Barriers and facilitators to implementing enteral resuscitation for major burn injuries: Reflections from Nepalese care providers

Abstract

Introduction:

Burn injuries present a significant challenge globally, particularly in low- and middle-income countries (LMICs) where access to standard intravenous (IV) fluid resuscitation is often limited. In such austere settings, the feasibility of enteral resuscitation via oral rehydration solution (ORS) as an alternative to burn resuscitation is a critical consideration. We aimed to investigate the barriers and facilitators perceived by burn care providers in Nepal trained to use an enteral resuscitation protocol.

Methods:

We conducted seven focus group discussions (FGD) with burn care providers (n = 45) involved in the resuscitation of burn-injured patients. These discussions centered on their experiences using enteral resuscitation in burn patients. We employed a semi-structured interview guide using Consolidated Framework for Implementation Research (CFIR), used deductive thematic analysis of the transcripts, and organized them based on CFIR constructs.

Results:

Intensive involvement of stakeholders in the protocol development facilitated acceptance of enteral resuscitation. Stakeholders were motivated by a perceived desire to change practice to improve outcomes. Familiarity with ORS, operational advantages of ORS, and the perceived benefits of enteral resuscitation when struggling to obtain IV access in dehydrated patients furthered acceptance among participants. Recurring formal and informal training sessions aided uptake and fidelity to the protocol. However, challenges emerged in precise volume administration, miscalculations, technical errors, and structural resource limitations (e.g., limited staff time to monitor patients) related to the goal-directed resuscitation strategy.

Conclusion:

This study highlights the importance of stakeholder engagement, iterative refinement, and contextual adaptation in implementing an enteral resuscitation protocol for acute burn injuries. Findings offer insights into real-world applications and future clinical and research endeavors, informing the potential scalability and sustainability of enteral resuscitation protocols more broadly, to improve the care of patients with major burns in LMICs.

1. Introduction

Burns are a leading cause of injury globally with nearly 9 million injuries and an estimated 120,000 to 180,000 deaths annually, with the majority occurring in low- and middle-income countries (LMICs) [1,2]. Initiating fluid resuscitation promptly after major burn injury is a fundamental aspect of acute treatment to reduce the risk of shock, kidney injury, sepsis, tissue loss and ultimately, death [3–5]. Although the established standard for major burns is intravenous fluid (IV) resuscitation [6], this is not always be feasible in LMICs due to inadequate resources such as catheters, IV tubing, fluid, and trained healthcare personnel to administer and monitor large volume IV resuscitation [7–9]. Similar resource limitations and resuscitation delays have been reported after mass casualty incidents (MCIs) globally.

Nepal, like other LMICs, has a substantial burden of burn injuries, with an overall incidence of 2 % of the population annually suffering from any burn injury [10,11]. Despite this large disease burden, only 20.3 % of the national population has access to organized burn care within 2 h of travel, and 72.6 % within 12 travel hours [11]. As such, delays in resuscitation are common. Enteral resuscitation—the administration of Oral Rehydration Solution (ORS) either by drinking or via nasogastric tube—can be operationally advantageous to IV resuscitation for burn patients in limited resource settings, as it can be performed by the patient, the patient’s family, or lay providers until advanced burn care is accessed [12,13]. Despite limited randomized controlled trials assessing the effectiveness of enteral resuscitation, expert consensus suggests that enteral resuscitation holds promise for successfully resuscitating patients with burn injuries up to 40 % total body surface area and emerges as a pragmatic alternative [14,15].

To address this gap, our research collaborative developed an effectiveness-implementation randomized controlled trial (RCT) protocol to evaluate the effectiveness of enteral-based resuscitation versus IV resuscitation, while gathering quantitative and qualitative information regarding implementation strategies for enteral resuscitation. We hypothesize that enteral resuscitation will be at least as effective as IV resuscitation with regards to clinically obtained and simply obtained outcomes like urine output; that it will have operational advantages over IV resuscitation; that it will be easier to implement in low-resource setting without experienced burn care providers; and that it will result in better adherence to the resuscitation protocol. We conducted a pilot study ahead of this RCT at our study setting, a tertiary burn center in Nepal which had no prior clinical trial experience. In the updated UK Medical Research Council (MRC) guidance on designing and evaluating complex interventions, such feasibility trials are emphasized as a critical step for assessing the practicality of conducting comprehensive trials and ensuring necessary refinements for the interventions and study procedures before proceeding with a full trial [16]. Thus, this paper specifically focuses on the qualitative results from the implementation aims of this pilot study, which helped refine our study protocol and strategy. We aimed to understand the barriers and facilitators to enteral resuscitation which may affect the acceptability, uptake, or sustainability of this intervention in Nepal and beyond.

2. Methods

2.1. Study setting

The trial was conducted at the Nepal Cleft and Burn Center (NCBC) at Kirtipur Hospital, a national-level referral center for burn injured patients. NCBC provides multispecialty care to the local community, and has annual admission of 600–700 burn injured patients [17]. The study is a collaboration between NCBC at Kirtipur Hospital in Nepal and University of Washington (UW) Medicine Regional Burn Center.

2.2. Study design

2.2.1. Study design – intervention

This report focuses on implementation barriers and facilitators to enteral resuscitation based on qualitative data from burn care providers, obtained during a single-center, pilot study of a hybrid type I effectiveness-implementation RCT of enterally-based versus enhanced standard of care (i.e., protocolized IV resuscitation). The protocol is briefly described to provide context to the qualitative results, with the detailed protocol included in the Supplementary materials. Effectiveness results of the RCT will be reported separately.

The intervention component of the RCT enrolled 30 total patients who were randomized to either of two study arms: 1) standard of care IV fluid resuscitation bundle with Lactated Ringer’s solution or 2) enteral-based resuscitation bundle (EResus; enteral resuscitation with WHO ORS +/− supplementary IV fluids), with tenets of goal-directed resuscitation incorporated into both resuscitation protocols [18]. In the EResus arm, WHO ORS was administered orally or via nasogastric tube (NGT), with IV fluids supplemented as needed. Adult patients with ≥ 20% TBSA presenting within 24 h of acute flame or scald burn injury, without overt evidence of shock were eligible for enrollment. The intervention bundles included a resuscitation toolkit with clinical support tools such as a resuscitation flowsheet for clinical documentation of goal-directed resuscitation parameters and 2-hourly fluid adjustments, supplies, communication pathways and training sessions. Gastrointestinal symptoms such as nausea and vomiting were tracked in both study arms, along with urine output, and guided interventions such as anti-emetic medication administration or supplementation with IV fluids. Laboratory parameters were measured for the first 72 h after admission. The primary intervention effectiveness outcome was average urine output per hour during the first 24 h of admission, with secondary outcomes including 24-hour resuscitation volumes, occurrence of shock, acute kidney injury, gastrointestinal intolerance, death and additional outcomes. These results are outside of the scope of this report.

Development of both the enhanced standard of care IV resuscitation and the EResus protocols involved more than six months of weekly virtual meetings between study team members and burn care providers. Continuous refinement was achieved via routine communication and incorporation of key stakeholder feedback Comprehensive two-day training sessions were conducted focusing on the EResus bundle, clinical documentation using the resuscitation flowsheet, study protocol, and logistics. Reference videos were provided, and refresher training sessions were scheduled every three months. After finalizing the protocol and conducting necessary team-building measures, we enrolled 15 subjects in each arm and collected information on both the effectiveness of the intervention and its implementation.

2.2.2. Study design – implementation

We sought to understand barriers and facilitators to implementation from both the patient and provider perspective. Patients enrolled in the EResus arm underwent in-depth interviews after completion of the resuscitation period. These results will be reported separately. To understand the provider perspective, focus group discussions (FGD) were conducted at multiple time points with NCBC providers. The results of these FGDs are the primary focus of this report, and the methods are described in detail below.

2.2.3. Study participants and data collection

We conducted focus group discussions (FGD) with nurses and physicians working at NCBC who were clinically involved in the fluid resuscitation of burn injured patients. We focused on understanding their experiences with implementation of the IV and EResus resuscitation bundles using a semi-structured interview guide informed by the Consolidated Framework for Implementation Research (CFIR) [19], described in Table 1. The CFIR is composed of five major domains (i.e., intervention characteristics, inner setting, outer setting, characteristics of individuals involved, and implementation process), which were utilized to assess the challenges and facilitators regarding the acceptability, implementation, and sustainability of the resuscitation bundles.

Table 1.

Shows Consolidated Framework for Implementation Science (CFIR) domains for interview prompt generation: intervention background, inner setting, individual and implementation process, in addition to their corresponding topic and sample questions based on each domain and theme.

Assessment Area	Topic	Prompt Questions
Intervention Background	Innovation Characteristics and perceptions	• Who do you believe is leading and developing this intervention? • What are some of the things you are worried about or don’t feel ready for in using the new resuscitation protocol? • What are the reasons to transition to the new resuscitation protocol. Do you think ORS will provide an effective method of resuscitation? • What are the challenges with using ORS? What do you think is easy about using ORS?
Inner Setting	Access to knowledge and information Compatibility Tension for change	• Do you feel like you have enough training? What was the most helpful in learning? • Tell us about your experience using Oral Rehydration Solution (ORS), both personal knowledge and professionally. • What do you think will be the difficulty in using ORS with your normal work activity? • Why do you think it is important to use a new resuscitation protocol?
Individual	Knowledge and beliefs about the intervention	• Have you previously been exposed to enteral resuscitation? Do you feel comfortable using ORS in burn resuscitation? • Do you think ORS will provide an effective method of resuscitation?
Implementation Process	Opportunities for Feedback	• Do you feel comfortable with sharing feedback to the research team? • Tell us about a time you gave feedback. Was the concern addressed? • Do you have any additional ideas, comments, questions about the intervention?

Shows Consolidated Framework for Implementation Science (CFIR) domains for interview prompt generation: intervention background, inner setting, individual and implementation process, in addition to their corresponding topic and sample questions based on each domain and theme.

Our sampling strategy involved a combination of purposive and convenience sampling to ensure that we captured the range of provider experiences. Inclusion criteria encompassed healthcare providers at Kirtipur Hospital directly involved in burn care, while those associated as investigators of the study were excluded. We contacted individuals with relevant experience in resuscitation based on study team knowledge, extending invitations through email and telephone communications.

Participant interviews were conducted at three time points: i) prior to initiation of patient enrollment for the planned RCT (“pre-enrollment”), ii) after 15 resuscitations i.e., mid-point of pilot phase of the trial (“mid-enrollment”) and iii) after 30 resuscitations i.e., conclusion of pilot phase of the trial (“post-enrollment”). The interviews were conducted at approximately 6-month intervals. FGDs of 6–8 providers were performed at each timepoint until the saturation of information was achieved, signifying that no new insights were emerging.

The interviews were conducted by Nepalese research assistants and a research coordinator in both Nepali and English. All interviews were audio recorded, transcribed verbatim, and subsequently translated from Nepali to English by a certified translator.

2.3. Data analysis

We conducted a deductive thematic analysis of the FGD transcripts using NVivo 14 software^®. CFIR was the primary framework utilized for coding to organize the data into constructs that we identified as factors influencing the implementation of the resuscitation bundles and EResus, specifically [20]. To create the initial codebook, the qualitative lead (RS) linked each interview question to the applicable CFIR domain. Two team members (RS and KM) independently reviewed the transcripts, and a third team member (AM) performed consistency checks and arbitrated differences between the two primary coders. Challenges and facilitators related to the implementation were organized into the relevant CFIR domains and constructs in a table and reviewed to establish a final coding structure that was used to systematically code all transcripts. Next, summary themes were developed from the coded data. The results, which included barriers and facilitators, were grouped by construct. Illustrative quotations were selected.

2.4. Ethics

The study was approved by the Nepal National Health Research Council (NHRC) (628/2020) and University of Washington Institutional Review Board. The trial protocol is available at Clinicaltrials.gov (NCT04732624). Written, informed consent was obtained from all interviewed participants prior to the FGDs.

3. Results

3.1. Participants characteristics

Out of the 106 total invitations extended, 45 accepted to participate in the interview process. Seven FDGs were conducted with a total of 45 interview participants, including 37 nurses and 8 physicians. Among the 8 physicians, 2 were plastic surgeons, and 6 were medical officers (Table 2).

Table 2.

Shows focus group discussion participants based on the time of trial when they were interviewed.

	Nurses N = 37 (%)	Doctors N = 8 (%)
Pre-enrollment	13(35.13 %)	0(0 %)
During pilot trial	14(37.83 %)	3(37.5 %)
Post-enrollment	10(27.04%)	5(62.5 %)

Shows focus group discussion participants based on the time of trial when they were interviewed.

At pre-enrollment, 13 nurses participated in interviews, during mid-enrollment, 14 nurses and 3 physicians participated, and at post-enrollment, 10 nurses and 8 physicians participated. In total, the FGDs resulted in 3.9 h of recorded transcripts, with an average interview duration of 33.57 min (a range of 20 to 45 min).

3.2. Implementation themes, domains, and constructs

A total of 16 themes were generated with 13 related to implementation facilitators and 3 to barriers. One emerging theme was noted related to the participant’s recommendations. These themes were organized into the five CFIR domains: 1. Intervention Characteristics 2. Outer Setting 3. Inner Setting 4. Characteristics of Individual and 5. Process. Within these domains, the themes were mapped into 12 CFIR constructs (Fig. 1).

Fig. 1.

Presents facilitators and barriers that healthcare providers(n = 45) identified in the study. We present each factor within its corresponding CFIR domain (e.g., intervention characteristics), and its relevant construct (e.g., complexity).

3.3. CFIR domain – intervention characteristics

The first CFIR domain focused on the characteristics of enteral resuscitation in comparison with the standard of care, IV resuscitation. We identified key intervention characteristics that influenced protocol implementation. Each of these are presented below with exemplar quotes from one or more participants. For facilitators of protocol implementation, we found themes relating to the intervention’s internal development, relative advantage comparing to the standard-of-care, adaptability to the context, compatibility with other health practices, and simplicity in determining the protocol calculations. We describe each in detail below.

3.3.1. Facilitators

3.3.1.1. Innovation developed internally with the help of the external experts.

Participants, familiar with local challenges in treating burn injuries and resuscitation, found the EResus intervention bundle suitable for their patient population, who frequently experience delays in IV resuscitation due to various factors. Despite its relative novelty, participants assumed ownership of the study protocol, recognizing its potential to help patients locally in Nepal and in other low-resource settings. One participant commented: “[the] team of doctors at Kirtipur hospital must have put together this as most of the burn patients in the country are referred here and people take more than 24 h to arrive at our center and patients come without any resuscitation.” Most participants viewed the EResus protocol as a locally driven innovation, enriched with valuable international collaboration.

3.3.1.2. Relative advantage: enteral resuscitation provided an advantage since establishing IV access can be difficult in dehydrated burn injured patients.

Participants reported operational benefits of enteral resuscitation, particularly among patients with dehydration and difficult IV access or for those presenting from remote areas where IV access and resuscitation were not feasible during transport. Participants frequently noted the advantage of initiating enteral resuscitation while awaiting IV access or based on patient preference. One provider shared an illustrative experience: “Everyone worked together to gain IV access, but we couldn’t, so we used Jeevan Jal [ORS] until the central line was placed, and IV fluid was started.” Enteral resuscitation was noted to be a straightforward solution to minimize resuscitation delays, which contributed to its acceptance, with one participant commenting: “ORS resuscitation can be done by anyone if given information, [it] doesn’t always require medical personnel” and mentioned “ORS is easy, cheap, and veins don’t have to be opened [i.e. IV access is not required].”

3.3.1.3. Adaptability: stakeholders were closely involved with planning and multiple cycles of feedback and improvements for the protocol.

Participants reported on the strategic development and implementation process of the EResus protocol, which spanned six months. Throughout this period, a series of informal training sessions and FGDs were conducted with doctors and nurses specializing in burn care to facilitate open and candid dialogue. The insights gathered were instrumental in refining the intervention to align with and effectively address the local context. One participant commented: “Much has changed since the beginning of resuscitation and all of [the changes] are based on our suggestions.”

3.3.1.4. Compatibility: ORS already used in routine care and familiar to providers.

Healthcare providers welcomed the integration of ORS given their existing familiarity with this widely utilized remedy for managing dehydration, with one participant describing: “We use ORS in our daily life to prevent dehydration, used in burn patients sometimes, used in diarrhea, low blood pressure.”

3.3.1.5. Complexity: simplicity of the protocol and facilitated calculations.

Participants collectively expressed appreciation for the simplicity of the calculations to start resuscitation and to derive the 2-hourly fluid titration goals using the resuscitation flowsheet. A majority of participants believed that 1–2 h of training was adequate to attain proficiency in implementing the protocol stating: “The protocol is simple and easy to understand and can be trained in less time…1- or 2-hour training is more than enough.”

3.3.2. Barriers

One notable recurring theme was that providers found EResus time-intensive and challenging if patients had large body burns, refused a nasogastric tube, or had other comorbidities, described below. Some of the challenges were related to the frequent volume administration adjustments related to goal-directed nature of both the IV and EResus bundles.

3.3.2.1. Complexity of implementation: time intensive and challenges in larger burns and comorbidities.

While participants generally exhibited competence in the calculation and adjustment of fluid volume based on urine output, a large portion of participants reported challenges in administering the calculated fluid volume, particularly when patients had extensive injuries necessitating substantial fluid volumes. A participant commented: “[A] person with larger surface area burns, they require many fluids. How can you expect a person [patient] has more than like 3 liters of fluid calculated to drink [that] within 2 h? And a lot of them refuse nasogastric tubes (NG)”. As the participant noted, many patients are averse to the use of NG tubes, rendering it challenging to orally administer the required volume within a short timeframe. Further, other challenging circumstances that emerged include when the patient has hand injuries, when there is no family member or friend to assist with administration, after being medicated for wound care, and at night while the patient is sleeping.

There were also concerns regarding how handoffs, between shifts, which occur three times a day and between wards, as patients were frequently transferred one to two times within the first 24 h of admission, would affect the implementation. One participant mentioned: “[It is] difficult to adjust when the calculated fluid has not been administered according to the time and if a staff member forgets to record urine output.” Miscommunication and technical errors resulted in reported miscalculations in the resuscitation protocol during such transitions despite the use of the same resuscitation flowsheet across all settings.

Additionally, doctors emphasized the potential limitations of the protocol in cases involving impaired renal function, which could obscure accurate urine output information, potentially leading to miscalculations of fluid volume if clinicians were not aware of acute kidney injury. One stated: “It gets tricky, especially with impaired renal function which might not give us accurate information as to what volume status of the patient is.”

3.4. CFIR domain – inner setting

The examination of the “inner setting” focuses on the hospital’s structural components, communication systems, existing resources, and the prevailing institutional culture. Facilitators for the adoption of the EResus were identified among burn care providers who perceived the need for change in response to unfavorable resuscitation scenarios with incoming patients. Other key factors included their receptiveness to learning EResus through training sessions and the presence of approachable leadership within the institution.

3.4.1. Facilitators

3.4.1.1. Implementation climate: need for change to address high mortality rate.

The implementation climate within the hospital was characterized by a strong sense of urgency and the need for change to improve the outcomes of people with burn injury. Participants consistently expressed profound concern over the alarming mortality rates among burn-injured patients, particularly those referred from remote areas within Nepal who are not properly resuscitated, summarized by a participant as: “Makes it difficult [for us] in earlier stages of management when a patient comes dehydrated, poor urine output.” The formidable challenges posed by Nepal’s unique topographical landscape and the absence of an adequately equipped interhospital transfer system frequently leads to patients arriving without fluid resuscitation. Considering these challenges, participants felt a pressing need for an operationally advantageous resuscitation strategy that addresses these issues, such as EResus with an interviewee mentioned: “We are willing to do this because it is a matter of the patient’s life…if we can resuscitate properly, the patient’s conditions can be improved.”

EResus offered simplicity and the potential to mitigate the difficulties of IV resuscitation in rural clinics and during interhospital ambulance transport without a medical provider present (i.e., driver only). The concept of enteral resuscitation was well-received by the participants, encouraging their openness to trying further enhancements in burn care practices, such as the adoption of rounding checklists and the implementation of enteral nutrition strategies.

The interviewees overwhelmingly advocated for an advance in resuscitation practices within the country, emphasizing the importance of a protocol that could be readily implemented in austere settings, including while being transported to the hospital. One participant commented: “IV fluid needs [a] hospital setting but patients can take ORS on the way, so they don’t get dehydrated.”

3.4.1.2. Recurrent formal and informal training sessions; learning and teaching attitude in team and willingness to learn new protocol.

Overall, participants expressed enthusiasm towards learning about resuscitation. Many reported to be driven to learn for the benefit of their patients and liked that everyone was learning together, one stated: “In-person training and group discussion was very effective; it was difficult at first but became easier gradually.” The structured formal training sessions were widely acknowledged as highly beneficial, particularly the mock resuscitations.

Moreover, there were comments about collaboration and shared learning, including through senior clinicians in aiding their junior counterparts in becoming acquainted with EResus, and well-versed nursing staff taking the initiative to educate new nurses and assist one another in the implementation process. Many commented “I did not get the formal training, but the senior nurses taught me when I joined and was able to understand it pretty well.” Peer-to-peer training was evidence of the protocol’s penetration into daily practice, and refresher training was consistently provided to prevent disparities in resuscitation knowledge and skills.

3.4.1.3. Leadership engagement: burn center leaders and study investigators were very approachable.

Participants highlighted the approachability of the burn center leadership and research team members during the initial introduction of the protocol. Specifically, participants found it reassuring that the research team members were consistently available and open to receiving their input and feedback. One participant mentioned: “In case of any difficulties, we are very comfortable sharing it [with the research team] and everyone is very approachable here.”

Although recognizing the logistical challenges associated with sustaining round-the-clock availability in real-world healthcare settings, participants perceived the ongoing support from the research team as an endorsement of the importance of the intervention. An interviewee stated: “They [the research team] were very appreciative of our work, and they have encouraged us a lot from time to time.”

3.4.2. Barriers

Most barriers that were raised related to structural issues, including limited staff and time, and high turnover of staff, described below.

3.4.2.1. Structural characteristics: limited hospital staff and resources.

Considering the demanding and time-intensive nature of burn care and resuscitation, the development and implementation of the newly introduced EResus posed several formidable challenges. Notably, staffing and resource limitation emerged as major obstacles encountered by healthcare providers during the implementation of the resuscitation bundle. These limitations primarily revolved around the inadequacy of critical medical supplies, equipment, and essential infrastructure essential for the successful execution of the protocol.

3.4.2.1.1. Staff limitations affect the ability to monitor resuscitation.

One of the themes that emerged that the high patient-to-healthcare worker ratio caused difficulties in monitoring resuscitation. Participants reported that inadequate staffing levels impeded their capacity to execute the protocol, which requires frequent monitoring, with high fidelity.

Statements from the interviewees demonstrated this included: “… like yesterday, ten patients came and there were only 2 staff members [so] we had difficulty in handling resuscitation.” and “It becomes difficult to orally resuscitate the patients every 2 h when there are a lot of patients and since only two of us are on duty.”

Another resource challenge was difficulty weighing the patient, a critical first step in determining resuscitation volume. It was noted that some patients were unable to stand on a digital weighing scale, posing a challenge to accurate fluid estimations.

Additionally, nurses encountered difficulties in accurately measuring fluids due to the unavailability of sufficient and appropriate infusion pumps and urimeters. One participant commented: “We could send the desired amount of fluid easily if we had a good digital measuring device.” It is worth noting that some of these challenges improved over time, and were no longer mentioned in subsequent FGDs, as the issues were addressed by the study team. For example, the study team helped obtain a weight scale capable of recording weight without patients needing to stand.

3.4.2.1.2. High staff turnover affected the implementation.

Most participants described that NCBC experiences significant and recurrent turnover of nursing and medical staff, which requires frequent training and orientation of new staff members. The high turnover rates among both doctors and nurses were frequently emphasized, leading to challenges in achieving the sustained implementation of the protocol until the newly onboarded staff members were adequately trained. One participant said: “Since the doctors and nurses are frequently changing, the new staff are confused about the calculations.”

3.5. CFIR Domain – outer setting

Within this domain, we considered factors outside of the NCBC. A facilitator that emerged was that providers believed that the intervention was innovative as it was developed with international collaborators.

3.5.1. Facilitator

3.5.1.1. Cosmopolitanism: International collaboration supported the local team.

Burn care providers stated that the EResus protocol, while although originally developed by the internal team, received the support of international collaborators through academic partnerships. Some participants mentioned: “It seems this protocol was developed by the doctors at this center with the help of some foreign doctors.” This input from external collaborators was frequently perceived as an advantage.

3.6. CFIR Domain – characteristics of individual

This domain focused on providers’ perceptions towards new care practices. The positive perception of the intervention was bolstered by the providers’ familiarity with the widely used ORS, instilling confidence in their ability to embrace and implement the new intervention, thus serving as facilitators for its adoption.

3.6.1. Facilitators

3.6.1.1. Knowledge and beliefs about the intervention: Well-acquainted with ORS and its benefits leading to positive outlook towards intervention.

Participants existing knowledge and beliefs about the intervention were significant facilitators in the implementation process. The use of ORS in the EResus protocol was met with a positive response, as providers were familiar with reconstituting and administering ORS and believed in its efficacy, particularly in managing dehydration.

Additionally, many participants held the conviction that transitioning from an 8-hourly resuscitation schedule to goal-directed resuscitation for both IV and EResus with more frequent monitoring at 1–2-hour intervals would bring substantial benefits to patients. One stated: “We used to resuscitate based on 8 h and 16 h, compared to that 2 hourly seems to have positive benefit.”

The majority expressed a favorable perspective regarding enteral resuscitation using ORS, citing: “This resuscitation will help people from rural areas and prevents wound from getting deeper.”

3.6.1.2. Self-efficacy: Healthcare workers reported confidence in using ORS.

Most participants conveyed a notable sense of self-efficacy in providing the enteral resuscitation. They regarded EResus as readily comprehensible, integrating it into their daily practices. They believed that a single training session equipped them with the requisite knowledge and skills for protocol execution, which bolstered their confidence in its implementation. One participant commented “We all seem to be ready for this because ORS is something we’ve been learning since we were little. Even if we are not able to attend to the patient, we can tell the visitors (i.e. bedside family members) to how to feed them [i.e. provide resuscitation] in a short time.”

3.7. CFIR domain – process

This domain included factors involved in the active change processes aimed at implementing the new enteral resuscitation practices. Stakeholder engagement during the planning and implementation phases was key in fostering the adoption of enteral resuscitation.

3.7.1. Facilitators

3.7.1.1. Engagement and Feedback: Heavily involved stakeholders in the process of development and implementation of intervention.

As noted above in the Intervention Characteristics Domain, EResus was developed internally with the burn providers contributing numerous ideas and iterative suggestions for the implementation strategy, which were incorporated into the program. This fostered a sense of collective endeavor, and the healthcare professionals feeling valued and acknowledged. One participant stated, “we feel very involved and feel okay to give each other suggestions.”

4. Emerging Theme: recommendation by the participants

When asked for ways to improve the process or EResus overall, participants had recommendations related to the pre-hospital and hospital care, and to specific patient populations. One participant described the need for education and improved pre-hospital resuscitation, stating: “[the] message needs to be conveyed to people coming from rural areas to take ORS on their way, this may improve patient’s condition.” Another respondent stated, “Separate wards to keep patients until they are resuscitated may ease the monitoring considering the staff shortage.” Finally, one participant acknowledged the specific difficulties associated with treating children, which may require modification of EResus: “IV access is more difficult in children so the study must include children.”

5. Discussion

In this study, we assessed the implementation of enteral resuscitation for major burn injuries at a tertiary burn center in Nepal. Our FGDs provided a deeper understanding of barriers and facilitators within CFIR Domains and provided insight into how factors related to the intervention, setting, healthcare providers, and implementation processes affected the implementation. Lessons from this work are critical to inform successful implementation and eventual scaling efforts of enteral resuscitation in Nepal and other low-resource settings. Below, we summarize our key findings and recommendations guided by our qualitative data.

In terms of facilitators, though enteral resuscitation for patients with major burn injuries was a new concept for burn care providers at Kirtipur Hospital, EResus was highly acceptable as providers described a need for change given persistent delays in resuscitation, and alarmingly high associated mortality rate of patients. In Nepal, even those with small and survivable burns have a high risk of mortality due to delays in resuscitation [21]. This facilitator may appealing to stakeholders’ emotional side. Prior research has shown that and engaging stakeholders with sympathetic and positive emotions is recognized as an effective strategy in change psychology [22]. Similarly, highlighting enteral resuscitation as a chance to enhance care proved to be a powerful positive motivator for providers in gaining acceptance. Enteral resuscitation has had demonstrable effectiveness and evidence in small animal studies and in highly controlled environments [23,24], and is recommended in austere, disaster and mass casualty settings in the literature and by burn care and major public health organizations [8,14,15,25,26]. In addition EResus has well-documented operational advantages, including easy administration, no specialized equipment, and lightweight, easily reconstituted sachets [27]. In IV fluid-limited settings, it optimizes resources while achieving resuscitation targets (e.g., urine output, vital signs) and minimizing gastrointestinal and immune risks [28]. Another key facilitator to implementation of enteral resuscitation was familiarity with ORS as a resuscitation fluid, as well as the simplicity in utilizing ORS. Prior research has indicated that learners make judgments based on perceived effort and familiarity with experiences, which play an important role in the uptake of new interventions [29]. Both uptake and fidelity to the protocol were enhanced through formal training sessions conducted within a supportive learning environment and among staff who valued professional education. A systematic review by Powell et al. identified tension for change, relative advantage, and learning climate as important measures used in behavioral health-focused implementation studies [30]. Lastly, the adaptability and responsiveness to the local context were critical in generating ownership, facilitating uptake, and laying the groundwork for penetration into the burn center’s standard clinical practices [31].

On barriers, there were several commonly reported challenges encountered during the implementation. The human resource constraints were perhaps most frequently reported and continue to be a major challenge in Nepal and many low-resource settings worldwide. In LMICs, limited human resources have been described as a major limiting factor to scaling up health interventions by Yamey et al. [32]. Although enteral resuscitation can be performed or augmented by patients themselves, their family or friends, and is less resource intensive than IV resuscitation, this remained a challenge throughout this study. Providers were burdened with additional workload particularly due to the integration of goal-directed resuscitation protocols for both enteral and IV resuscitation that require frequent monitoring and fluid volume adjustments. These observations may signal benefit in further simplification of the protocol in less resourced settings such as rural health posts, during pre-hospital transport or in mass casualty scenarios, such as consideration of single baseline hourly resuscitation without a focus on goal-directed resuscitation [26]. However, as NCBC provider familiarity increased with the resuscitation protocols, enteral resuscitation was reportedly easier to perform than IV resuscitation.

Additionally, there was also a high turnover rate of doctors and nurses staffing the burn wards during the pandemic and post-pandemic era. The frequent arrival of new providers required serial trainings to improve uptake of the EResus protocol that was unfamiliar to the new staff and to reduce errors in fluid volume calculations for goal-directed resuscitation. However, just-in-time training with providers unfamiliar with such resuscitation protocols may be more reflective of real-world application. Additionally, in the context of high staff turnover rates, we had limited longitudinal data across the three study timepoints during which FGD were conducted (pre-, mid- and post-enrollment).

In light of these reported challenges, providers were given an opportunity to to refine the protocol and study, which was seen as a key faciltator. For example, burn providers emphasized the need for including children in the study given that they represent a subsantial protion of burn-injured patients in Nepal. They cited specific challenges to resuscitation in this group due to additional technical complexities in securing IV access and the lack of availability of appropriately sized supplies [14]. To address this, we adapted the protocol for use in children and ensured access to appropriately sized resources in our further studies. Being responsive to both the concerns of stakeholders and the potential beneficiaries of the intervention were seen as evidence of collaboration and commmittement to the burn care problem in Nepal. Although our aim was to develop a safe, effective and contextually useful enteral resuscitation strategy, additional feedback included the importance of decentralizing this technique to more remote, first-level hospitals countrywide. In low-resource countries like Nepal, patients are often treated outside specialized burn centers, lacking adequate resources and trained burn care specialists [33]. This feedback was evidence of widespread acceptability, penetration, and potential for sustainability and led to development of contextually-informed educational tools on enteral resuscitation that may be utilized in its more broad implementation in rural contexts [33]. We have gained significant insights into implementation of EResus, although further study in more remote contexts is required and planned.

Guided by our findings, we share some key recommendations for burn providers to implement similar enteral resusitation programs. First, meaningful engagement with burn providers throughout the planning and implementation is critical for success. As noted, the providers felt a need for change, developed the protocol internally, and sought external advice and feedback from providers. This continous learning and refinement process ensured that the intervention was contextually appropriate and acceptable, and a similar approach would be recommended in other settings. Next, there were several resource limitations which were critical to address and note for the successful implementation. Some resources, such as a weighing scale, urimeter, and infusion pump are important for the monitoring. Adequate staff to monitor patients is also important, and posed a challenge in the Nepalese context.

There are some limitations worth consideration: The FGDs may not fully encapsulate the evolving experiences of healthcare providers as they become more adept at enteral resuscitation. Approximately one-third of nursing staff participated at each interview timepoint. Multiple FGD sessions were offered at each timepoint, however there were also logistical challenges in coordinating sessions optimal to all schedules which may have led to less robust participation. However, FGD were continued until data saturation and this was achieved at all time points. Moreover, the high turnover rate of staff at the hospital suggests that the perspectives of longterm users might not be reflected in the findings as it was challenging to obtain longitudinal data. The current findings represent single institution experience and may not represent the variety of implementation environments and practice across different hospital settings within Nepal. Furthermore, the enteral resuscitation protocol’s adoption required substantial commitment and was facilitated significantly by the research team’s presence, which may not be reflective of resources and support available in more austere settings such as rural health centers, during pre-hospital transport or mass casualty/disaster scenarios. The challenges and facilitators uncovered in this study provide an initial framework to enhance the deployment of enteral resuscitation in rural and resource-limited settings. This will necessitate additional refinement of the protocol to better fit local contexts, as well as the development of specialized and adaptive training approaches.

6. Conclusion

We studied the key aspects of the implementation of protocolized enteral resuscitation among burn-injured patients in Nepal and described the challenges and facilitators to its acceptability, fidelity, penetration, and sustainability. The findings can be utilized in developing contextually effective implementation strategies in other austere settings globally.

Supplementary Material

Supplement

Supplementary material 1: Final resuscitation flowsheet for bedside documentation of clinical and resuscitation parameters adapted according to local context and stakeholder feedback.

Fig. 2.

Presents adult burn fluid resuscitation protocol for enteral-based resuscitation with fluid rate adjustment every 2 h according to urine output.

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.burns.2024.107302.