Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework

Abstract

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guidelines (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, and developed and tested specific strategies. Results: A total of 114 clinicians completed surveys and 32 clinicians and stakeholders participated in interviews. Results from the surveys and interviews indicated low awareness of syncope guidelines, communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change as major barriers to CPG implementation. Thirty-one patients and their family caregivers participated in interviews and expressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. Identifying change methods to address the clinician barriers and patients and family caregivers expectations informed development of the multilevel, multicomponent implementation strategy, MISSION, which includes patient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and a corresponding mobile app, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Conclusions: Effective multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.

Results from a type two hybrid‐effectiveness study to implement a preoperative anemia and iron deficiency screening, evaluation, and management pathway

“…So, although the package did significantly improve clinician compliance, there remains room to improve how it is delivered and supported to better address barriers that are not yet mitigated (e.g., knowledge and beliefs, culture, learning climate, complexity, lack of champions, etc.). Li and colleagues report a similar experience from a 2021 study that used CFIR‐ERIC to implement a syncope management pathway 50 . They measured both implementation and compliance outcomes and found that, although there was high acceptability at 91.7% (22 of 24 participant responses), the intervention was only performed on 15–40% of patients across providers 50 …”

“…Li and colleagues report a similar experience from a 2021 study that used CFIR‐ERIC to implement a syncope management pathway 50 . They measured both implementation and compliance outcomes and found that, although there was high acceptability at 91.7% (22 of 24 participant responses), the intervention was only performed on 15–40% of patients across providers 50 …”

“…Li and colleagues report a similar experience from a 2021 study that used CFIR-ERIC to implement a syncope management pathway. 50 They measured both implementation and compliance outcomes and found that, although there was high acceptability at 91.7% (22 of 24 participant responses), the intervention was only performed on 15-40% of patients across providers. 50 The 2022 ICCAMS recommended "patients should be educated about the impact of anemia" and "patients should be educated about the relationship between anemia and RBC transfusion and the impact of increased RBC transfusion."…”

Applying Implementation Science Methods to Address Barriers to Employment Services Offered through the United States Department of Veterans Affairs Health Care for Homeless Veterans Program

“…The CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) offers a structured approach to identifying strategies to implementation barriers and has been recently used in a variety of settings to conceptualize provider views and refine implementation processes (Godbee et al, 2019;Juckett et al, 2020;Li et al, 2021;Waltz et al, 2019). Given that HCHV Employment Specialists overlap with homeless and employment providers both within VHA and the broader community, the CFIR offered an appropriate tool to understand these separate spheres and their impact on implementation efforts.…”

Strategies for implementing pet robots in care homes and nursing homes for residents with dementia: protocol for a modified Delphi study

“…The outputs of this tool include implementation strategies in relation to the input on CFIR determinants, along with percentages, which reflect the proportion of experts that have endorsed the strategy as being appropriate to address each CFIR determinant [ 21 ]. It has been previously used in empirical studies to guide the identification of implementation strategies [ 24 – 26 ], ( www.cfirguide.org/choosing-strategies ). This study aims to use our previous studies [ 15 , 27 ] to identify relevant implementation strategies for identified implementation determinants, contextualise the strategies for our setting and obtain expert consensus on the most relevant strategies for implementing pet robots in care homes and nursing homes for PLWD.…”