Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
Ann Emerg Med. 2023 Sep;82(3):381-393. doi: 10.1016/j.annemergmed.2023.02.021. Epub 2023 Apr 12.
Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology.
We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks-the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process.
We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes.
In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory.
尽管专业学会指南推荐，但美国急诊科（ED）对低危肺栓塞（PE）患者进行门诊管理仍不常见。本研究旨在使用实施科学方法，确定 ED 中 PE 门诊管理的障碍和促进因素。
我们采用最大变异抽样法，对急诊科的急诊医师进行半结构式访谈，旨在招募在低危 PE 管理方面具有不同实践模式的医师。我们使用实施科学框架（实施研究综合框架和理论领域框架）制定了访谈指南。访谈采用录音、转录，并在迭代过程中进行分析。
我们采访了来自 11 个医院系统的 26 名急诊医师，这些参与者在执业年限、执业环境和参与低危 PE 门诊管理方面存在差异。尽管外在环境决定因素（如法医学气候、随访和保险状况）普遍存在，但我们的参与者揭示了这些决定因素的重要性受到个体和内在环境决定因素的调节。主要主题包括对后果的信念、对能力的信念以及机构支持和文化。临床实践的惯性和过程的复杂性是重要的子主题。
在这项定性研究中，临床医生报告了常见的障碍和促进因素，这些因素最初集中在外部环境和外部障碍上，但集中在临床医生的信念、恐惧和当地文化上。为了增加对特定急性 PE 患者的门诊治疗，应根据这些障碍和促进因素进行干预，这些因素与去实施理论相一致。
