance or support the implementation process | Support and commitment staff |
II. Process of implementing cardiac risk scores | Clinical reminders: posters (passive), written and oral reminders (active) | ||
Data feedback | |||
Education: practical and theoretical | |||
Development project plan | |||
Appointment working committee | |||
Facilitators and barriers | Influential factors enhancing or hindering the implementation process |
Facilitating factors
| |
Innovation level: clinical relevance | |||
Practitioner level: commitment staff | |||
Organization level: management support, IT support | |||
Barriers
| |||
Innovation level: administrative burden, complexity of underlying algorithm of risk score, loss of time | |||
Practitioner level: level of work experience, familiarization with new practices, lack of knowledge, lack of relevance | |||
Organization level: frequent staff rotation, high work load, lack of time, lack of management priority, lack of resources, fast update of guidelines, unexpected circumstances | |||
Sustainability | Interventions undertaken to sustain change in practices | Redesigning systems: integration of risk score(s) in existing electronic hospital systems, protocols or clinical pathways | |
Audit and feedback | |||
Appointment of champions | |||
WHAT content | Choice of risk score | Motivation for implementing cardiac risk score and its use in practice | Choice of risk score based on: purpose, availability relevant parameters, complexity, validity and available scientific evidence, recommendations of clinical guidelines, accordance own practices |
III. Perceptions of health care practitioners | |||
Use in practice: type of risk score (GRACE, TIMI, FRISC or HEART), intended users (interns, residents, less often cardiologist, nurse specialists), target group (patients with chest pain, unstable angina, non-ST-elevation myocardial infarction or acute coronary syndrome), location (emergency department, chest pain unit, coronary care unit) | |||
Unintended benefits and risks | Implementation effects in terms of benefits and risks for quality and safety of care | Expected benefits: improved uniformity, educational support, scientific benefits | |
Unintended benefits: support system, enhanced patient safety | |||
Risks: regulatory medicine | |||
Impact on treatment policies | Impact on physician’s decision-making process in terms of admission and treatment policies | Treatment policy: no consequence, conservative treatments (pharmacological), invasive treatments (cardiac catheterization or revascularization) | |
Admission policy: admission protocol, patient allocation, patient flow | |||
Effects on process of care | Effectiveness of cardiac risk score implementation | Current practice and variation in practice |