Background
Method
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Internal factors that increase guideline use,
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Internal factors that decrease guideline use,
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External factors that increase guideline use,
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External factors that decrease guideline use,
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Positive aspects of the local TBI guidelines, and
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Negative aspects of the local TBI guidelines.
Main theme | n/total |
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Content and presentation | 28/28 |
“There are guidelines that leave some room for interpretation with regards to clinical evaluation of a patient, and it can be hard for a novice doctor that hasn’t seen many such patients, to separate pathology from normal. So, the younger…or more novice, a doctor is, the more information a guideline should contain and the more experienced you are, the simpler and easier the guideline” #16—Specialist in Emergency Medicine | |
“It is pretty good with flowcharts where you can see that “Yes, okay, if it gets to this I will go to this box and if gets to that I will go to that box”. I think that is pretty easy to understand” #5—Resident in Emergency Medicine | |
“That there are clear rules regarding on whom the guideline is applicable and that it is easy to follow, that there are no uncertainties within the guideline” # 13—Resident in Emergency Medicine | |
Effect on care and caregivers | 28/28 |
Guidelines’ effect on patient care | 18/28 |
“Then I think it should say a little about how to proceed and investigate. What is especially important in the anamnesis and not important in the anamnesis? Which laboratory tests should you order? Then I think it should say how to interpret different findings and how to proceed with processing, how to, for example, admit the patient or discharge with a certain medicine and at what dosages […] I have more than once come across colleagues who have only assessed the head injury and not the cervical spine” # 20—Resident in General Surgery | |
Guideline use and doctors’ emotions | 28/28 |
“What you have heard from older colleagues is that it makes you stupid, that you stop thinking a little […] You just do as the guideline says and sometimes you have to think outside the box. I can agree with that, but at the same time you develop guidelines to reduce healthcare injuries, I often think, that you miss things or that you make mistakes” # 4—Resident in Emergency Medicine | |
“… Otherwise I only think it is an advantage for the patients, because it is faster, the doctor knows what to do, it is like no decision fatigue, you know exactly how to proceed, you know how to manage the patient. So, in that sense, I think it's only beneficial”. # 18—Intern | |
Equality of care and resource utilisation | 18/28 |
“Because then you know that all patients are treated in the same way. So, it is a sign… relatively safe, compared to when people read in different books and act accordingly. Then everyone gets different kind of care “ # 26—Intern | |
“So, you may get a gut feeling or that you have met so many patients and the patient you have in front of you may not fit in the guideline. But still, according to the guideline you have to do… So maybe you do order a lot of unnecessary tests or examinations that you think is a little unnecessary” # 28—Resident in Emergency Medicine | |
Availability | 28/28 |
Technical conditions | 28/28 |
“So, I think the intranet is the worst in the world. It's so… yes, but it's such a shame. There are a lot of clicks and then you often end up wrong” # 10—Intern | |
“I think it would have taken a collective approach for them to be accessible easily on the intranet in some way, that they are not divided into different clinics” # 24—Resident in General Surgery | |
Access time | 24/28 |
“Then you could make a guideline book that you could have in your trouser pocket. I know, when I did my internship in Lund, there was this small guideline book, thin, which was very good” # 23—Resident in General Surgery | |
“It should not be more difficult than that you have an icon on the desktop, whether it is a link or if it is a program or whatever it is, it does not matter much, but you should sort of get straight to it… it should not be more than two keystrokes away” # 3—Resident in General Surgery | |
Knowledge about guidelines and where to find them | 17/28 |
“And I think many of the employees are too poorly versed in the guidelines. Both doctors and other healthcare professionals about which guidelines we have” # 14—Resident in Emergency Medicine | |
Finding the right one among many | 6/28 |
When you check up on guidelines, it sometimes comes up things like “Central venous catheter”. That there can be such strange things that are not at all what you want to find. You want to get to the medically specific guidelines, and it is very difficult. So, there should only be one direct link there.” # 11—Intern | |
Trust in the guidelines | 22/28 |
Collective perception | 13/28 |
“And the person who has written our local guideline is very up to date in the research, so I completely trust his judgment” # 14—Resident in Emergency Medicine | |
“Because there have been some errors in our guideline book that they have had to correct afterwards. There may be on Internedmedicin.se as well, I know nothing about that, but there are more people who read it daily and I think it has been examined even harder because it is so publicly available” # 8—Intern | |
Scientific evidence | 14/28 |
“It is not always the case that the guideline is updated every six months and research is progressing fairly quickly in different areas. So, the absolute newest or latest recommendation for investigation and management syndrome X may not have had time to diffuse into our local guideline” # 9—Resident in Emergency Medicine | |
Workload | 27/28 |
Subjective stress | 15/28 |
“When you get stressed you become a little more primitive, you go into your inner self, you solve problems, and you do what you think is best and go more on gut feeling” # 21—Intern | |
“I almost think that it [stress] makes you use it [guidelines] more, because if there is a lot that bothers and interrupt you think a little worse” # 4—Resident in Emergency Medicine | |
Work environment | 15/28 |
“It sometimes happens, when there are a lot of patients that seek care, that we can get a shortage of nurses who can take this test which has a limit of six hours. I would probably say that it may be a reason to do a CT then because we also have a lack of beds, we cannot admit and observe them for twelve hours in a simple way” # 16—Specialist in Emergency Medicine | |
Amount of time at disposal | 13/28 |
“No, I do not sit and look for a guideline that I cannot find in half an hour, instead I can take the next patient” # 15—Resident in Emergency Medicine | |
Culture | 28/28 |
Attitude among staff | 25/28 |
“The nurses are well acquainted with it, so often even before we meet the patient, they have taken a history of the patient and asked how long it has been since the head injury and if they are on anticoagulation. And then they come and ask us if we want to order an S100B” # 14—Resident in Emergency Medicine | |
“The nurses or assistant nurses believe that the patients should be managed in a certain way. They often want things to flow on and go fast and so on” # 12—Resident in General Surgery | |
Leadership | 23/28 |
“On the other hand, it has happened that I have wanted to treat the patient according to our local guideline, but the person I consult with wants to do something else. But then it’s on them” # 7—Intern | |
Patient-related factors | 24/28 |
Incompatibility between patient and guideline | 20/28 |
“So, it is me who sees the patient in front of me, it's not our guideline that sees it. So, if I think it's wrong, I’ll do it my way.” # 15—Resident in Emergency Medicine | |
Complexity in the individual case | 11/28 |
“Then there are always patients who are… it is difficult to really put your finger on what is the cause of seeking care or what is the triggering problem and then you cannot turn to specific guidelines, because… Yes, if the symptoms go together and it is not really clear, then you do not know which guideline to choose “ # 7—Intern | |
“While a local guideline is often based on the patient having a medical condition. But if the patient has more than one condition that you have to weigh in, you may sometimes need to make an intermediate solution, which means that you have not fully followed the local guideline, which can sometimes make it a little difficult. “ # 9—Resident in Emergency Medicine | |
Doctor-related factors | 23/28 |
Individual doctor competence | 13/28 |
“… There are those who temporarily work at the clinic who may need a local guideline and also older colleagues who have not encountered this for a long time, or… yes, also need a little… go back and check” # 11—Intern | |
Experience | 13/28 |
“Less experienced, new doctors, I think use local guidelines in the best possible way. But an older experienced person, a doctor, is probably able to tailor his patient management better than a local guideline” # 29—Resident in Emergency Medicine | |
Convenience and ego | 8/28 |
“If I have received a positive that I should x-ray the neck and the patient has a small cut in the forehead, then I usually have a fairly low threshold to X-ray the head as well” # 9—Resident in Emergency Medicine | |
“If you feel that you would not want to follow it [local guideline], there can be quite a lot of problems if a problem or complication should arise later. And if you have not followed the local guideline, many will be afraid of it as well” # 28—Resident in Emergency Medicine |
Results
Content and presentation
Effects on care and caregivers
Guidelines’ effect on patient care
Guideline use and doctors’ emotions
Equality of care and resource utilisation
Availability
Technical conditions
Access time
Knowledge about guidelines and where to find them
Finding the right one among many
Trust in the guidelines
Collective perception
Scientific evidence
Workload
Subjective stress
Work environment
Amount of time at disposal
Culture
Attitudes among staff
Leadership
Patient-related factors
Incompatibility between patient and guideline
Complexity in the individual case
Doctor-related factors
Individual doctor competence
Experience
Convenience and ego
Thoughts on the local TBI guidelines
“There is nothing about how severe the head trauma needs to be. If you walk into a lamppost, does it count as a sufficiently serious trauma to justify a CT just because you are over 65 and are under treatment with a platelet aggregation inhibitor?”#2—Resident in General Surgery.
“The care might be a bit exaggerated, especially for those with minimal head injury and ongoing anticoagulation. If you then have to follow it [local guideline], it will be a lot of CT, a lot of hospitalisation and a lot of care.”#13—Resident in Emergency Medicine.
“And you order an S100B that is false positive, which when I feel can sometimes force you to do a CT on a patient when you really wanted to not do it, if it is a young patient, for example.”#14—Resident in Emergency Medicine.
“I think if I had done it, I would have made larger letters or capital letters where it says acetylsalicylic acid or NOAC, so that when you look at it quickly it is clear that ‘Oh, here it was something different. Those patients should go into another category’.”#9—Resident in Emergency Medicine.