A Qualitative Study to Understand Barriers to Implementation of National Guidelines for Prehospital Termination of Unsuccessful Resuscitation Efforts

Abstract

Background. The American Heart Association's (AHA's) Advanced Cardiac Life Support guidelines act as the national standards for termination of resuscitation (TOR) in cases of refractory out-of-hospital cardiac arrest. However, local emergency medical services (EMS) implementation of these guidelines has been nonuniform. Objective. To identify the operational issues within local EMS systems that may serve as barriers or facilitators to full acceptance of national guidelines for prehospital TOR in appropriate circumstances. Methods. We conducted three focus groups at the January 2008 National Association of EMS Physicians (NAEMSP) annual meeting. Snowball sampling was used to recruit 19 physicians, two EMS providers, one research director, one nurse, and one medical student attending the conference. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. Results. We identified three distinct stakeholder groups whose current beliefs and practices may influence local implementation of TOR: EMS providers with variations in education and work culture; EMS medical directors with responsibility but little authority; and online medical control physicians who do not communicate effectively with the other groups. Our focus group participants suggested that national organizations, such as the AHA and the American College of Emergency Physicians, may serve a role in overcoming the overarching barriers of communication, standardized educational requirements, and coordination of local services. Conclusion. We have identified operational barriers that may impede implementation of TOR guidelines. Three influential stakeholder groups will need to work with national organizations to overcome these local barriers.