Abstract

BackgroundAcute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The 2020 Canadian clinical practice guidelines for the diagnosis of AAS incorporate all available evidence into four key recommendations. In order to facilitate the implementation of these recommendations, a clinical decision aid was created. The objective of this study was to identify barriers and facilitators among physicians prior to implementation of the guideline recommendations in a multicentre step wedge cluster randomized control trial.MethodsWe conducted semi-structured interviews with nine emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to guideline recommendation uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified.ResultsTwo themes and six subthemes encompassing 13 theoretical domains were identified. These included clinical decision-making support, awareness of the evidence, social factors, expected consequences, ability of physicians to acquire the necessary data and ease of use. A majority of interviewees anticipated that the guideline recommendations would support clinical decision making and more effectively risk-stratify patients. Other facilitators included endorsement of the guidelines by professional organizations and peers. Barriers to implementation include the fact that laboratory testing and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the clinical decision aid and concerns about test specificity were also identified as potential barriers to use.ConclusionPhysicians were amenable to using the AAS guideline recommendations to support clinical decision-making and to reduce resource use. A structured intervention should be developed to address the identified barriers and leverage the facilitators in order to ensure successful implementation. Our findings may have implications for the implementation of other guidelines used in emergency departments.

Highlights

  • Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed

  • The guidelines incorporate all available evidence for the historical risk factors, patient symptoms, and physical exam findings associated with AAS into a clinical decision aid for risk stratification

  • One hundred twenty-two utterances were coded into the 14 Theoretical Domains Framework (TDF) domains, thirteen of which were identified as potentially influencing guideline recommendation uptake and accurate use

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Summary

Introduction

Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The 2020 Canadian clinical practice guidelines for the diagnosis of AAS incorporate all available evidence into four key recommendations. Acute aortic syndrome (AAS) refers to a group of lifethreatening aortic pathologies including aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. This uncommon but potentially lethal condition is challenging to diagnose [1]. The guidelines incorporate all available evidence for the historical risk factors, patient symptoms, and physical exam findings associated with AAS into a clinical decision aid for risk stratification (see Additional file 1). The purpose of the guideline recommendations is to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging

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