Research Article: Barriers and enablers to a physician-delivered educational initiative to reduce low-acuity visits to the pediatric emergency department

Date Published: May 29, 2018

Publisher: Public Library of Science

Author(s): Gregory Huyer, Samia Chreim, Wojtek Michalowski, Ken J. Farion, Bianca Huurneman.


Use of the pediatric emergency department (PED) for low-acuity health issues is a growing problem, contributing to overcrowding, longer waits and higher health system costs. This study examines an educational initiative aimed at reducing low-acuity PED visits. The initiative, implemented at an academic pediatric hospital, saw PED physicians share a pamphlet with caregivers to educate them about appropriate PED use and alternatives. Despite early impacts, the initiative was not sustained. This study analyzes the barriers and enablers to physician participation in the initiative, and offers strategies to improve implementation and sustainability of similar future initiatives.

Forty-two PED physicians were invited to participate in a semi-structured individual interview assessing their views about low-acuity visits, their pamphlet use, barriers and enablers to pamphlet use, and the initiative’s potential for reducing low-acuity visits. Suggestions were solicited for improving the initiative and reducing low-acuity visits. Constant comparative method was used during analysis. Codes were developed inductively and iteratively, then grouped according to the Theoretical Domains Framework (TDF). Efforts to ensure study credibility included seeking participant feedback on the findings.

Twenty-three PED physicians were interviewed (55%). Barriers and enablers for pamphlet use were identified and grouped according to five of the 14 TDF domains: social/professional role and identity; beliefs about consequences; environmental context and resources; social influences; and emotions.

The TDF provided an effective approach to identify the key elements influencing physician participation in the educational initiative. This information will help inform behavior change interventions to improve the implementation of similar future initiatives that involve physicians as the primary educators of caregivers.

Partial Text

Hospital emergency departments (EDs) are highly specialized environments designed to treat acute illnesses and injuries requiring immediate attention. However, many ED visits are in fact for non-emergent or low-acuity conditions, representing 48% of visits to Canadian EDs in 2010–11 [1]. The situation is similar in pediatric EDs (PEDs); for example, 55% of PED visits in the province of Ontario, Canada in 2005–06 were classified as low acuity (defined as triage levels IV or V on the five-level Pediatric Canadian Triage and Acuity Scale) [2]. The problems created by low-acuity use of the PED have been extensively studied and documented [3–6]. Perhaps the most significant issue is overcrowding, leading to increased wait times for those who actually require emergent medical attention. Low-acuity use of the PED also leads to increased health system costs, as an ED visit is significantly more expensive than being seen by a primary care provider [7–9]. In fact, estimates suggest that over $4 billion annually could be saved in the United States if all non-emergent care was diverted from the ED to retail clinics [9].

The educational initiative examined in this study was developed at the PED of the Children’s Hospital of Eastern Ontario (CHEO), an academic, tertiary PED serving patients up to 17 years of age (with 72,142 patient arrivals in 2016–17). The hospital is located in Ottawa, Ontario, which is bordered by the province of Quebec. CHEO and its PED are the only pediatric centre to serve the large geographic area of eastern Ontario and western Quebec with a pediatric population of 500,000.

Of the 42 physicians who met the inclusion criteria, 23 agreed to be interviewed (55%). Interviews lasted on average 40 minutes. The physicians’ years of experience at the hospital ranged from 1.5 to 31 years (mean of 12 years, median of 8 years).

Organizations often experience difficulties in implementing new initiatives and ensuring their sustainability, and hospitals are no exception. The landscape is littered with well-designed programs that addressed an important problem and had a good level of support at their inception, only to fail to gain traction and ultimately fade away, thus the need for studies of this nature that analyze the views of those involved in implementation. In terms of the “Choosing Wisely” educational initiative examined here, an important feature was the inclusion of PED physicians in the interdisciplinary design team. However, this proved to be insufficient to ensure the initiative’s success, in part because it is not always possible to anticipate all barriers during the design phase. Instead, additional efforts should have been made to solicit feedback and adjust the initiative during the initial roll-out. This is especially true since physicians can be a challenging group to bring on board when processes and practices are changed because, as professionals, they exercise a high degree of independence, and implementation strategies need to engage them in ways that are compatible with how they view their professional role [35]. Thus, clear and consistent support from organizational leadership throughout the implementation is essential; indeed, one of the barriers identified by the physicians that contributed to the failure of the “Choosing Wisely” initiative was a lack of clarity and inconsistent messaging from the hospital administration.

PED physicians can play an important role in educating caregivers about appropriate PED use, but they are rarely involved in formal educational initiatives. We found that PED physicians were motivated to participate in the “Choosing Wisely” initiative because of the many problems created by high volumes of low-acuity PED visits. However, sustaining physician participation was a challenge. The barriers and enablers of PED physician participation that we identified mapped to five TDF domains: social/professional role and identity; beliefs about consequences; environmental context and resources; social influences; and emotions. These domains and associated barriers and enablers represent key factors influencing physician behavior towards the “Choosing Wisely” initiative and can help inform which behavior change techniques should be considered as part of the initiative’s design and implementation to improve physician participation. More broadly, the results of this study can also guide others who wish to develop similar educational initiatives that depend on physician participation, to help ensure their successful implementation.




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