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Table 1 Theoretical domains, themes and example participant comments

From: Facilitators and barriers for emergency department clinicians using a rapid chest pain assessment protocol: qualitative interview research

Theoretical DomainThemeExample Participant Comments
KnowledgeKnowledge about the protocol“Everyone uses it. Everyone knows about it.” (P149)
Knowledge of the contents of the protocol“We still have the low-risk, intermediate-risk, and high-risk groups, but our approach to investigations within those groups has changed with the new process. So specifically, for the low-risk group, so patients less than 40, they now only need to have two troponins and two ECGs two hours apart, and then they are able to be discharged home if they are both negative or normal. Whereas previously they would need a 6-h troponin (Tn) or stress test, potentially. The intermediate risk group, likewise have troponin at two hours and two ECGs and if those are negative they can then have a stress test. So shortening the serial assessment from 6 h down to 2 h.” (P150)
Social/Professional Role and IdentityAll professionals have a role within the pathway“We have to be trained to like to be able to take bloods but once you are able to do that, we can initiate troponin etc. if we believe that they meet the criteria for the chest pain pathway. That’s not frowned upon, that’s encouraged by doctors. Chest x-rays, they have to be signed off by a medical officer, but we can go to them and say “the patient requires a x-ray for the chest pathway” and they will sign off” (P152)
“From a nursing perspective we’re aware of it, but ultimately the responsibility of going on whatever sort of, you know, low-, intermediate-, or high-risk is up to the medical staff and they oversee medical staff who are overseeing that” (P151)
The protocol fostered teamwork and cooperation“It needs to be a team effort” (P149)
“I put them on high risk and then have a chat with cardiology and then they’re admitted” (P154)
“I think most people are on board with it, in terms of our medical colleagues in cardiology as well” (P154)
The protocol provides professional confidence“I think it tends to protect the practitioner … because I’m actually following what is actually agreed upon between the departments” (P148)
“But it’s very reassuring to be able to do that second troponin and it very rarely delays their stay. So, I think probably people are still getting put on the pathway because it is considered so low-harm and low-cost. And it’s reassuring” (P150)
There is a trusted leader supporting the protocol“Here, we believe in [study lead], it’s easy if I say [study lead] said this is what we’re do, this is what we do.” (P148)
Beliefs about CapabilitiesThe protocol is easy to use“It’s easy to use and it cuts out any indecision” (P149)
Confidence in using the pathway“If my seniors and consultants and registrar are using the pathway then I feel empowered, I guess, and confident that they have put their confidence in the pathway so that I should be able to as well” (P154) “I wouldn’t make that part of my triage because I don’t have confidence in my entire grasp of it. And also, I think it needs to be something led from a team perspective” (P149)
Empowerment“… created autonomy as nurses because since the pathway has been brought out, if we think they are a very low-risk pathway then we won’t initiate blood work on them. But if they meet the intermediate- or high-risk pathway then we, as nurses, can initiate the measurement of the troponin and the cut off markers, so,. I think it’s given us, if anything, a little bit more autonomy” (P152)
GoalsStandardized evidence- based practice“They are a pathway and a guide so there are times when patients don’t fit the mould and it’s important that we don’t try to make them fit the pathway. But for ensuring consistency of practice and making sure that we are working with the best evidence I think I all pathways can be very helpful” (P150)
“it’s like a checklist thing to make sure that you are achieving what the researchers have proven to be the best for the patient” (P151)
Improved patient flow, reduced length of stay and reduced cost“Faster time to assessment; faster time to discharge; less length of stay; saving money for the health services. We, like I said earlier, don’t tend to over investigate them as much anymore.” (P152)
“It’s good for the patient and its good for patient flow” (P 148)
“Total length of stay was much shorter than it otherwise would have been” (P150)
“We’re picking up things a lot quicker now” (P154)
“We know the destination for the patient, we can pre-plan our movement, bed bookings, booking different types of investigations, all the self-initiated investigation of the patient” (P152)
A goal is to enhance patient safety“They’re [pathway] a great safety net” (P 147)
“It’s the outcomes that have been achieved from it have proved positive. And you know we are working collectively towards again, improving patient outcomes” (P151)
“it’s just a, a way that we can more efficiently and better treat all our chest pain pathway patients. And we manage them and, you know, allocate appropriate resources and time and make it safe for the patient” (P149)
Reduced unnecessary testing“It avoids unnecessary inpatient testing” (P154)
“they’re not getting stress testing and they’re not getting those sorts of things” (P154)
Social influencesThe use of the pathway is a group norm“I would see it as an exception if people don’t use it. Like I would say the majority of people use it” (P153)
“In Emergency, I’m not aware of any of us who are using the previous process. All of us would be, well I believe we are all using it” (P150)
“Basically, everyone refers to it” (P148)
“it’s sort of embedded in the culture” (P151)
There is social pressure to conform to the group norms“They hear the “pathway.” Because the nurse prompts “are they going to, will we go and put them on the pathway, because we are taking the blood. Do you want a troponin; okay put them on the pathway”. They are sort of going “Oh what’s a pathway?” And then they’ll come along and just it’s just like they’ve come along for the ride with you.” (P147)
“They’ll go work elsewhere and what they do elsewhere is slightly different. And when they initially start here they’ll probably actually just do what they are familiar with. But once it’s been pointed out “hey this is what we do here” and then I think most of them tend to follow it” (P148)
Intergroup support facilitates protocol use“There’s actually agreement between us and inpatient teams, so there’s actually no disagreement to what needs to be done” (P148)
“I think it must be easier for the inpatient units to accept referrals from us, having a protocol like this to drive their admissions they know that it’s there, they’ve had buy in to the process so that allows them to monitor” (P149)
“In ED it’s very well regarded. Nursing staff like it, again because they know what’s going to happen with a patient. Hopefully there is less individual practitioner variability. That’s a good thing. The medical staff like it, again for the same reasons. It’s clear what the processes are and it won’t depend on who the consultant supervising is as to what will happen with a patient. Inpatient teams, may have been sceptical at first but I think they quite like it also because it’s probably diverted a lot of referrals that might have come their way” (P150)
Memory, Attention and Decision ProcessesStaff reported that they were not always able to remember the guideline.“You don’t need to keep looking at the poster once you know the principles, you know the risk factors, you know what it is, it’s easy to remember and the fact that it’s colour coded” (P147)
“I don’t know them off by heart” (P149)
“You’ll see people looking at it all the time just to confirm that patients really are low risk or intermediate risk. ‘Cause they would previously have fallen into different group. And you’ll see nurses looking at them, you’ll see the residents and the registrars as well. And you’ll see consultants checking, especially the diabetic patients, just making sure that we are doing the right thing. And like, I think that’s great. I don’t think there’s any problem with people checking it. It’s important that we are doing the right thing” (P150)
“I can’t tell you it verbatim, but I know it’s there.” (P151)
Decision making was aided through the use of a standardised protocol“There’s some really clear, clear guidelines and they’re quite easy to follow and really spells it out. And everyone’s kind of on board with it as well, so, bit of a no brainer. But very logical and clear guidelines so, and just helps you to sort of come up with your decision making as well” (P154)
“It just helps you, yeah, not make mistakes based on the evidence from the research. And you know if you’re busy, it’s always busy, and chaotic in an emergency department, so it gives you again the structured approach so you’ve got some steps to follow, you know what you are doing” (P151)
SkillNot all individuals have the skills required to identifying patients eligible for the pathway“It’s an easy route for less experienced decision makers to confuse. So more junior registrars for example, especially on nights, it can, you can find patients who have been put on this pathway but who it’s not appropriate” (P150)
“One of the things that people still struggle with is that is it a PE or is it a, is it cardiac. And so they get put on a double protocol. They get a PE protocol and a chest pain pathway. You know, like it’s almost, at times it’s almost without, without thinking and you say, well we do this, we’ll follow this. But sometimes we don’t really think enough” (P148)
“Usually women who have come in with atypical pain which can sometimes be difficult to differentiate. And they will, or should have, a PE exclusion first. Occasionally that does happen, and we just need to keep that in front of our mind” (P150)
There is some de-skilling“I think it takes away from clinical, your own individual clinical assessment. But that’s happening with all pathways. Clinical deskilling, definitely. Definitely. Especially with the junior medical staff. They hear the “pathway.” Because the nurse prompts “are they going to, will we go and put them on the pathway, because we are taking the blood. Do you want a troponin; okay put them on the pathway” … (P147)
Improving skills through interpersonal communication“As a nurse, like for me, if I, when I look after the chest pain patient, I think in my head where they fall. I go to the pathway to double check, talk to the doctors and say is this right?” (P149)
“When I call them [cardiology] on that I actually say, this person’s on the high-risk chest pain pathway. I just, I like, some of the features that are in this high-risk box really. And it’s fairly straight forward and self-explanatory and usually cardiologists and all the registrars that we talk to are very receptive and they’re pretty good” (P154)
Staff turnover and training new staff is a barrier to protocol use“Staff are changing so often and it’s really hard to keep up with the training or the education for this so it slows down the staffing abilities to follow the protocol accurately” (P152)
“We’ve had a big change over staff have, it probably would be a good idea in some way for new grads and all that sort of staff to be aware of what this is cause they have so many other things that they need to achieve that they probably don’t, they’re not always aware of this sort of thing” (P151)
“So the registrars change about every 6 months usually. So, the first week of their term under, they get the hospital orientation and then a department orientation and then I think they get on the Thursday, they have a more in-depth orientation about clinical and education and training issues” (P150)
Having an accessible, clear, easy to follow protocol is a facilitator“It’s behind the computer when you walk up the stairs from resus, it’s behind the wall on a computer there and it’s blown up, really. It’s great. But it’s like, it’s blown up really big. It’s a spot that’s easy to access, it’s close to resus side where most of the time we use it. You can get it off the [ED resource website] as well. There’s copies of it in each resus bay” (P149)
“The chest pain pathway is very accessible. Like it’s something that we use very frequently, everyone knows a little bit about it, and even if you don’t know a lot about it you know where you can go and stand at the wall. And it’s one of those algorithms, like the actual, it’s easy to read, it’s easy to follow” (P149)
“From a visual perspective, it’s not busy. There’s not a lot of wording in it. It’s colour coded. It’s got arrows showing flow” (P149)
“We’ve got posters around the department just to prompt us if we’re uncertain which is handy” (P150)
Environmental Context and ResourcesPerson x person interaction overcomes the barrier of training new staff“From my encounters it’s usually when they are on the floor so they’ll encounter this patient and there’s always a senior staff member somewhere and we will inform them of this pathway and I’d have to check with our educator to see if there is a formal education process surrounding it. It seems to be floor and word of mouth” (P152)
The resources required to utilise the protocol are provided by the department“We’ve got 24-h access to troponin here. But I suppose there would be places that might have bedside troponin point of care testing, which would be okay. We’ve got very good access to stress tests. Quite often same day, but if not same day, then next day, even on the weekend. And I think that has been crucial and it’s shown that this pathway has been as successful as it has been” (P150)
“We have the ability to do the blood tests along with the specialised accelerated blood tests with the delta Z times et cetera. We have the ability to access ECGs easily, along with chest x-rays, we also have the capacity to do exercise stress testing (EST), 7 days a week. It’s for less resourced centres, this may not be appropriate” (P152)