Table 1 Barriers to and facilitators of uptake of EBCAs in the TASH-ED

 Barriers

Resource constraints.

Lack of consultant level EM physician and nursing staff, high frequency of turnover of trainees rotating through the ED.

Lack of medication and equipment, delays in care while patients/families purchase necessary supplies.

Infrastructure.

Lack of computers and internet connectivity within the TASH-ED, limit accessibility and therefore use EBCAs.

Fit of the EBCA with the TASH-ED context.

Lack of fit of published EBCAs with the TASH-ED context with respect to both resources and local data.

 Facilitators

Strong ED leadership.

ED leadership developed a supply of essential drugs and equipment available for immediate use to reduce delays in urgent care.

Ministry of health support.

Investment in EM over last decade has and continues to improve EM resources, including material resources and EM trained staff.

Embedding EBCA into policy.

Embedding the EBCA into the system as hospital policies or guidelines and attaching consequences for non-use, were suggested as facilitators to uptake that had met with success with some previous implementation efforts within the department.

Endorsement by leadership.

Endorsement by ED and hospital leadership, and the ministry of health, would improve uptake of the EBCA.

EBCA design and accessibility.

Clear, concise, easy to follow, paper based design, tailored for the practice context in terms of resources and local disease patterns, essential to EBCA uptake.

 Barriers

Acceptance of EBCA approach to clinical care.

While EBCAs reported to be valued by EM staff, participants felt non-EM providers would be resistant to use of EBCAs as a result of differences in work place culture among other clinical departments.

Attitudes.

Lack of interest/poor attitude among some trainees rotating through the ED.

Habits.

Practice habits hard to change.

Knowledge and skills.

Lack of knowledge of EBCA development and basis in evidence and lack of experience with EBCAs common, an important potential barrier to uptake.

Lack of knowledge or skills needed for EBCA implementation among non-consultant level staff who provide the majority of hands on care, a key barrier to EBCA uptake.

 Facilitators

EM specialty relatively new.

May be fewer habits to break among EM practitioners. Enthusiasm for learning and development of the specialty may be an asset to uptake.

Perceived benefit of EBCA use.

EBCAs more likely to be used if perceived to benefit the patient and/or provider, ideally both.

EBCA specific knowledge and skills training.

Provision of appropriate theoretical and practical, knowledge and skills training through didactic and simulation based techniques essential to EBCA uptake and use.

Wide stakeholder engagement.

Wide stakeholder engagement during development of EBCAs for use in the TASH-ED, particularly inclusion of participants from relevant non-EM departments, suggested to facilitate uptake.

 Barriers

Patient ability to pay.

Many patients lack financial resources to pay for recommended care.

 Facilitators

Patient acceptance.

Patients generally accept/agree to provider recommendations.