Exploring modifiable factors towards COPD guideline non-concordance and development of an electronic integrated COPD proforma to improve emergency department interdisciplinary staff concordance: Mixed methods and modified Delphi study

Exploring modifiable factors towards COPD guideline non-concordance and development of an electronic integrated COPD proforma to improve emergency department interdisciplinary staff concordance: Mixed methods and modified Delphi study

Chronic obstructive pulmonary disease is a prevalent chronic illness. It is a significant cause of avoidable hospital presentations and the fifth leading cause of death in Australia. An Electronic Integrated COPD Proforma (E-ICP), endorsed and informed by interdisciplinary staff from the Emergency Department (ED), was prioritised using frequency scores to be the most pragmatic solution to mitigate identified barriers of guideline non concordance. The unprecedented pace of clinical care in the ED often only facilitates acute management which exhausts patients, primary care givers and tertiary hospital resources with readmissions and exacerbations. Achieving a consistent pharmacological and nonpharmacological management concordant with the COPD-X plan guidelines is expected to improve health related quality of life in patients with COPD.

OBJECTIVES: This research explored barriers and modifiable factors causing guideline non-concordance that assist the development of an electronic integrated COPD care proforma (E-ICP), through a process of national interdisciplinary (Emergency departments and Respiratory departments), expert consensus.

METHODS: This mixed methods research involved a convergent integrated mixed methods approach that included a systematic review (phase-1), qualitative interdisciplinary staff interviews (phase-2), and an E-modified Delphi method (phase-3) for the development of an electronic proforma with guideline recommendations for use in emergency departments (EDs) in the Australian health system. Phase 2 of this research comprised qualitative interviews with data analysis aligning with Braun and Clarkes (2006), thematic analysis method. The Theoretical Domains Framework including capability, opportunity, motivation, and a behaviour change wheel (COM-B BCW) was adopted as a priori to systematically extract data through all phases. The outcomes propose a range of implementation strategies to the clinical stakeholders/policy makers on improved guideline concordance. In Phase 3, a modified Delphi study was employed to select interventions for the proforma. This phase used a consensus process of three iteration surveys including quantitative survey and qualitative interview thematic analysis on each indicator.

RESULTS: Barriers and modifiable factors explored in this study included lack of knowledge (guidelines and referral methods), skills, staffing, time constraints, memory attention and decision making, professional role identity confusion, and clinical behaviour regulation. Development of an electronic proforma with interdisciplinary staff/patient resources and direct referrals from national interdisciplinary experts from ED and respiratory departments was prioritised as an implementation strategy to address all modifiable factors. The E-ICP demonstrated acceptable and good internal consistency through all iterations from national emergency department and respiratory department interdisciplinary experts.

CONCLUSION: Future outcomes from the E-ICP are its potential to facilitate direct referrals from the ED, leading to reduced hospital admissions, reduced length of hospital stays, holistic care, improved health care and quality of life including improved interdisciplinary guideline concordance.

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