Leveraging implementation science to improve uptake of an ED decision support aid for heart failure patients

Background

Changing clinical practice is difficult. An innovative risk stratification process to triage patients presenting to the Emergency Department (ED) with heart failure (HF) exacerbation who were safe for discharge, CodeHF, was inconsistently used in an ED, despite strong evidence of its benefits. Understanding barriers and facilitators to its use is needed to improve adoption. The objective of this study was to understand barriers and facilitators to CodeHF use in routine practice and address determinants of adoption.

Methods

A qualitative study was conducted in a four-hospital healthcare system to explore CodeHF implementation and use after three years’ use of CodeHF as part of routine clinical care. The Tailored Implementation in Chronic Diseases (TICD) determinants was used to guide semi-structured interviews and organize themes identified through open coding. Themes were then mapped to Expert Recommendations for Implementing Change (ERIC) strategies.

Results

Interviews (n=20) conducted with ED, HF, and hospitalist clinicians; administrative leaders; and researchers revealed five barriers (lack of initial buy-in, validity concerns, lack of clarity around purpose/target, communication gaps, and liability/malpractice concerns) and three facilitators (prompt patient follow-up, decision support, nurse championship). ERIC strategies were adapted to optimize future CodeHF use, and novel strategies were proposed to supplement those from ERIC. Recommendations were created to share with stakeholders and support future implementation efforts.

Conclusions

Systematically evaluating the implementation of novel evidence-based treatment strategies can identify barriers and facilitators that can then be mapped to refined implementation strategies. This study exemplifies a pragmatical approach to improve uptake, sustained use, and scalability of an evidence-based intervention for future sites seeking to implement ED pathways for risk-stratifying patients with HF.

What is known

• CodeHF, an algorithmic decision support aid (DSA) for emergency department (ED) physicians triaging disposition for patients experiencing heart failure exacerbation, is underutilized at a large health system despite evidence of clinical and process quality improvements associated with its use.

• Different implementation science tools can be used to assess barriers to uptake of an intervention or to identify potential strategies to improve uptake.

What the study adds

• In addition to barriers found in other ED-based qualitative studies of similar DSAs, this study identifies interdepartmental communication gaps and use of a novel implementation path that ED physicians felt was imposed onto them, hindering initial buy-in to use.

• The study provides a novel example of how to use multiple implementation science tools to plan qualitative interviews, organize coded themes, and tailor strategies to address identified barriers, by mapping identified determinants from the Tailored Implementation in Chronic Diseases framework to known implementation strategies from the Expert Recommendation for Implementing Change (ERIC) framework.

• Five additional strategies are suggested for the ERIC framework: (1) clarify roles and responsibilities, (2) de-implement interventions or intervention components, (3) demonstrate responsiveness to reported barriers and needs, (4) automate processes, and (5) leverage acceptable implementation pathways.