• Knowledge translation in emergency medical services: A qualitative survey of barriers to guideline implementation.

    by Marc Colbeck. Last modified: 26/02/15

    Bigham BL1, Aufderheide TP, Davis DP, Powell J, Donn S, Suffoletto B, Nafziger S, Stouffer J, Morrison LJ; ROC Investigators. Knowledge translation in emergency medical services: a qualitative survey of barriers to guideline implementation. Resuscitation. 2010 Jul;81(7):836-40. PMID: 20398994.

    The ROC is a group of EMS agencies in North America that study resuscitation outcomes. In 2005 the AHA published the latest ACLS guidelines and this group became aware …

    that while 99% of EMS agencies participating in the Resuscitation Outcomes Consortium (ROC) implemented the 2005 AHA guidelines, delay to implementation was significant and highly variable (median 415 days, range: 49 to 750 days).

    This study sought to determine why there was such a long delay (sometimes more than two years!) by doing a semi-structured interview with the different services in the group.  In general the delay came down to 3 things:

      1. Training: (reported by 41% of all respondents). This included getting instructors, facilities, printed resources, and students all together at the same time.  This is not only the most commonly reported cause of delay – it is also the one most amenable to a technological solution.  The authors suggested a training plan advocated by Haines and Jones as at least a partial step towards a solution.  See:  Implementing findings of research.
      2. Decision Making: (reported by 38% of all respondents).  This included getting governmental bodies, medical oversight committees and other regulatory agencies to agree to the changes.  It also included getting the various responder agencies to agree to all change their approach simultaneously in order to maintain consistency of care.  The authors suggested two resources related to implementation leadership.  See:
        Successes and failures in the implementation of evidence-based guidelines for clinical practice and The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. They also suggested using clinical opinion leaders to share stories of success in order to encourage adoption once guidelines have been introduced.
      3. Defibrillators: (also reported by 38% of all respondents). The 2005 changes included the change from 3 stacked shocks to single shocks and there were challenges in getting the equipment compliant with the changes.  Lot’s of AEDs needed replacement, and some of the advanced monitor/defibrillators needed to be reprogrammed.

    There are three sections of this paper (IntroductionDiscussion, and Improving Knowledge Translation in EMS) that give some very good, detailed, and referenced information.  I’m going to be retrieving many of the studies they refer to. Some quotes from these sections:

    Little evidence is available to guide prehospital translation. Cone (2007) found that there is little evidence related to knowledge translation in emergency medical services and Haskell has described that only 30% of EMS providers were aware of AHA recommendations for paediatric defibrillation.

    Obviously as someone undertaking a PhD “related to knowledge translation in emergency medical services” it’s good to know I’m not reworking broken ground.

    McGlynn and colleagues estimate that only about half of all patients in the United States are treated in accordance with best practice. In intensive care units, nearly half of physicians reported in 2008 that they have never employed therapeutic hypothermia in the treatment of resuscitated patients despite strong recommendations supporting its use published in 2003. Further, although several randomized controlled trials have shown that statin therapy can decrease morbidity and mortality in post-stroke patients, they are under prescribed. It has been estimated that cancer mortality could be reduced by 10% if current knowledge research was implemented.

    In 2000, the American Heart Association launched “Get With The Guidelines” (GWTG), an in-hospital quality improvement program for three diseases; coronary artery disease, heart failure and stroke. Several studies have demonstrated that participation in GWTG increases adherence to evidence based guidelines and improves patient outcomes [emphasis added]. With regards to stroke, adherence to diagnostic guidelines was improved and rates of thombolytic therapy for stroke patients was “drastically improved”, among hospitals participating in the GWTG Stroke program. Patients with coronary artery disease received recommended therapy more often after the implementation of the GWTG program. These improvements have been shown to be sustained over a time period of at least two years. We can speculate that a similar program of knowledge translation support would improve the outcomes in other settings, such as the prehospital environment.

    There were some interesting methodological notes too.  The researchers used the “Glaser and Strauss Grounded Theory” method for conducting their interviews, which I’d like to look into more because it sounds pretty useful.  They cited: Collecting data using a semi-structured interview: a discussion paper.

    The authors also used something called “member validation” to confirm the results of their studies, which sounds like they basically checked with stakeholders to make sure the findings made sense to them too, and cited  A member check procedure to enhance rigor in naturalistic research.

    Both articles are behind the great Wiley/Elsevier paywalls of course (grrrrrr – see
    Academic Journals: The Most Profitable Obsolete Technology in History – thanks Rob Theriault) but I have them and will review them.

    I think I’ll get more from this paper from the discussion parts and references then I will the actual study itself, but the study itself is an interesting one that should be of use to clinical managers responsible for the implementation of CPGs.

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    Marc Colbeck

    Marc Colbeck

    Senior Lecturer at Australian Catholic University
    Marc is a Canadian Critical Care Paramedic with 14 years of clinical experience who has been working as a professional educator since the early 2000's. He has taught at the College and University level in the Middle East and Australia, and worked as the General Manager of Clinical Governance for an Australian State Ambulance Service. He is currently a Senior Lecturer at Australian Catholic University in Queensland, Australia. His undergraduate degree is in PreHospital Care and his MA is in Counseling Psychology. He is currently working on a PhD in Translational Health Sciences with the Joanna Briggs Institute at the University of Adelaide, with a special interest in the development and maintenance of paramedic CPGs. His website is www.marccolbeck.info.

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