Reasons behind non-adherence of healthcare practitioners to pediatric asthma guidelines in an emergency department in Saudi Arabia

Abstract

BackgroundThe prevalence of childhood bronchial asthma in Saudi Arabia has increased in less than a decade from 8% to 23%. Innovations in the management of asthma led to the development of evidence based clinical practice guidelines and protocols to improve the patients’ outcomes. The objectives of this study are to examine the compliance of the healthcare providers in the Pediatrics Emergency Department, in King Khalid University Hospital, with the recommendations of the Pediatrics Asthma Management Protocol (PAMP), and to explore the reasons behind non-adherence.MethodsThis study is designed in 2 parts, a patients’ chart review and a focus group interview. The medical records of all the children who presented to the Pediatric Emergency Department (PED) and were diagnosed as asthmatic, during the period from the 1st of January 2009 to the 31st of March 2009, were reviewed to investigate the compliance of healthcare providers (physicians and nurses) with 8 recommendations of the PAMP which are considered to be frequently encountered evidence-practice gaps, and these are 1) documentation of asthma severity grading by the treating physician and nurse 2) limiting the prescription of Ipratropium for children with severe asthma 3) administration of Salbutamol through an inhaler and a spacer 4) documentation of parental education 5) prescription of systemic corticosteroids to all cases of acute asthma 6) limiting chest x-ray requisition for children with suspected chest infection 7) management of all cases of asthma as outpatients, unless diagnosed as severe or life threatening asthma 8) limiting prescription of antibiotics to children with chest infection. The second part of this study is a focus group interview designed to elicit the reasons behind non- adherence to the recommendations detected by the chart review. Two separate focus group interviews were conducted for 10 physicians and 10 nurses. The focus group interviews were tape-recorded and transcribed verbatim. Theory-based content analysis was used to analyze interviews into themes and sub-themes.Results and discussionA total of 657 charts were reviewed. The percentage of adherence by the healthcare providers to the 8 previously mentioned recommendations was established. There was non-adherence to the first 5 of the 8 aforementioned recommendations. Analysis of the focus group interview revealed 3 main themes as reasons behind non-compliance to the 5 recommendations mentioned above and those are 1) factors related to the organization, 2) factors related to the asthma management protocol 3) factors related to healthcare providers.ConclusionThe organizational barriers and the lack of an implementation strategy for the protocol, in addition to the attitude and beliefs of the healthcare providers, are the main factors behind non-compliance to the PAMP recommendations.

Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East

“…Another study in our institute investigated the barriers that faced the implementation of 1 CPG at KKUH and identified several barriers including organizational barriers (eg, staff and bed shortage, deficient outpatient referral system, and availability and cost of certain devices), CPG intrinsic barriers (eg, lack of clear dissemination and implementation strategies and lack of recommendations suitable for the characteristics of some patients), and health care provider barriers (eg, attitudes and beliefs of providers, language barrier between nurses and parents, lack of awareness and familiarity with the CPGs, and disagreement with some recommendations). 11,31 In this study, we used the FMEA in the pre-implementation phase of the CPG at our institution. This The strength of this study comes from the fact that it is the first to use FMEA as an approach to enhance CPGI.…”

“…Research groups worldwide have studied trends in implementation and suggested that CPGI requires the use of different measures including assessment framework, implementation‐planning checklist, revised taxonomy of implementation strategies, and implementation tools . The CPG programs in the Middle East (eg, Bahrain, United Arab Emirate, Oman and other programs in Riyadh and Jeddah, Saudi Arabia), albeit of a limited experience, have used the previous measures but not the Failure Mode and Effect Analysis (FMEA) to enhance the implementation process . FMEA is defined as “a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change.” FMEA may be performed to improve a system, design, and/or a process.…”

“…[4][5][6][7] The CPG programs in the Middle East (eg, Bahrain, United Arab Emirate, Oman and other programs in Riyadh and Jeddah, Saudi Arabia), albeit of a limited experience, have used the previous measures but not the Failure Mode and Effect Analysis (FMEA) to enhance the implementation process. [8][9][10][11][12] FMEA is defined as "a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change." 13,14 FMEA may be performed to improve a system, design, and/or a process.…”

Implementation research in emergency medicine: a systematic scoping review

“…Only two papers explicitly stated that they used theory to explore barriers and enablers; using a conceptual model of the innovation in diffusion theory18 to analyse the results of focus groups and to determine the barriers to implementation of a paediatric asthma management protocol19 and the Cabana taxonomy20 to assess barriers to behaviour change for the appropriate use of tissue plasminogen activator (tPA) in ischemic stroke 21…”

AGREEing on Guidelines for Nutrition Management of Adult Severe Burn Patients

“…12 Resistance of health professionals toward guideline adherence appears unanimous in the literature. [27][28][29] Health professionals are in need of simple, current, reliable, and accessible guidelines, 28 while, in parallel, the demand for training health professionals in guideline usage becomes a priority. 30 Additionally, a recent systematic review 31 highlighted the issue of sustainability of professionals' adherence to clinical practice guidelines, with the majority of professionals abandoning guideline usage, a year after being familiar with the recommendations.…”