TABLE 3.

Five themes of selected guidelines that were investigated, and key barriers and issues related to implementation in general

Theme	Issues	Key barriers/gaps identified related to the issue*
Guideline implementation (in general)	General attitude about guidelines: “Guidelines are just guidelines”	Attitude
	The majority of health care professionals perceived that knowledge and application of guidelines were not optimally monitored in their hospital settings for various reasons:	Knowledge
	Health care professionals’ lack of awareness of any monitoring process	Behaviour, Context gap
	Lack of formalized monitoring process
	Unwillingness on the part of some pharmacists to challenge physicians’ prescribing behaviours, although they are more informed about the treatment guidelines than most health care professionals	Attitude, Context gap
1. Initial clinical evaluation and resuscitation	ER and ICU physicians’ current practice behaviours are based on “good common practice”, not specific guidelines	Attitude
	The majority of them were not aware of specific guidelines on evaluation and resuscitation for NVUGIB	Knowledge
	The majority assume that their practice is already currently aligned with the guidelines	Attitude, Knowledge
	The majority assume guidelines offer no substantive value over and above current practice behaviours	Attitude
	Lack of coordination/collaboration among ER, ICU, and GI	Behaviour, Knowledge
	For example, there is a lack of clarity for ER and ICU physicians regarding when GI should be involved at the evaluation stage	Behaviour, Context gap
	Lack of agreement between GI and ER physicians on the value of the nasogastric aspiration procedure to assess patients with NVUGIB. GI perceived the need to reinforce for ER physicians the necessity of performing this procedure; however, ER physicians are not convinced of this procedure’s reliability	Attitude, Knowledge
		Attitude
2. Risk stratification	ER and ICU physicians acknowledged they do not follow a set protocol with clear criteria to classify patients with NVUGIB	Knowledge, Behaviour
	Not aware of specific classification and/or tools available	Knowledge
	Not convinced of value to classify patients	Attitude
	Most GI were not convinced of value of Rockall and Blatchford tools	Attitude, Behaviour
	The score will not change the care patients will receive	Attitude
	Experienced/mature physicians believe they do not need the scale	Attitude
	Not convenient to carry around	Behaviour
3. Endoscopy therapy	Lack of agreement among ER, ICU and GI about what “urgent endoscopy” means (ER, ICU)	Attitude, Knowledge
	Lack of information within guidelines to specify timing for intervention on unstable patients (GI)	Knowledge, Context gap
	Variability of nurses’ knowledge and skills (GI)	Knowledge, Skills
	Impact on endoscopy procedure (eg, nurses’ knowledge of where the equipment is, and which tools are needed, will facilitate the procedure)
4. Intravenous proton pump inhibitors	Most health care professionals acknowledged an overuse of IV PPI	Behaviour
	They are not concerned about cost and/or side effects, if any	Attitude, Context gap
	Lack of knowledge about when to start and stop IV PPI; in particular, before the endoscopy procedure (ER and GI)	Knowledge
	GI and Directors perceived that everyone is prescribing IV PPI these days (ER, ICU, GI, surgeons), but sometimes incorrectly	Knowledge, Behaviour
	In particular, some Directors are concerned that almost every patient is receiving the IV formulation when the oral formulation may be enough	Knowledge, Context gap
5. Testing for Helicobacter pylori and eradication therapy	Most GI acknowledged that testing for H pylori is not performed systematically (GI)	Knowledge, Attitude
	The reliability of the testing for H pylori is questioned (possibility of false negative) (GI)	Attitude
	Confusion about how to test, and about which test is more accurate (ER, ICU, GI)	Knowledge
	Many health care professionals acknowledged their lack of awareness of guidelines on testing for H pylori (ER, GI, nurses)	Knowledge

^*Key barriers subdivided into challenges related to knowledge, skills, attitude, behaviour and context gaps. ER Emergency room physicians; GI Gastroenterologists; ICU Intensivists; IV PPI Intravenous proton pump inhibitor therapy; NVUGIB Nonvariceal upper gastrointestinal bleeding