Improving early recognition and treatment of sepsis in paramedic services and emergency departments: a pan-Canadian mixed methods application of the Theoretical Domains Framework.

objectivesEfforts to implement evidence-based guidelines for sepsis care (Surviving Sepsis, CAEP guideline) have met with limited success and mortality from sepsis remains high. We sought to understand barriers and facilitators from the frontline perspective of emergency nurses, physicians, and paramedics.

methodsIn an explanatory sequential mixed methods approach, a 55-question survey was developed using the Theoretical Domains Framework (TDF) and scoping review (reported separately) and distributed via Canadian emergency, nurse, physician, and paramedic organizations in English and French. Purposeful recruiting of interviewees followed, using an interview guide informed by the scoping review and survey. Recordings were transcribed, and audit trails were maintained. A coding tree was developed and findings from the thematic analysis were mapped to TDF constructs, triangulating findings from all data sources.

resultsData consisted of 545 surveys from paramedics (37%), nurses (20%), and physicians (27%), spanning all provinces and the territories in Canada, and 15 interviews (4 nurses, 6 physicians, 5 paramedics).Six themes emerged: access block, recognition by the public, resources (human, physical), leveraging scopes of practice (paramedics, nurses), recognition by healthcare, and the importance of communication. Many of these map to the TDF domain of Environment, Context, and Resources. There was support for guidelines (88% physician/93% paramedic/89% nurse), but interprofessional differences include awareness/understanding the guidelines (92% physician/72% paramedic/84% nurse) and trust in the evidence behind the guidelines (70% physician/85% paramedic/94% nurse). Reinforcement strategies at the point of care were more highly supported (74%/76%/81%) than education (physician 59%, paramedic 85%, nurse 78%).

conclusionThe themes of this work confirm many of the issues known from previous publications, but also added key insights such as access block and recognition by the public. It also reinforces that raising awareness/more education is not a strong facilitator for physicians or nurses.The frontline perspective adds key insights that can improve sepsis care by overcoming key barriers and leveraging facilitators that have been highlighted as important in the complex healthcare implementation environment that is the ED.