Baykan Altay, Lafreniere Ann-Sophie, Fraulin Frankie O G, Hartley Rebecca, Harrop Alan Robertson, Love Shannan, Ronksley Paul, Donald Maoliosa
Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Plast Reconstr Surg Glob Open. 2023 Mar 28;11(3):e4896. doi: 10.1097/GOX.0000000000004896. eCollection 2023 Mar.
We recently highlighted shortcomings in the care of pediatric hand fractures in our local context. The Calgary Kids' Hand Rule (CKHR) was developed to predict hand fractures that require referral to a hand surgeon. The aims of this study were to identify barriers to a new care pathway for pediatric hand fractures, based on the CKHR and to generate tailored strategies to support its implementation.
We performed a conventional content analysis of transcripts from four focus groups (parents, emergency/urgent care physicians, plastic surgeons, and hand therapists) to identify relevant concepts (facilitators and barriers). These concepts were mapped to two frameworks. Generic strategies to address the barriers were identified, and further discussions with key stakeholders resulted in tailored strategies for implementation.
Five facilitators to implementation of a CKHR-based hand fracture care pathway included established rapport between hand therapists and surgeons, potential for more streamlined care, agreement on identifying another care provider, positive perceptions of hand therapist expertise, and opportunity for patient education. Two individual barriers were concern for poor outcomes and trust. Three systemic barriers were awareness and usability, referral process, and cost and resources. Strategies to address these barriers include pilot-testing of the new care pathway, ensuring closed loop communication, multiple knowledge translation activities, integration of CKHR into the clinical information system, coordinating care and development of parent handouts.
Mapping barriers to established implementation frameworks has informed tailored implementation strategies, bringing us one step closer to successfully implementing a new pediatric hand fracture pathway.
我们最近强调了本地小儿手部骨折护理方面的不足。卡尔加里儿童手部规则（CKHR）旨在预测需要转诊至手外科医生的手部骨折情况。本研究的目的是确定基于CKHR的小儿手部骨折新护理路径的障碍，并制定针对性策略以支持其实施。
我们对四个焦点小组（家长、急诊/紧急护理医生、整形外科医生和手部治疗师）的记录进行了常规内容分析，以确定相关概念（促进因素和障碍）。这些概念被映射到两个框架中。确定了应对障碍的通用策略，并与关键利益相关者进行进一步讨论，得出了实施的针对性策略。
基于CKHR的手部骨折护理路径实施的五个促进因素包括手部治疗师和外科医生之间已建立的融洽关系、护理流程更简化的可能性、就确定另一位护理提供者达成一致、对手部治疗师专业知识的积极看法以及患者教育机会。两个个人障碍是对不良结果的担忧和信任。三个系统障碍是认知度和可用性、转诊流程以及成本和资源。应对这些障碍的策略包括对新护理路径进行试点测试、确保闭环沟通、开展多项知识转化活动、将CKHR整合到临床信息系统中、协调护理以及编写家长手册。
将障碍映射到既定的实施框架为制定针对性的实施策略提供了依据，使我们朝着成功实施新的小儿手部骨折护理路径又迈进了一步。
