A Qualitative Study to Identify Barriers to Local Implementation of Prehospital Termination of Resuscitation Protocols

Abstract

Background— Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level. Methods and Results— Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care. Conclusion— We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.

Termination of Resuscitation of Nontraumatic Cardiopulmonary Arrest: Resource Document for the National Association of EMS Physicians Position Statement

“…Results from focus groups at the NAEMSP annual meeting demonstrated three groups whose policies have created barriers to implementation of TOR protocols: payers that incentivize transport, legislators that mandate prehospital resuscitation, and community expectations that EMS will transport for resuscitation. 26 In addition, within the EMS community, the prevalent "rescue culture" of EMS providers and concerns about liability have also been barriers to implementation of TOR protocols. 26 In a study on barriers to removing pediatric intubation from an EMS system, Youngquist et al found that the most common reasons for barriers to change were a feeling that ".…”

Promoting Publication of Rigorous Qualitative Research

“…When a research question would best involve qualitative research methods and a study is conducted according to these standards, this journal would welcome this approach. 8,9 Qualitative research is defined by a substantial body of literature from multiple disciplines [10][11][12][13][14][15] and has been applied in the study of health and health care since the mid-1990s. …”

“…When a research question would best involve qualitative research methods and a study is conducted according to these standards, this journal would welcome this approach. 8,9 Qualitative research is defined by a substantial body of literature from multiple disciplines [10][11][12][13][14][15] and has been applied in the study of health and health care since the mid-1990s. 15,16 The methods can be used to understand complex social processes, organizational change, individual health behaviors, and nuanced aspects of environmental context that influence quality of care, healthcare delivery, and health outcomes for individuals and populations.…”

Emphasizing Methods in Outcomes Research

“…Examples include articles that report on randomized trials, 1,2 cross-sectional studies, 3 observational cohort studies, 4 economic analyses, 5-7 meta-analyses, 8 systematic reviews, 9,10 prepost designs, 11 simulations, 12 and qualitative research. 13,14 A glance at this content quickly dispels the myth that outcomes research is primarily associated with secondary data analyses and data mining. That type of work, for the appropriate questions and with the appropriate methodological approach, can make important contributions, but is hardly the only study design used by the field.…”