Barriers and Facilitators in Implementation of a New Postoperative Esophagectomy Care Pathway: A Qualitative Analysis

Abstract

INTRODUCTION: We recently implemented a new esophagectomy pathway that included significant practice changes, including gastric ischemic preconditioning 4 weeks before definitive surgery and routine placement of feeding jejunostomy tubes. Practice pattern changes can prove challenging. We therefore sought to determine barriers and facilitators to the implementation at the provider level. METHODS: We utilized qualitative method guided by the Theoretical Domains Framework to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen interviews with providers involved with the pathway were conducted and analyzed using Matrix Analysis. RESULTS: Salient Theoretical Domains Framework domains identified included: knowledge, beliefs about consequences, and environmental context and resources. Facilitators included electronic health record tools (note templates including pathway components, pathway specific order set), patient satisfaction, and preliminary data suggesting reduced anastomotic leak rate. Barriers reported included hesitance to abandon previous practices and a desire for more concrete data prior to changing practice; these were most prevalent at the faculty level. Suggestions included improving post-discharge communication between providers and access to pathway documents by the clinical team. CONCLUSION: The Theoretical Domains Framework was successfully able to identify individuals’ perceived barriers and facilitators to implementation and adoption of an esophagectomy pathway that included significant practice changes. This analysis helped inform faculty about implementation and promoted communication between providers about pathway components. The findings of this qualitative methodology may inform future surgical patient care protocol implementations.