Puchalski Ritchie Lisa M, Debebe Finot, Azazh Aklilu
Department of Medicine, University of Toronto, Toronto, Canada.
Department of Emergency Medicine, University Health Network, Toronto, Canada.
BMC Health Serv Res. 2019 Mar 20;19(1):181. doi: 10.1186/s12913-019-4008-2.
Evidence-based clinical algorithms (EBCA) are knowledge tools to promote evidence use by codifying evidence into action plans to facilitate appropriate care. However, their impact on process and outcomes of care varies considerably across practice settings and providers, highlighting the need for tailoring of both these knowledge tools and their implementation strategies to target end users and the setting in which EBCAs are to be employed. Leadership at the Tikur Anbessa Specialized Hospital emergency department (TASH-ED) in Addis Ababa, Ethiopia identified a need for context-appropriate EBCAs to improve evidence uptake to mitigate care gaps in this high volume, high acuity setting. We aimed to identify barriers and facilitators to utilization of EBCAs in the TASH-ED, to identify priority targets for development of EBCAs tailored for the TASH-ED context and to understand the process of care in the TASH-ED to inform implementation planning.
We employed a multi-component qualitative design including: semi-structured interviews with TASH-ED clinical, administrative and support services staff, and Toronto EM physicians who had worked in the TASH-ED; direct observation of the process of care in TASH-ED; document review.
Although most TASH-ED participants reported an awareness of EBCAs, they noted little or no experience using them, primarily due to the poor fit of many EBCAs to their practice setting. All participants felt that context-appropriate EBCAs were needed to ensure standardized and evidence-based care and improve patient outcomes for common ED presentations. Trauma, sepsis, acute cardiac conditions, hypertensive emergencies, and diabetic keto-acidosis were most commonly identified as priorities for EBCA development. Lack of medication, equipment and human resources were identified as the primary barriers to use of EBCAs in the TASH-ED. Support from leadership and engagement of stakeholders outside the ED where EBCAs were believed to be less well accepted were identified as essential facilitators to implementation of EBCAs in the TASH-ED.
This study found a perceived need for EBCAs tailored to the TASH-ED setting to support uptake of evidence-based care into routine practice for common clinical presentations. Barriers and facilitators provide information essential to development of both context-appropriate EBCAs and plans for their implementation in the TASH-ED.
循证临床算法（EBCA）是一种知识工具，通过将证据编纂为行动计划以促进适当的护理，从而推动证据的应用。然而，它们对护理过程和结果的影响在不同的实践环境和提供者之间差异很大，这凸显了需要针对最终用户和EBCA应用环境定制这些知识工具及其实施策略。埃塞俄比亚亚的斯亚贝巴提库尔·安贝萨专科医院急诊科（TASH-ED）的领导层发现，需要适合当地情况的EBCA，以提高证据的采纳率，从而弥合这个高流量、高急症环境中的护理差距。我们旨在确定TASH-ED中EBCA使用的障碍和促进因素，确定为TASH-ED环境量身定制的EBCA开发的优先目标，并了解TASH-ED的护理过程，以为实施规划提供信息。
我们采用了一种多组件定性设计，包括：对TASH-ED的临床、行政和支持服务人员以及曾在TASH-ED工作的多伦多急诊医学医生进行半结构化访谈；直接观察TASH-ED的护理过程；文件审查。
尽管大多数TASH-ED的参与者表示了解EBCA，但他们指出使用EBCA的经验很少或没有，主要原因是许多EBCA与他们的实践环境不太匹配。所有参与者都认为需要适合当地情况的EBCA，以确保标准化的循证护理，并改善常见急诊表现的患者预后。创伤、脓毒症、急性心脏疾病、高血压急症和糖尿病酮症酸中毒最常被确定为EBCA开发的优先事项。药物、设备和人力资源的缺乏被确定为TASH-ED中使用EBCA的主要障碍。领导层的支持以及在EBCA被认为接受度较低的急诊科之外的利益相关者的参与，被确定为TASH-ED中EBCA实施的重要促进因素。
本研究发现，人们认为需要为TASH-ED环境量身定制EBCA，以支持将循证护理纳入常见临床症状的常规实践中。障碍和促进因素为开发适合当地情况的EBCA及其在TASH-ED中的实施计划提供了至关重要的信息。
