Barriers and Facilitators to Intensivists' Adherence to Hyperinsulinemia-Euglycaemia Therapy in the Treatment of Calcium Channel Blockers Poisoning
CCCF ePoster library. Brassard E. Oct 3, 2017; 198096
Eric Brassard
Eric Brassard
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Abstract
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Barriers and Facilitators to Intensivists’ Adherence to Hyperinsulinemia-Euglycaemia Therapy in the Treatment of Calcium Channel Blockers Poisoning

Brassard, Eric (1), St-Onge, Maude (2), Lacombe, Guillaume (3), Archambault, Patrick (4)



(1) Département d’anesthésiologie et de soins intensifs, Université Laval, Québec, Canada; (2) Quebec Poison Control Center, CHU de Québec Research Center, Population Health and Optimal Health Practices, Université Laval, Québec, Canada; (3) Département de médecine familiale et de médecine d’urgence, Université Laval, Québec, Canada; (4) Centre de recherche du CHAU Hôtel-Dieu de Lévis, Québec, Canada

INTRODUCTION
Calcium channel blocker (CCB) poisoning is an increasing problem associated with significant morbidity and mortality. In the province of Quebec, the number of CCB poisoning went from 100 cases in 1991 to 315 in 2006, with a mortality rate of 6% (1). Hyperinsulinemia-euglycemia therapy (HIET) have been described in observational studies as being effective and safe (2,3). Two studies have shown a low 42% adherence rate to Poison Control Centers (PCC) recommendations for the management of calcium channel blocker poisonings (1,4). Although frequent barriers to guidelines adherence and various implementation strategies have been described (5,6,7,8,9), there is no study on limiting and facilitating factors for adherence to PCC recommendations.

OBJECTIVE
To determine the behavioral determinants to adhere to PCC recommendations about treatment for CCB poisoning. The goal is to eventually facilitate collaboration between PCC and clinicians, in order to optimize knowledge transfer

METHODS
We recruited intensivists by convenience sampling, sending invitations to intensivists across the provinces of Quebec and Ontario. Eighteen participants from nine different academic hospitals were interviewed. We recruited participants until we reached data saturation. We explored factors influencing the decision to initiate HIET using semi-structured interviews and analyzed the content of the interviews with an integrative framework using 14 theoretical domains (Theoretical Domains Framework) (10,11). Two independent reviewers performed qualitative analysis of the interview transcripts and classified behaviors as being likely to facilitate, likely to be a barrier or unlikely to affect adherence. We used likely size of the impact and frequency of the behavior to determine relevant domains and resolved disagreements through discussion.

RESULTS
We identified the main positive determinants in the following domains: ‘behavioral regulation' (i.e. algorithm for adjustment of perfusions and information provided to nurses), ‘self-efficacy' (i.e. confidence about being able to manage HIET), ‘belief about consequences' (i.e. fear of clinical deterioration or medicolegal consequences), ‘reinforcement' (i.e. clinical instability), ‘nature of behavior' (i.e. positive past experiences) and ‘memory, attention and decision process' (i.e. impact of PCC suggestion to use HIET). We identified the main negative determinants in the following domains: ‘nature of behavior' (i.e. preference for vasopressors over HIET), ‘environmental context and resources' (i.e. accessing D50% and increased nurse workload) and ‘memory, attention and decision process' (i.e. hypoglycaemic or hypokalemic patient, clinical improvement or stability with minimal vasopressor support).

CONCLUSION
Behavioral determinants that we identified might not be applicable in community hospitals. Our results are limited by the explorative nature of this study. Implementation strategies targeting these behavioral determinants should be developed to improve adherence to CCB poisoning treatment recommendations.

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