"What is the actual goal of the pathway?": examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

Anh Ly, Roger Zemek, Bruce Wright, Jennifer Zwicker, Kathryn Schneider, Angelo Mikrogianakis, Alf Conradi, David Johnson, Brenda Clark, Karen Barlow, Joseph Burey, Ash Kolstad, Keith Owen Yeates, Anh Ly, Roger Zemek, Bruce Wright, Jennifer Zwicker, Kathryn Schneider, Angelo Mikrogianakis, Alf Conradi, David Johnson, Brenda Clark, Karen Barlow, Joseph Burey, Ash Kolstad, Keith Owen Yeates

Abstract

Background: Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion.

Methods: Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation.

Results: The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2-4 predominant topics that can be condensed into six overarching themes regarding clinicians' views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes.

Conclusion: Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

Keywords: Clinical pathway; Emergency care; Health outcomes; Implementation; Pediatric concussion; Standardization; Theoretical domains framework.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Theoretical domains framework collapsed for project interviews

References

    1. National Center for Injury Prevention and Control . Report to congress on mild brain injury in the United States: steps to prevent a serious public health problem. Atlanta: Centers for Disease Control and Prevention; 2003.
    1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
    1. Gilchrist J, Thomas KE, Xu L, McGuire LC, Coronado V. Nonfatal traumatic brain injuries related to sports and recreation activities among persons ages < 19 years—United States, 2001-2009. Morb Mortal Wkly Rep. 2011;60:1337–1342.
    1. Barlow KM. Postconcussion syndrome: a review. J Child Neurol. 2016;31:57–67. doi: 10.1177/0883073814543305.
    1. Barlow KM, Crawford S, Stevenson A, et al. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126:e374–e381. doi: 10.1542/peds.2009-0925.
    1. Yeates KO, Taylor HG, Rusin J, et al. Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics. 2009;123:735–743. doi: 10.1542/peds.2008-1056.
    1. Zemek R, Barrowman N, Freedman S, Gravel J, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315(10):1014–1025. doi: 10.1001/jama.2016.1203.
    1. Ledoux AA, Tang K, Yeates KO, Pusic M, et al. Natural progression of symptom change and recovery from concussion in a pediatric population. JAMA Pediatr. 2019;173(1):e183820.
    1. Bressan S, Babl FE. Diagnosis and management of paediatric concussion. J Paediatr Child Health. 2016;52:151–157. doi: 10.1111/jpc.12967.
    1. Novak Z, Aglipay M, Barrowman N, Yeates KO, Beauchamp MH, Gravel J, et al. Association of Persistent Postconcussion Symptoms with pediatric quality of life. JAMA Pediatr. 2016;170(12):e162900. doi: 10.1001/jamapediatrics.2016.2900.
    1. Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families, Institute of Medicine, National Research Council . In: Sports-related concussions in youth: improving the science, changing the culture. Graham R, Rivara FP, Ford MA, Spicer CM, editors. Washington, DC: National Academies Press, National Academy of Sciences; 2014.
    1. McCrory P, Meeuwisse WH, Aubry M. Consensus statement on concussion in sport: the 4th international conference on concussion in sport, Zurich, November 2012. J Athl Train. 2013;48:554–575. doi: 10.4085/1062-6050-48.4.05.
    1. Zemek R, Duval S, Dematteo C, et al. Guidelines for diagnosing and managing pediatric concussion: recommendations for health care professionals. Toronto: Ontario Neurotrauma Foundation; 2014.
    1. Zemek R, Eady K, Moreau K, et al. Knowledge of paediatric concussion in front-line primary care providers. Paediatr Child Health. 2014;19:1–6. doi: 10.1093/pch/19.9.475.
    1. Zemek R, Eady K, Moreau K, et al. Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management. CJEM. 2015;17:115–122. doi: 10.1017/cem.2014.38.
    1. Carson JD, Lawrence DW, Kraft SA, Garel A, et al. Premature return to play and return to learn after a sport-related concussion. Physician’s chart review. Can Fam Physician. 2014;60:10–15.
    1. Kurtin P, Stucky E. Standardize to excellence: improving the quality and safety of care with clinical pathways. Pediatr Clin North Am. 2009;56:893–904. doi: 10.1016/j.pcl.2009.05.005.
    1. Browne GJ, Giles H, McCaskill ME, Fasher BJ, Lam LT. The benefits of using clinical pathways for managing acute paediatric illness in an emergency department. J Qual Clin Pract. 2001;21:50–55. doi: 10.1046/j.1440-1762.2001.00405.x.
    1. Rotter T, Kinsman L, James E, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;3:CD006632.
    1. Kinsman LD, Buykx P, Humphreys JS, et al. A cluster randomised trial to assess the impact of clinical pathways on AMI management in rural Australian emergency departments. BMC Health Serv Res. 2009;9:83. doi: 10.1186/1472-6963-9-83.
    1. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26–33. doi: 10.1136/qshc.2004.011155.
    1. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:1–17. doi: 10.1186/1748-5908-7-37.
    1. French SD, Green SE, O’Connor DA, Mckenzie, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the theoretical domains framework. Implement Sci. 2012;7:1–8. doi: 10.1186/1748-5908-7-38.
    1. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived Behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57(4):660–680. doi: 10.1111/j.1464-0597.2008.00341.x.
    1. Francis JJ, O’Connor D, Curran J. Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implement Sci. 2012;7:1–9. doi: 10.1186/1748-5908-7-35.
    1. Mazza D, Chapman A, Michie S. Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study. BMC Health Serv Res. 2013;13:1–8. doi: 10.1186/1472-6963-13-36.
    1. Boscart VM, Fernie GR, Lee JH, Jaglal SB. Using psychological theory to inform methods to optimize the implementation of a hand hygiene intervention. Implement Sci. 2012;7:1–12. doi: 10.1186/1748-5908-7-77.
    1. Dyson J, Lawton R, Jackson C, Cheater F. Does the use of a theoretical approach tell us more about hand hygiene behaviour? The barriers and levers to hand hygiene. J Infect Prev. 2011;12(1):17–24. doi: 10.1177/1757177410384300.
    1. McSherry LA, Dombrowski SU, Francis JJ, Murphy J, et al. ‘It’s a can of worms’: understanding primary care practitioners’ behaviours in relation to HPV using the theoretical domains framework. Implement Sci. 2012;7:1–15. doi: 10.1186/1748-5908-7-73.
    1. Bussières AE, Patey AM, Francis JJ, Sales AE, Grimshaw JM. Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the theoretical domains framework. Implement Sci. 2012;7:1–11. doi: 10.1186/1748-5908-7-82.
    1. Mckenzie JE, French SD, Oconnor DA, Grimshaw JM, et al. IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): cluster randomised controlled trial study protocol. Implement Sci. 2008;3:1–12. doi: 10.1186/1748-5908-3-11.
    1. Mckenzie JE, Oconnor DA, Page MJ, Mortimer DS, et al. Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): a cluster randomised trial protocol. Implement Sci. 2010;5:1–17. doi: 10.1186/1748-5908-5-86.
    1. Francis JJ, Stockton C, Eccles MP, Johnston M, et al. Evidence-based selection of theories for designing behaviour change interventions: using methods based on theoretical construct domains to understand clinicians blood transfusion behaviour. Br J Health Psychol. 2009;14(4):625–646. doi: 10.1348/135910708X397025.
    1. Islam R, Tinmouth AT, Francis JJ, Brehaut JC, et al. A cross-country comparison of intensive care physicians’ beliefs about their transfusion behaviour: a qualitative study using the theoretical domains framework. Implement Sci. 2012;7:1–16. doi: 10.1186/1748-5908-7-93.
    1. Duncan EM, Francis JJ, Johnston M, Davey P, et al. Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. Implement Sci. 2012;7:1–13. doi: 10.1186/1748-5908-7-86.
    1. Michie S, Pilling S, Garety P, Whitty P, et al. Difficulties implementing a mental health guideline: an exploratory investigation using psychological theory. Implement Sci. 2007;2:1–8. doi: 10.1186/1748-5908-2-1.
    1. Taylor N, Conner M, Lawton R. The impact of theory on the effectiveness of worksite physical activity interventions: a meta-analysis and meta-regression. Health Psychol Rev. 2012;6(1):33–73. doi: 10.1080/17437199.2010.533441.
    1. Bengtsson M. How to plan and perform a qualitative study using content analysis. Nursing Plus Open. 2016;2016:8–14. doi: 10.1016/j.npls.2016.01.001.
    1. Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(42).
    1. Munroe B, Curtis K, Buckley T, Lewis M, et al. Optimising implementation of a patient-assessment framework for emergency nurses: a mixed-method study. J Clin Nurs. 2018;2018(27):e269–e286. doi: 10.1111/jocn.13932.
    1. Murphy M, McCloughen A, Curtis K. Using theories of behaviour change to transition multidisciplinary trauma team training from the training environment to clinical practice. Implement Sci. 2019;14(43).
    1. Kourouche S, Buckley T, Van C, Munroe B, et al. Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study. BMC Health Serv Res. 2019;19(461).
    1. O’Hara K, Tanverdi M, Reich J, Scudamore DD, et al. Qualitative study to understand pediatric hospitalists and emergency medicine physicians’ perspectives of clinical pathways. Pediatric Qual Safety. 2020;2(5):e270. doi: 10.1097/pq9.0000000000000270.
    1. Craig LE, Taylor N, Grimley R, Cadilhac DA, et al. Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the theoretical domains framework (TDF): the T3 trial. Implement Sci. 2017;12(88).
    1. Butterfoss FD, Major DA, Clarke SM, Cardenas RA, et al. What providers from emergency departments say about implementing a pediatric asthma pathway. Clin Pediatr. 2006;45:325–333. doi: 10.1177/000992280604500404.
    1. Yamada J, Potestio ML, Cave AJ, Sharpe H, et al. Using the theoretical domains framework to identify barriers and enablers to pediatric asthma management in primary care settings. J Asthma. 2018;55(11):1223–1236. doi: 10.1080/02770903.2017.1408820.
    1. Cabana MD, Rand CS, Becher O, Rubin H. Reasons for pediatrician nonadherence to asthma guidelines. Arch Pediatr Adolesc Med. 2001;155:1057–1062. doi: 10.1001/archpedi.155.9.1057.
    1. Davis P, Man P, Cave A, McBennett S, et al. Med Educ. 2000;34:987–993. doi: 10.1046/j.1365-2923.2000.00685.x.
    1. Byrne M, Cupples ME, Smith SM, Leathem C, et al. Development of a complex intervention for secondary prevention of coronary heart disease in primary care using the UK Medical Research Council framework. Am J Manag Care. 2006;12(5):261–266.
    1. Cox NS, Oliveira C, Lahham A, Holland AE. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the theoretical domains framework. Aust J Physiother. 2017;63:84–93. doi: 10.1016/j.jphys.2017.02.002.

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