A qualitative study exploring factors associated with provider adherence to severe paediatric traumatic brain injury guidelines

S. M. Brolliar, M. Moore, H. J. Thompson, L. K. Whiteside, R. B. Mink, M. S. Wainwright, et al . A qualitative study exploring factors associated with provider adherence to severe paediatric traumatic brain injury guidelines. J Neurotrauma. 2016 Jan 13. Adherence to paediatric traumatic brain injury (TBI) guidelines[ 1 ] results in a documented improvement in patient outcomes,[ 2 ] but there are differential rates of adherence. It has been demonstrated in literature that adherence to paediatric TBI guideline during the first 72 h post-admission has been associated with better survival and better discharge scores.[ 2 ] Neither the initial guidelines of paediatric TBI nor the 2012 revision have addressed the implementation and adherence issues. This study was conducted to identify the provider perspective on factors associated with adherence to the guidelines using 19 focus groups with nurses and physicians at five university-affiliated level 1 trauma centres across the United States. Physicians and nurses (e.g., providers) were recruited as a part of the protocol involving multiple subspecialities. Interviews which included open-ended questions mostly aimed at eliciting perspectives on facilitators and barriers to successful adoption of the guidelines, as well as organisational factors and local characteristics that impacted adherence to the guidelines and potential solutions to problems identified. On the basis of both deductive and inductive content analysis, three interrelated domains were formulated. Those are (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. The results were built on existing knowledge related to guideline implementation and adherence strategies in critical care.[ 3 ] Previous studies have shown that physicians’ and nurses’ decisions to use evidence-based clinical practice guidelines are broadly influenced by their knowledge and attitudes about guidelines, local professional norms and institutional factors.[ 4 ] [ 5 ] [ 6 ] [ 7 ] This particular study is unique in the applicability of interdisciplinary dynamism and addressing their needs for acute management of paediatric TBI. Adherence to the guidelines is increased when the providers are sufficiently skilled in the content and have the belief in its ability to result in good outcome.[ 4 ] [ 5 ] [ 7 ] [ 8 ] Two different terms applicability and adherence are important from the different provider perspective. It is the physician who decides the guideline applicability to a particular patient, but adherence is influenced by the nursing staffs. The roles of institutes are crucial in guideline applicability and adherence by devising a method to endorse, codify, and implement the guidelines into the local culture. Adherence was determined by the interaction of each of this 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 towards improving adherence and ultimately patient outcomes. The authors addressed few limitations. First, the study results obtained from a small number of paediatric trauma centres. However, the total number of participants was large. Second, providers with strong opinions regarding barriers and facilitators to guideline adherence may have been more willing to participate in the focus groups. There is a possibility of recall bias as study data are based on provider recall and disclosure of events taking place at their worksite. The authors concluded that the human factors, organisational cultures and institutional structures are the real barriers to guideline adherence but not physical or financial constraints. Whereas the facilitators are included transparent, high functioning teams of providers and the institutional policies that allow them to flourish. Finally creating a culture of collaboration, delivering standardised paediatric TBI care, and open communication while considering local barriers and facilitators between treatment teams and among providers may facilitate guideline adherence.