A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines

Abstract

Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.

Implementation strategies in pediatric neurocritical care

“…Effective implementation strategies can amplify the crucial work done in basic and translational research by closing the gap between knowledge and practice, increasing the impact of on patient survival and outcomes. A rigorous scientific approach to the development and testing of implementation strategies will be required, and barriers such as guideline credibility and applicability to individual patients, provider culture, communication style and attitudes towards care protocols will have to be addressed (34). As translational and clinical research continue to generate knowledge and strengthen clinical evidence, effective implementation science strategies will facilitate the application of precision medicine to neurocritical care, allowing care providers to identify, select and schedule therapies that are most likely to yield a favorable outcome for and individual patient (35).…”

Frequency of and factors associated with emergency department intracranial pressure monitor placement in severe paediatric traumatic brain injury

“…The decision to place an ICP monitor in the ED may also depend on physician preference or practice, as well as on organizational culture around placement of other advanced monitoring techniques relevant to severe TBI care. As we relied on existing data, we were unable to study whether physician level factors [30] were associated with ED ICP monitor placement. Finally, because we excluded patients who died within the first 48 hours of admission to trauma center in the parent PEGASUS study, select factors in our study may not have shown significant associations with ED ICP monitor placement.…”

Development and implementation of a standardized pathway in the Pediatric Intensive Care Unit for children with severe traumatic brain injuries

“…1 2 Factors associated with clinician non-adherence to TBI guidelines were: 1) concern about guideline credibility and applicability to patient care, 2) lack of implementation, dissemination, and enforcement strategies, and 3) provider culture, communication style, and attitudes towards protocols. 3 The global objective of this project was to reduce variability among care provided to children with severe TBI by developing and implementing a standard clinical care TBI pathway to promote adherence to the evidence-based TBI Guidelines.…”