Strategies Addressing Barriers to the Implementation of a Pediatric Hand Fracture Care Pathway

Background:

We recently highlighted shortcomings in the care of pediatric hand fractures in our local context. The Calgary Kids’ Hand Rule (CKHR) was developed to predict hand fractures that require referral to a hand surgeon. The aims of this study were to identify barriers to a new care pathway for pediatric hand fractures, based on the CKHR and to generate tailored strategies to support its implementation.

Methods:

We performed a conventional content analysis of transcripts from four focus groups (parents, emergency/urgent care physicians, plastic surgeons, and hand therapists) to identify relevant concepts (facilitators and barriers). These concepts were mapped to two frameworks. Generic strategies to address the barriers were identified, and further discussions with key stakeholders resulted in tailored strategies for implementation.

Results:

Five facilitators to implementation of a CKHR-based hand fracture care pathway included established rapport between hand therapists and surgeons, potential for more streamlined care, agreement on identifying another care provider, positive perceptions of hand therapist expertise, and opportunity for patient education. Two individual barriers were concern for poor outcomes and trust. Three systemic barriers were awareness and usability, referral process, and cost and resources. Strategies to address these barriers include pilot-testing of the new care pathway, ensuring closed loop communication, multiple knowledge translation activities, integration of CKHR into the clinical information system, coordinating care and development of parent handouts.

Conclusion:

Mapping barriers to established implementation frameworks has informed tailored implementation strategies, bringing us one step closer to successfully implementing a new pediatric hand fracture pathway.

Takeaways

Question: How do we overcome the concerns of stakeholders to implement a new pediatric hand fracture pathway?

Findings: This qualitative study identified five tailored strategies, which include pilot testing the new pathway, ensuring closed loop communication with the alternative care provider, holding multiple knowledge translation activities, integrating the clinical prediction rule into EPIC, and developing educational handouts for parents.

Meaning: In collaboration with parents and health care providers, we have developed strategies to ensure successful implementation of a new pediatric hand fracture care pathway.

INTRODUCTION

We are working toward a new triage and care pathway for pediatric hand fractures. We have found that these fractures are over referred, as most have excellent outcomes without surgical intervention,¹ and there is a distinct lack of standardized guidelines for referral to hand surgeons (pediatric plastic surgeons in the Canadian context).² These discrepancies present a unique opportunity to provide more efficient care, which would open the door for other surgical problems to be seen, thereby addressing surgical wait times and limited healthcare resources.^3,4

Our team has developed a clinical prediction rule (the Calgary Kids’ Hand Rule, CKHR) to identify which pediatric hand fractures should be referred to hand surgeons (Fig. 1).^5,6 Clinical prediction rules improve care by avoiding unnecessary interventions and standardizing management. Examples include the Ottawa Ankle Rules and the Canadian CT Head Rule, which assist providers in determining the need for diagnostic imaging.^7,8 The CKHR could safely divert most hand fracture referrals to a nonsurgeon, such as a hand therapist (occupational therapists and physiotherapists with additional hand therapy certification), potentially reducing surgical referral volumes while maintaining good patient outcomes.⁶

Fig. 1.

The Calgary Kids’ Hand Rule is a clinical prediction rule intended to be used by emergency and urgent care physicians upon initial examination of a pediatric hand fracture patient to identify “complex” fractures that require referral to a hand surgeon.

In a recently published qualitative study, we explored the perspectives of parents and healthcare providers on the current management of pediatric hand fractures. This work highlighted four themes around current management: a need for improved parent education throughout the hand fracture journey, lack of a streamlined referral process for simple hand fractures, need to identify the most appropriate care provider for simple hand fractures, and importance of maintaining strong multidisciplinary connections to facilitate care.⁹ Building on the findings in that study, we aimed to further identify barriers to a new care pathway for pediatric hand fractures based on the CKHR and to generate tailored strategies to support its implementation.

METHODS

Design and Ethics

This qualitative descriptive study involved secondary analysis of data from four 90-minute virtual focus groups previously held with healthcare providers involved in the management of children treated for hand fractures and the children’s parents in Alberta, Canada (February 2020).⁹ We used purposive sampling to include a broad representation of stakeholders: parents, physicians within emergency departments and urgent care centers, plastic surgeons, and hand therapists from both hospital and community settings. All participants were English-speaking and provided informed consent. Parents were recruited by hand therapists at the Alberta Children’s Hospital plastic surgery clinic; clinicians were recruited locally by our core stakeholder group (emergency/urgent care physicians, allied health administrators, and hand therapists). Our patient/parent partner (SL) was extensively involved throughout the entire study.

Family physicians were invited but decided not to participate in the focus groups given the low volume of hand fracture referrals they receive.

Ethics approval was obtained from the Conjoint Health Research Ethics Board (REB20-1101). We reported our study according to the Consolidated Criteria for Reporting Qualitative studies checklist (COREQ).¹⁰

Data Collection and Analysis

All focus groups were led by an experienced health services researcher (MD), using a semistructured interview guide (Fig. 2). Some participants knew the interviewer before the study from her role as a physiotherapist; however, they did not know her research motivations, goals, or interests. Focus group participants were asked to share their experiences with existing care for pediatric hand fractures (Fig. 3) and provide input on the design of a new care pathway (Fig. 4). Audio recordings were transcribed verbatim, and transcripts were entered into NVivo (QSR International Pty Ltd. Version 12, 2018) to facilitate data management, coding, and retrieval. Data analysis was conducted by two members of the research team: a plastic surgery resident (A.S.L.) and a research assistant (A.B.). Conventional content analysis was performed to analyze the focus group data (Fig. 5).¹¹

Fig. 2.

Interview guide used for focus group sessions.

Fig. 3.

Schematic representing current pediatric hand fracture referral and management pathways (shown to focus group participants).

Fig. 4.

Schematic representing proposed pediatric hand fracture referral and management pathways (shown to focus group participants).

Fig. 5.

Roadmap describing data collection and analysis process.

Identifying Barriers

AB and ASL independently reviewed the focus group transcripts to inductively code related excerpts of text. Initially, 14 codes were identified. Similar codes were later combined through discussion to create a final set of seven codes. Related excerpts within a code were grouped together as “concepts.” Concepts were then labeled as either barriers (factors opposing implementation) or facilitators (factors supporting implementation). The research team met at regular intervals to discuss and refine the codes and concepts and resolving discrepancies through discussion.

Two knowledge translation frameworks were applied to characterize both individual and systemic factors, respectively: the Theoretical Domains Framework (TDF)¹² and Consolidated Framework for Implementation Research (CFIR).¹³ The TDF is an integrated framework that uses theoretical approaches aimed at behavior change. The CFIR provides a set of constructs for identifying potential influences on implementing an intervention into a health system. The same research team members independently mapped each barrier identified by participants to relevant CFIR and TDF domains; joint discussion then took place to resolve any disagreement. The CFIR and TDF frameworks were used together to obtain a multi-level view of the relevant implementation factors.¹⁴

Identifying Strategies

The strategies identified to address each of the barriers were informed by Expert Recommendations for Implementing Change (ERIC), a compilation of 73 implementation strategies developed by a diverse panel of clinicians and experts in implementation science.¹⁵ Where possible, the CFIR-ERIC matching tool was used to identify relevant strategies for each barrier based on the associated CFIR domains.¹⁶ These generic strategies were used to prompt discussion with stakeholders and inspire “tailored strategies” adapted to our local context. We held a meeting with pathway stakeholders (emergency/urgent care physicians, allied health administrators, and hand therapists) to present our initial findings, and invited suggestions of strategies from each stakeholder group. A second meeting was later held, where stakeholders were asked to evaluate strategies in terms of feasibility and importance. The stakeholder meetings were led by an experienced health services researcher (M.D.). Finally, our research team convened to review and summarize the strategies.

Several measures were used to ensure rigor. Firstly, coding was performed independently by two researchers (A.B. and A.S.L.) and regular discussions were held to reach agreement and ensure alignment with evidence-based frameworks. Secondly, the coding process was documented in detail, including decision-making and dispute resolution. Thirdly, participant responses were triangulated between the four focus groups, to ensure trustworthiness.¹⁷

RESULTS

Participant Characteristics

The focus groups involved 24 participants (eight emergency/urgent care physicians, four plastic surgeons, six hand therapists, and six parents). Most were under 50 years of age (n = 17) and women (n = 17); all were urban residents.

The final coding framework consisted of seven codes: accessibility of care, communication, cost and resources, most appropriate care provider, provider education, patient expectations, and provider comfort. Five facilitators supporting pathway implementation were identified: established rapport between hand therapists and surgeons that could facilitate interdisciplinary care, potential for more streamlined care, attitudes on the need for surgeon oversight, positive perceptions of hand therapist expertise, and opportunity for patient education. (Table 1). Two of the facilitators were mapped to the TDF domain of social/professional role and identity. Each of the facilitators was mapped to a different CFIR domain (Table 1). Knowledge of facilitators will be very helpful for guiding implementation, but detailed discussion will not be a focus of this article.

Table 1.

Identified Facilitators and Mapped Domains that Support Implementation of the Calgary Kids’ Hand Rule Care Pathway for Pediatric Hand Fractures

Code	Facilitator	Representative Quotes	TDF Domain(s)	CFIR Domain(s)
Communication	Established rapport between hand therapists and surgeons	“They [hand therapists] have good communication with the plastic surgeons if there are issues and that just takes all of the complexity and follow-up out of the equation” (ED P3)	Social/professional role and identity	Network and communications, structural characteristics
Efficiency	Potential for more streamlined care	“I think this pathway provides a much clearer referral process in the sense for family confusion, efficiencies in the system because and consistency of treatment.” (HT1)		Implementation climate
Most appropriate care provider	Attitudes on the need for surgeon oversight: Existing sentiment that patients and providers agree that surgeon visits are not always necessary	“I don’t think she needed to see him [plastic surgeon] at all. I think she could have gone straight to OT and dealt with the splint and so forth that way and the exercises.” (CG3) “I agree like many of these patients do not need plastic surgery.” (PS1) “The fundamental problem is that it swamps our plastic surgery service with patients that, as you pointed out don’t often require surgery.” (PS2) “The bulk of these patients do not need a plastic surgeon.” (ED3)		Inner setting: compatibility, available resources
	Positive perceptions of hand therapist expertise: Hand therapists are the appropriate expert in nonsurgical hand fracture management	“An occupational therapist will help you with everything. And I love them down there” (CG4) “A hand therapist is the most appropriate.” (ED7) “I think they are very experienced and very appropriate to do that” (PS1) “We have a very well-established protocol now for the simple fracture kids.” (HT2)	Social/professional role and identity	Inner setting: compatibility
Patient education	Opportunity for education: Care pathway provides an opportunity to educate patients/families about splinting, exercises, and return to activities	“if we had known maybe don’t tamper with the splint, don’t try to fix it, just give us a call, we probably would have done that more efficiently.” (CG1) “… clear guidance about return to activities, return to sport for example or when can they go back out for recess... That’s a really common issue, I think they really appreciate the expert guidance there.“ (PS3)		Outer setting: Patient needs and resources

Barriers to Hand Fracture Care Pathway Implementation

After reviewing all codes and corresponding text, five barriers to pathway implementation were identified, two at the individual level (concern for poor outcomes and trust) and three at the systemic level (awareness and usability, referral process, and cost and resources) (Table 2).

Table 2.

Identified Barriers, Mapped Domains, and Associated Strategies for Implementation of the Calgary Kids’ Hand Rule Care Pathway for Pediatric Hand Fractures

Code	Barrier	Representative Quotes	TDF Domain(s)	CFIR Domain(s)	ERIC Strategies	Tailored Strategies
INDIVIDUAL
Provider comfort	Concern for poor outcomes	“How long to splint it; how and when to mobilize it; what the long term follow-up should be… These are things I actually wouldn’t have comfort with.” (ED4) “When you have a kid that has been immobilized for four weeks and now, they are extremely stiff, that’s very sobering.” (ED2) “I would prefer not to see every X-ray to be honest, but I would really not like to have anything missed.” (PS2) “…the rule could potentially classify a child’s fracture as simple when it is actually complex. The consequences of missing that are quite high, so it will lead to permanent deformity or disability” (PS3)	Beliefs about capabilities, beliefs about consequences	Intervention characteristics: evidence strength and quality Characteristics of individuals: knowledge and beliefs about the intervention	Audit and feedback, conduct cyclical small tests of change	Pilot test CKHR pathway implementation, provide referring physician with written feedback from follow-up provider (“closed loop”)
	Trust	“When we send to plastics that’s a closed loop. I know for sure what’s going to happen.” (ED3) “I agree with (ED3) about the comfort it provides us as a referring team kind of knowing the anticipated next steps if it goes directly to plastic surgery.” (ED1) “Before they get classified as simple, I still want to look at the X-ray.” (PS1)
SYSTEMIC
Provider education	Awareness and usability	“You can blitz education now, but what happens five years from now?” (ED4) “It would be much easier to educate the relatively smaller group of emergency physicians than every family physician in the city.” (ED3) “… it’s not a problem you can solve through education… I think many referring physicians don’t want to have this as part of their practice, so it’s a never-ending problem… (PS1)	Knowledge	Inner setting: access to knowledge and information	Conduct educational meetings, develop educational materials	Clarification of CKHR predictors, presenting at local rounds, distributing educational resources (eg, clinician FAQ, posters)
Accessibility of care	Lack of existing referral process	“As an emerg doc I don’t feel like I have a streamlined process to connect to a hand therapist at all.” (ED7) “Having a way to change the path that they’ve been placed in and go see a surgeon if things do change or if there is concern.” (PS2)	Not applicable	Inner setting: compatibility	Change record systems, tailor strategies	EPIC integration, process for redirecting
Cost and resources	Limited follow-up staff and resources	“I think your workload is going to increase a lot.” (HT4) “[families] don’t want to drive from the deep south to see us.” (HT1) “There are only three certified hand therapists in Calgary and a huge waitlist” (ED5)	Environmental context and resources	Inner setting: available resources	Access new funding	Coordination of care; teamwork between interdisciplinary team members, develop handouts for patients/families, offer virtual/phone appointments

Individual Level Barriers

Concern for poor outcomes was commonly raised by health care providers. Emergency and urgent care physicians frequently reported general discomfort and uncertainty managing hand fractures, along with a fear of poor outcomes such as hand deformity or stiffness. Plastic surgeons were concerned that the CKHR might not capture all fractures requiring surgical referral.

“…the rule could potentially classify a child’s fracture as simple when it is actually complex. The consequences of missing that are quite high, so it will lead to permanent deformity or disability” – Plastic Surgeon 3.

Trust pertains to clinicians’ trust in both clinical decision aids and each other. Plastic surgeons expressed specific concerns about the safety and reliability of other physicians using the CKHR, with one surgeon stating that they would still like to review X-rays for all fractures. Referring providers told us they felt reassured by their existing practice of referring hand fracture patients to plastic surgeons, citing “closed-loop communication” as a key benefit.

“When we send [a patient] to plastics that’s a closed loop. I know for sure what’s going to happen.” – Emergency Doctor 3.

Systemic Level Barriers

Awareness and usability. Health care providers highlighted the importance of raising awareness of the CKHR and clarifying its intended use, including terminology and prediction criteria. Emergency physicians and plastic surgeons commented on the difficulty of educating general physicians on pediatric hand fracture care, suggesting that it would be more feasible to engage smaller specialized groups like hand therapists and emergency physicians than the larger decentralized population of family physicians. Additionally, the inherent challenge of sustaining education-based approaches was brought forth.

“You can blitz education now, but what happens five years from now?” – Emergency Doctor 4.

Referral process. A second systemic barrier mentioned by referring physicians was the lack of an existing referral process between the emergency or urgent care physician and nonsurgical providers. Currently, in most Canadian systems, follow-up for hand fractures is provided by hand therapists only after they have been seen by a surgeon. Though plastic surgeons were mostly open to the idea of sending “simple” fractures directly to a nonsurgeon for follow-up, they urged the importance of ensuring that patients could be redirected to a surgeon, if felt necessary.

“…Having a way to change the path that they’ve been placed in and go see a surgeon if things do change or if there is concern.” – Plastic Surgeon 2.

Limited follow-up staff and resources. Cost and resources were also seen as barriers to implementation, particularly with regard to follow-up care for simple hand fractures. Hand therapists and emergency physicians commented on the limited and localized availability of hand therapy facilities and resources, with concerns that altering current practice could overwhelm existing capacity. Currently, pediatric hand therapy is only offered at a single pediatric hospital in Calgary, Alberta by a limited number of providers. This presents an inconvenience and inequitable access to care for patients and families in distant parts of the city. Hand therapists noted that in their current practice, many parents are frustrated by the long commute.

“I think [our] workload is going to increase a lot.” – Hand Therapist 4.

Implementation Strategies

ERIC-derived strategies to address the barriers concerning for poor outcomes and trust included audit and feedback and conducting cyclical small tests of change. Along these lines, stakeholders suggested small-scale pilot-testing of the CKHR pathway before full implementation. This would provide an opportunity to demonstrate the real-world effectiveness of the CKHR pathway and identify any areas for refinement before widespread adoption. Additionally, written feedback from follow-up providers to provide “closed-loop” communication with the referring provider was recommended.

For the systemic barriers, awareness and usability, general strategies recommended by ERIC pertained to education: conducting educational meetings and developing educational materials. Tailored strategies based on these recommendations included clarification of CKHR predictors, multiple knowledge translation activities including presenting at local research and divisional rounds and developing a clinician frequently asked question sheet. Each of these strategies will require engagement with clinicians to ensure widespread and appropriate use of the CKHR.

Regarding the lack of a referral process to nonsurgical providers, the ERIC recommendation suggested modification of record systems and tailored strategies. Along these lines, integration of the CKHR and pathway components into the provincial clinical information system (EPIC) was one strategy proposed to address this concern. Stakeholders also urged the need for follow-up providers to be capable of identifying concerns that require special attention and referring to a surgeon as needed.

Notably, upon discussing concerns about limited hand therapy resources, the stakeholders concluded that the CKHR pathway would not increase the hand therapy patient load since, in our current hand fracture management workflow, hand therapists are already providing care for these patients. With our proposed changes, a subset of patients could be followed up entirely by hand therapists, obviating the initial surgeon visit and referral to hand therapy. This could increase the workload for clerks who schedule patients for the hand therapists. Several strategies were suggested by stakeholders to mitigate the burden on hand therapy resources. Coordination of care including preparation of standardized education materials, such as written handouts, could streamline patient teaching and ensure that patients and families are informed about their care and at-home management.

Based on our discussions with stakeholders, we have created a revised care pathway wherein the hand therapist has been selected as the “appropriate expert in nonsurgical hand fracture management” (Fig. 6). This decision was supported unanimously by all participant groups based on the specialized training, knowledge, and resources hand therapists possess versus less-specialized practitioners. For the infrequent pediatric patient with a hand fracture who presents to their family physician as the initial point of contact, the family physician would not use the CKHR and they would contact the pediatric plastic surgeon on call (no change in practice).

Fig. 6.

Revised new care pathway for pediatric hand fractures based on study findings and stakeholder input.

DISCUSSION

This study brings us one step closer to our goal of developing and implementing a new pathway for pediatric patients with hand fractures that matches patients’ clinical need to the appropriate provider. The existing discrepancy, where simple fractures are managed by hand surgeons, presents a burden on health care resources that could be better utilized. We have identified perceived barriers to a new pathway and generated strategies to address these barriers.

Care pathways are a means of promoting evidence-based practices and improving health system efficiency for target populations.^18,19 It is well known that analysis of barriers and engagement of pathway stakeholders is critical for the successful implementation of a new care pathway.^20,21 In this analysis, each barrier was referenced by participants from at least two different stakeholder groups, suggesting shared concerns and corroborating individual input. Two of the barriers identified in this study (concern for poor outcomes and trust) reflect the notion that existing referral practices are largely dictated by the referring physicians’ comfort level and existing workflows. It is natural that referring physicians, who seldom hear from patients after their departure from the emergency department and are comfortable with the current practice of referral to pediatric plastic surgeons, are disinterested in change. This phenomenon is corroborated by a UK survey of emergency physicians that reported lack of familiarity with a problem and lack of clear referral protocols as influential factors for specialist referrals.²² Conversely, some of the pediatric plastic surgeons were also apprehensive of handing over the decision process to the referring physician. Identifying these barriers allowed us to examine how to address these concerns.

Grol et al compiled a set of 16 attributes that influence the implementation of clinical guidelines^.23 These attributes are valuable to consider when developing clinical guidelines. Pertinent attributes to our study findings include relevance to daily practice, minimal changes to existing routines and habits, and minimal requirement for additional training and resources. Applying these attributes, we see that successful alteration of existing practices will require assurance of good outcomes for hand fractures diverted to nonsurgical follow-up providers (ie, hand therapists in our urban setting) and compatibility with existing resources. Pilot testing the pathway, with a built-in safety mechanism of plastic surgeons reviewing the X-rays initially, will reduce the risk to patients and help to further inform the pathway design. This pilot testing will also allow the hand therapy team to adapt their workflow. An example has been set by the success of a care pathway involving a therapy-led closed hand trauma clinic in the UK, which successfully diverted 53% of hand trauma referrals from plastic surgery. Numerous advantages included faster and more efficient care for hand trauma patients, fewer late referrals and complications, and reduced wait times for other plastic surgery referrals.²⁴

Despite substantial efforts to develop evidence-based clinical guidelines and prediction rules, many remain unused after dissemination. Sustained adoption of new practices requires comprehensive and ongoing dissemination activities and active stakeholder engagement.¹⁸ Combined use of tailored, multifaceted implementation strategies have been demonstrated to enhance uptake; education of end-users, visual reminders (posters and lanyards), and audit-and-feedback improved utilization of the Ottawa Ankle Rules from a baseline of 57.5% to 94.7%.²⁵ This concept of repetitive education of referring physicians will be crucial for successful implementation of our new pathway. We have proposed educational strategies that include attending local research rounds, distributing educational materials (eg, posters and clinician frequently asked question), and incorporating stakeholder input.

Although this study focused on identifying barriers to implementation of the new pathway, the finding of multiple facilitators to implementing a new pathway was an interesting result. The established rapport between hand therapists and the pediatric plastic surgeons was perceived to enhance their suitability as the default provider for simple hand fractures, creating a “safety net” that enables easy consult with surgeons if concerns arise. In addition, parents were positive about the idea of improved educational materials to help them understand the patient care journey, from emergency room to therapist to a healed state. Overall, our findings lend promise to the successful implementation of this new pathway. Although hand therapists are considered a suitable provider for simple hand fractures in our setting, adaptations of this pathway to other settings will likely require modification according to local resources and expertise.

This work was done in Canada, where healthcare is primarily funded by the public and patients do not directly generate revenue for the hospital.²⁶ In other countries, where healthcare funding is largely privatized, hand clinic visits would create revenue for hospitals and costs would be covered by patients and private insurers. Although further evaluation would be needed to evaluate the benefit of this sort of care pathway in other settings, the proposed pathway and its derivatives could benefit either system by bringing the right patient to the right provider, eliminating “unnecessary” clinic visits, and freeing up limited surgeon availability for other problems.

Limitations

Some perspectives were not captured in our focus groups, including those of rural populations, family physicians, and parents of children with hand fractures that were not seen by a surgeon. We recognize our data are not exhaustive, and we anticipate that other barriers and strategies may arise.

Future Directions

Further development and implementation of the strategies will be the focus of future work. Pilot testing of the pathway is planned to enable pre- and postimplementation analysis of process and patient outcomes, including absolute referral volumes of pediatric hand fractures to hand surgeons, relative proportion of “simple” fracture referrals to hand therapists, clinical outcomes for both fracture types, and patient/provider satisfaction.

CONCLUSIONS

Engagement with clinicians and families has identified barriers to the implementation of a CKHR-based care pathway for pediatric hand fractures. Mapping these barriers to established implementation frameworks has informed tailored implementation strategies to enhance the success of the CKHR pathway. More generally, this work demonstrates how qualitative research and knowledge translation frameworks can be applied to inform care pathway development.