Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study

Khara Sauro, Sean M Bagshaw, Daniel Niven, Andrea Soo, Rebecca Brundin-Mather, Jeanna Parsons Leigh, Deborah J Cook, Henry Thomas Stelfox, Khara Sauro, Sean M Bagshaw, Daniel Niven, Andrea Soo, Rebecca Brundin-Mather, Jeanna Parsons Leigh, Deborah J Cook, Henry Thomas Stelfox

Abstract

Objective: To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices.

Design: (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers.

Setting: Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers.

Participants: Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs.

Main outcome measures: (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices.

Results: LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively).

Conclusions: Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.

Keywords: appropriateness; healthcare system; intensive care; quality improvement; under-use and over-use.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Barriers to the adoption of high value practices (low molecular weight heparin for venous thromboembolism prophylaxis) and de-adoption of low value practices (albumin for fluid resuscitation). Abbreviations: ICU, intensive care unit.
Figure 2
Figure 2
(A) Barriers to the adoption of high value practices (low molecular weight heparin for venous thromboembolism prophylaxis) by professional group. (B) Barriers to the de-adoption of low value practices (albumin for fluid resuscitation) by professional group. ICU, intensive care unit; NP, nurse practitioner.
Figure 3
Figure 3
Facilitators to the adoption of high value practices (low molecular weight heparin for venous thromboembolism prophylaxis) and de-adoption of low value practices (albumin for fluid resuscitation). MD, medical doctor; QI, quality improvement.

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