Hayes Sean M, Murray Suzanne, Dupuis Martin, Dawes Martin, Hawes Ian A, Barkun Alan N
AXDEV Group Inc, Brossard, Quebec.
Can J Gastroenterol. 2010 May;24(5):289-96. doi: 10.1155/2010/878135.
BACKGROUND/OBJECTIVE: Guidelines for the management of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) are inconsistently applied by health care providers, potentially resulting in suboptimal care and patient outcomes. A needs assessment was performed to assess health care providers' barriers to the implementation of these guidelines in Canada.
Semistructured telephone interviews were conducted by trained research personnel with 22 selectively sampled health care professionals actively treating and managing NVUGIB patients, including emergency room physicians (ER), intensivists (ICU), gastroenterologists (GI), gastroenterology nurses and hospital administrators. Participants were chosen from a representative sample of six Canadian community- and academic-based hospitals that participated in a national Canadian audit on the management of NVUGIB.
Participants reported substantive gaps in the implementation of NVUGIB guidelines that included the following: lack of knowledge of the specifics of the NVUGIB guidelines (ER, ICU, nurses); limited belief in the value of guidelines, especially in areas where evidence is lacking (ER, ICU); limited belief in the value of available tools to support implementation of guidelines (GI); lack of knowledge of the roles and responsibilities of health care professions and disciplines, and lack of effective collaboration skills (ER, ICU and GI); variability of knowledge and skills of health care professionals within professions (eg, variability of nurses' knowledge and skills in endoscopic procedures); and perceived overuse of intravenous proton pump inhibitor treatment, with limited concern regarding cost or side effect implications (all participants).
In the present study population, ER, ICU and nurses did not adhere to NVUGIB guidelines because they were neither aware of nor familiar with them, whereas the GI lack of adherence to NVUGIB guidelines was influenced more by attitudinal and contextual barriers. These findings can guide the design of multifaceted educational and behavioural interventions when attempting to effectively disseminate existing guidelines, and for guideline implementation into practice.
背景/目的：医疗服务提供者对非静脉曲张性上消化道出血（NVUGIB）患者的管理指南应用不一致，可能导致治疗效果欠佳和患者预后不良。进行了一项需求评估，以评估加拿大医疗服务提供者在实施这些指南时面临的障碍。
由经过培训的研究人员对22名经过选择性抽样的积极治疗和管理NVUGIB患者的医疗专业人员进行半结构化电话访谈，这些人员包括急诊室医生（ER）、重症监护医生（ICU）、胃肠病学家（GI）、胃肠病学护士和医院管理人员。参与者选自六家加拿大社区和学术医院的代表性样本，这些医院参与了加拿大一项关于NVUGIB管理的全国性审计。
参与者报告了NVUGIB指南实施方面存在的实质性差距，包括以下方面：对NVUGIB指南具体内容缺乏了解（急诊室医生、重症监护医生、护士）；对指南价值的信心有限，尤其是在缺乏证据的领域（急诊室医生、重症监护医生）；对支持指南实施的现有工具的价值信心有限（胃肠病学家）；对医疗专业和学科的角色与职责缺乏了解，且缺乏有效的协作技能（急诊室医生、重症监护医生和胃肠病学家）；同一专业内医疗专业人员的知识和技能存在差异（例如，护士在内镜检查程序方面的知识和技能差异）；以及认为静脉注射质子泵抑制剂治疗存在过度使用情况，而对成本或副作用影响关注有限（所有参与者）。
在本研究人群中，急诊室医生、重症监护医生和护士未遵循NVUGIB指南，因为他们既不了解也不熟悉这些指南，而胃肠病学家未遵循NVUGIB指南更多地受到态度和背景障碍的影响。这些发现可为设计多方面的教育和行为干预措施提供指导，以便在试图有效传播现有指南并将指南实施到实践中时发挥作用。
