Multi-factorial barriers and facilitators to high adherence to lung-protective ventilation using a computerized protocol: a mixed methods study

Abstract Background Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through administration of low tidal volumes (≤ 6.5 ml/kg predicted body weight [PBW]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen. Many patients with ARDS, however, are not managed with LPV. The purpose of this study was to understand implementation barriers and facilitators to the use of LPV and a computerized LPV clinical decision support (CDS) tool in intensive care units (ICUs) in preparation for a pilot hybrid implementation-effectiveness clinical trial. Methods We performed an explanatory sequential mixed methods study from June 2018 – March 2019 to evaluate variation in LPV adherence across 17 ICUs in an integrated healthcare system with > 4,000 mechanically-ventilated patients annually. We analyzed 47 key informant interviews of ICU physicians, respiratory therapists (RTs) and nurses in 3 of the ICUs using a qualitative content analysis paradigm to investigate site variation as defined by adherence level (low, medium, high) and identify barriers and facilitators to LPV and LPV CDS tool use. Results Forty-two percent of patients had an initial set tidal volume ≤ 6.5 ml/kg PBW during the measurement period (site range: 21–80%). LPV CDS tool use was 28% (site range: 6%-91%). This study’s main findings revealed multi-factorial facilitators and barriers to use that varied by ICU site adherence level. The primary facilitator was that LPV and the LPV CDS tool could be used on all mechanically-ventilated patients. Barriers included a persistent gap between clinician attitudes regarding the use of LPV and actual use; the perceived loss of autonomy associated with using a computerized protocol; the nature of physician-RT interaction in ventilation management; and the lack of clear organization measures of success. Conclusions Variation in adherence to LPV persists in ICUs within a healthcare delivery system that was an early adopter of LPV. Strategies to increase adherence to LPV for ARDS patients should include initiating low tidal ventilation on all mechanically ventilated patients, establishing and measuring adherence measures, and focused education addressing the physician-RT interaction. These strategies represent a blueprint for a future hybrid implementation-effectiveness trial.

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The Transmural Trauma Care Model can be implemented well but some barriers and facilitators should be considered during implementation: a mixed methods study

Journal of Physiotherapy ◽

10.1016/j.jphys.2021.08.017 ◽

2021 ◽

Author(s):

Suzanne H Wiertsema ◽

Marianne H Donker ◽

Johanna M van Dongen ◽

Edwin Geleijn ◽

Frank W Bloemers ◽

...

Keyword(s):

Mixed Methods ◽

Trauma Care ◽

Mixed Methods Study ◽

Barriers And Facilitators ◽

Care Model

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A Mixed Methods Study on the Barriers and Facilitators of Physical Activity Associated with Residential Relocation

Journal of Environmental and Public Health ◽

10.1155/2018/1094812 ◽

2018 ◽

Vol 2018 ◽

pp. 1-12

Author(s):

Grazia Salvo ◽

Bonnie M. Lashewicz ◽

Patricia K. Doyle-Baker ◽

Gavin R. McCormack

Keyword(s):

Physical Activity ◽

Mixed Methods ◽

Statistical Significance ◽

Mixed Methods Study ◽

Barriers And Facilitators ◽

Residential Relocation ◽

Quantitative Phase ◽

Neighbourhood Walkability ◽

Perceived Change ◽

Leisure Physical Activity

Despite evidence suggesting that neighbourhood characteristics are associated with physical activity, very few mixed methods studies investigate how relocating neighbourhood, and subsequent changes in the built environment, influences physical activity. This sequential mixed methods study estimates associations between changes in overall physical activity and transportation walking and cycling and changes in objectively assessed neighbourhood walkability (quantitative phase) and describes perceived barriers and facilitators to physical activity following residential relocation (qualitative phase). During the quantitative phase, self-reported changes in transportation walking, transportation cycling, and overall physical activity following residential relocation were measured using a 5-point scale: (1) a lot less now, (2) a little less now, (3) about the same, (4) a little more now, and (5) a lot more now. Walkability improvers reported a slight increase in transportation walking (mean = 3.29, standard deviation (SD) = 0.87), while walkability decliners reported little or no perceived change in their transportation walking after relocation (mean = 2.96, SD = 1.12). This difference approached statistical significance (p=0.053). Furthermore, walkability decliners reported a slight decrease in transportation cycling (mean = 2.69, SD = 0.96), while walkability improvers reported little or no perceived change in their transportation cycling after relocation (mean = 3.02, SD = 0.84). This difference was statistically significant (p<0.05). Change in walkability resulting from relocation was not significantly associated with perceived change in overall physical activity. Our qualitative findings suggest that moving to a neighbourhood with safe paths connecting to nearby destinations can facilitate transportation walking and cycling. Some participants describe adjusting their leisure physical activity to compensate for changes in transportation walking and cycling. Strong contributors to neighbourhood leisure physical activity included the presence of aesthetic features and availability of recreational opportunities that allow for the creation of social connections with community and family.

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Health and Access to Healthcare in Homeless People: Protocol for a Mixed-methods Study

10.21203/rs.3.rs-880066/v1 ◽

2021 ◽

Author(s):

Miguel A. Bedmar Pérez ◽

Miquel Bennasar-Veny ◽

Berta Artigas Lelong ◽

Francisca Salvà Mut ◽

Joan Pou Bordoy ◽

...

Keyword(s):

Mixed Methods ◽

Health Status ◽

Homeless People ◽

Premature Death ◽

Access To Healthcare ◽

Mixed Methods Study ◽

Poor Health ◽

Barriers And Facilitators ◽

Second Phase ◽

Structural Factors

Abstract BackgroundHomelessness is a more complex problem than the simple lack of a place to live. Homeless people (HP) often suffer from poor health and premature death due to their limited access healthcare, and are also deprived of basic human and social rights. The study protocol described here aims to evaluate the complex relationship between homelessness and health, and identify the barriers and facilitators that impact access to healthcare by HP.MethodsThis is a mixed-methods study that uses an explanatory sequential design. The first phase will consist of a cross-sectional study of 300 HP. Specific health questionnaires will be used to obtain information on health status, challenges during the COVID-19 pandemic, self-reported use of healthcare, diagnoses and pharmacologic treatments, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and human basic needs and social support (SSQ-6). The second phase will be a qualitative study of HP using the “life story” technique with purposive sampling. We will determine the effects of different personal, family, and structural factors on the life and health status of participants. The interviews will be structured and defined using Nussbaum's capability approach. DiscussionIt is well-known that HP experience poor health and premature death, but more information is needed about the influence of the different specific social determinants of these outcomes and about the barriers and facilitators that affect the access of HP to healthcare. The results of this mixed methods study will help to develop global health strategies that improve the health and access to healthcare in HP.

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