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Table 2 Description of barriers and facilitators of enhanced recovery protocol (ERP) implementation along the 5 Active Implementation Frameworks (5 AIFs) and components

From: A qualitative examination of barriers and facilitators of pediatric enhanced recovery protocol implementation among 18 pediatric surgery services

Framework

Component

Barrier

Facilitator

Usable innovations (effective practices)

Operationalization

Surgeon: “And I think also training the surgeons. You’re going to have to wait to have a second IV. You’re going to have to wait for that block to happen. Adding that to our turnover time or our anesthesia preparedness time so that we can appropriately block that operative slot.”

Surgeon: “I’ll add that the success I’ve seen us do with the Pectus surgery was really getting down to the specifics and standardizing things. [ … ] So, for our group I think if we leave any kind of leeway, then there’s a chance that it won’t be followed. But if we give specifics that this is exactly how we do it for each one, then that’s more successful.”

Fidelity

Anesthesiologist: “And they re-looked at the data to how many people were being compliant with all the elements of the pathway and it dropped down to like 40%, and so having to go back and even though everyone knows what they’re supposed to do, you get a little bit lax and what’s kind of happening, and so when everyone’s busy clinically it’s hard to go back and having to remind people.”

Not identified as a facilitator

Function

Not identified as a barrier

Surgeon: “And then secondly, I think any kind of resource we put into it, whether it’s a toolkit or so forth, is how easily that will be galled and utilized for other diagnoses. Because if we’re using for a small subset of 50 patients a year, it’s hard to maintain.”

Philosophy

Not identified as a barrier

Surgeon: “ ..first making sure that [ … ] you have everybody .. being a part of the decision-making, and [ … ] making sure that patients and families are an important component of the whole process and that we don’t underestimate. [ … ] So I think that the family and the patient is an under-utilized resource[ … ] a lot of the programs that we try to implement would be far more effective.”

Stages (effective implementation)

Exploration

Surgeon: “I think that there’s no specific barriers. It’s just a matter of actually implementing those things and making it a priority.”

Surgeon: “We’ve had some training from adult colorectal surgeon who is working on ERP from their side of things, and they came to our group, one of our group meetings, and had some training on the ERP occurring in the adult side of things, and gave us some great ideas that we can do from the pediatric side.”

Installation

Surgeon: “And one of the challenges that we identified early on is identifying all the right stakeholders and getting buy-in broadly amongst the providers along the entire continuum of care.”

Surgeon: “I guess first making sure that [ … ] you have everybody at the table so that you’re not forcing someone to do something without being a part of the decision-making.”

Initial implementation

Surgeon: “And then you have these hiccups in the workflow. So, I think that tracking those measures is kind of the next step. I’ve been spending the last year, year and a half, with the help of kind of multiple team members trying to put this into place, but it hasn’t been a totally like, here’s a checklist guys, let’s go.”

Interviewer: “Probing for what intraoperative elements are easier to implement”

Surgeon: “The ones that I have direct control over. Whether they get prophylaxis, antibiotics, surgical technique, avoiding NG tubes, those are all easy to implement, because I’m the one kind of driving the ship.”

Full implementation

Surgeon: “if it can be applicable to thousands of our patients, then I think that would be easy to put more resources towards.”

Surgeon: “For our adults on the post-operative side, we have basically checklists and guidelines printed out in our workroom, and so all the residents have that. And then we also have little ERAS order sets in EPIC that we can order for a post-op patient as well. So it’s quite simple.”

Implementation drivers (effective implementation)

Organization drivers

Surgeon: “The part that it gets a little bit harder is the, the transition from the outpatient discussion to the inpatient side of things [ … ] the inpatient order set is super-duper easy to do. The outpatient order set is a little bit harder to do when we rely really more on our multidisciplinary care team, our pharm D to kind of make that happen. [ … ] I wish there was like one order set that was easy to order in clinic that did everything.”

Surgeon: “We’ve put together basically, a power point slide, which kind of lists the workflow, as far as this is what they get for preoperative, this is what they get day prior, intraoperative, postoperative, discharge plan. And that is available for our team, saved on a drive that they have access to. [ … ] it’s in multiple places for reference, and then it’s kind of built into our order sets.”

Competency drivers for clinicians

Surgeon: “I think one of the barriers is that we don’t have a specific team of nurses. We have lots of nurses and the hospital’s philosophy overall is that nurses should be trained in everything. [ … ] we have people who preferentially want to be in one room or another, but that doesn’t always work.”

Surgeon: “We have to try to work with them and convince them and show the evidence. Or, compromise and kind of decide, “Okay, well, we’re not going to do what I want. We’re not going to do what you want. We’ll do somewhere in the middle, so that both of us...” But, in general I think that there’s been a lot of good buy-in.”

Leadership drivers

Surgeon: “There’s a little bit of unfortunate politics and drama involved in leadership roles within the people that would make sense in my mind to play a role in this. So that needs to get sorted out and we’re working on it.”

Surgeon: “I think it takes resources. It takes people being given time away from clinical duty for either a very long day of planning or multiple repeated meetings. I think it takes administrative support.”

Teams (enabling context)

Receptiveness and buy-in

Surgeon: “We have the 30 anesthesiologists on faculty, and every day I could be with any one of them [ … ] Some of them are a little bit like – the data isn’t really clear about this, why are we doing it. And so there’s just been, depending on who I’m with, I may get a lot of engagement, or I may get... I think it’s just one of those things that’s going to take time to evolve. Physicians are not always easy to change.”

Surgeon: “Yeah, I would kind of agree that by and large there is fairly high institutional buy-in towards any of these quality improvement things, especially ones that don’t cost money [ … ] Sometimes there’s an issue if you want to implement a pathway, and surgeons kind of have their own ways of doing things. We have to try to work with them and convince them and show the evidence. Or, compromise [ … ] But, in general I think that there’s been a lot of good buy-in.”

Collaboration

Surgeon: “It highlighted to us the areas where we don’t have consensus amongst the surgeons and as far as components of the pathway, as well as consensus amongst the anesthesiologists for components of the pathway.”

Surgeon: “For us to choose an ERA approach, it’s a multidisciplinary input usually triggered by a discussion between the physician and the anesthesia pain team, but that case is usually identified by the surgeon saying, “I need to operate on this IBD patient.””

Team engagement

Anesthesiology: “Yeah. So we have a large surgical operation here and I think just what MD_10_1 is saying, we have to get so many different people on board. There’s literally 95 different anesthesiologists that might be in the room on a given day.”

Surgeon: “I guess first making sure that, as you even mentioned you have everybody at the table so that you’re not forcing someone to do something without being a part of the decision-making, and [ … ] I think that the number one thing is making sure that patients and families are an important component of the whole process and that we don’t underestimate. [ … ] I think that the family and the patient is an under-utilized resource. If there is a way to figure out how to tap into that resource, I think that a lot of the programs that we try to implement would be far more effective.”