Abstract
Introduction: High variability in heart failure (HF) readmissions persists despite national efforts and incentives. A standardized care path, CodeHF, was developed for use in the emergency department (ED) to better identify HF patients warranting admission. CodeHF was implemented in Kansas City in 2018. Despite positive patient and hospital-level outcomes, use of CodeHF has lagged. Hypothesis: A qualitative study was conducted to understand barriers and facilitators behind the implementation of CodeHF with the goal of tailoring strategies to increase usage and scalability to other hospitals. Methods: Semi-structured interview guides were developed based on the Tailored Implementation in Chronic Diseases (TICD) list. 21 stakeholder interviews were conducted and thematic coding of interview transcripts was performed. Codes were matched to a relevant TICD determinant and implementation strategy from the Expert Recommendation for Implementing Change project. A tailored recommendation was created for each strategy. Results: Analyses revealed 10 key themes: 1) Quality of Evidence: Skepticism of evidence; 2) Liability: Concern of CodeHF use in litigation; 3) Technical Difficulties: Challenges and errors during roll-out; 4) Ownership: Lack of ED ownership and champions; 5) Buy-In: Lack of ED buy-in due to the external project origin; 6) Understanding of Tool: Confusion of purpose and intended users; 7) Utility of Tool: Doubts of value in practice; 8) Exceptions to pathway: Concerns about inappropriate use; 9) Admitting Physician Awareness: Lack of recognition of CodeHF by admitting physicians; 10) Follow-up: Appreciation for rapid follow-up for discharged patients. Conclusions: Despite evidence supporting the positive impact of CodeHF, several implementation barriers and few facilitators were identified. Presenting updated evidence, partnering with new champions, educating providers on clinical and legally protective benefits, spreading awareness about technical solutions, inviting ED providers to lead redesign/relaunch, encouraging initial and ongoing educational meetings at all levels, emphasizing the follow-up benefit, and educating cardiologists and hospitalists are potential strategies for overcoming these barriers.
Published Version
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